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Colen Publishing
Colen Publishing, L.L.C. PO Box 36536 Grosse Pointe Woods, MI 48236 Author and Editor: Chaim B. Colen, M.D., Ph.D. Editorial Assistant: Roxanne E. Colen, PA-C COPYRIGHT © 2008 by Colen Publishing, L.L.C. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the author’s consent if illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Permissions may be sought directly from Colen Publishing, L.L.C. by writing to the above address. Colen Flash-Review: Neurology ISBN Volume 1: 0-9788502-4-6 Volume 2: 0-9788502-5-4 2 Volume Set: 0-9788502-9-7 Note: Knowledge in medicine is constantly changing. The author has consulted sources believed to be reliable in the effort to provide information that is complete and in accord with the standards at the time of publication. However, in view of the possibility of human error by the author in preparation of this work, warrants that the information contained herein is in every respect accurate and complete, and that the author is not responsible for any errors or omissions or for the results obtained from use of such information. The reader is advised to confirm the information contained herein with other sources. This is especially important in connection with new or infrequently used drugs. In such instances, the product information sheet included in the package with each drug should be reviewed.

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Glossary
COPYRIGHT-------------------------------------------------PREFACE -----------------------------------------------------HOW TO USE THIS CARD REVIEW-------------------CONTRIBUTORS-------------------------------------------GLOSSARY--------------------------------------------------NEUROSURGERY-----------------------------------------NEUROLOGY -----------------------------------------------NEUROPATHOLOGY-------------------------------------NEUROANATOMY----------------------------------------NEUROCRITICAL CARE---------------------------------NEURORADIOLOGY--------------------------------------NEUROBIOLOGY------------------------------------------BONUS BIOSTATISTICS---------------------------------1 1 1 4 1 110 86 238 57 80 73 64 6

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Preface
• The idea to undertake such a large Flashcard review spawned from watching my wife Roxanne study for her Physician Assistant Boards. Diligently every day she would create a set of 7-10 flashcards from her study material that she would take with her to work. Later on, when I was studying for my written Neurosurgery Board examination, I gleaned information from various texts and other study guides and wrote down the most relevant material on cards for quick review while at work. It was amazing how much time during the day would be available to review these cards. If there was a delay in a OR case, a long lunch-line, a traffic jam (especially the i94 on a Friday afternoon) or waiting for my wife at her OB/GYN appointment -these little cards were specially handy. Always ambitious in life, the thought of giving this study tool to the busy neurosurgery resident was captivating. My expectation is to enable the resident with a quick yet informative review of basic neuroscience principles. With positive encouragement from my fellow residents on the 1st edition, I cautiously proceed here with updating information, adding new images, improved illustrations and clarification of neuroscience concepts. May this endeavor serve to better our wonderful science inherited through the legacy of Harvey Cushing, Neurosurgery. Chaim September 9, 2008
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The Colen Flash-Review
Author and Editor Chaim B. Colen, M.D., Ph.D. Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan Assistant Editor Roxanne E. Colen, M.S., PA-C Colen Publishing, LLC Grosse Pointe, Michigan

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Acknowledgements
I would like to give thanks to a great many wonderful persons whose efforts, although not inscribed in these cards, were instrumental in making this monumental task possible. One exceptional individual to whom I owe special thanks is my mother in-in-law, Colleen Johns, who babysat my daughter Emily and son Joshua for hours on end, while my wife and I toiled through hundreds of pages of various textbooks and journal articles, formatted questions, and drew computer illustrations. To my daughter Emily Rivka, who incessantly tugged at my pants trying to get my attention to the squirrel in our backyard ;and that big bright smile from my son Joshua that continually sent me optimism. To Mahmoud and Abhi who spent hours at my home assisting with typing, researching and editing; Naomi whose positive attitude in life is exceptionally brightening and uplifted the group’s 2 am brainstorming sessions when I still had to wake up early to work the next day, all the pathologists, especially Doha, who assisted in taking photographs, Dr. William Kupsky, for allowing us access to his collection of unique neuropathology, and to all the medical students especially Kristyn, whose hard work is admirable. There are those whose names are not here but did assist in some way, thank you. I am forever indebted to my training program, the Wayne State University neurosurgery program, my Chairman Dr. Murali Guthikonda, and Associate Chairman Dr. Setti S. Rengachary whose moral support over the last five years has kept me on this educational drive. For this second edition, there were fellow residents that gave me input and new insight that has helped to improve this edition over the first. To my parents Joseph and Leila, educators of true dedicated quality, and to whom I owe my homeschooling education and self-motivation. Lastly to my wife Roxanne, whose patience with my ambitiousness knows no boundaries. ©™ Thank you All, Chaim September 9, 2008

How to use this Flashcard review
• These cards are intended to cover most of the aspects of the Neurosurgery Board Examination. They are not a COMPLETE review and therefore they are not intended to replace textbooks. We would advise using these cards during the last couple of weeks before your board exam except for the pathology section which you should go through all year to better remember the photographs in it (heavily encountered during the boards!). BOARD FAVORITE questions are of extreme importance and most likely to bump into during the boards, so make you sure you know how to answer them right. Good luck! Chaim B. Colen, M.D., Ph.D.
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Faculty Reviewers
Murali Guthikonda, MD Professor and Chairman Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan Setti Rengachary, MD Associate Chairman Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan William, J. Kupsky, MD Department of Neuropathology Wayne State University School of Medicine Detroit, Michigan

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Forward
• With ever increasing scope and complexity of knowledge base, the current day trainee or practitioner of neurosurgery finds it difficult to keep up with the explosion of neurosurgical information. This is compounded by a healthy growth in specialization in various branches of neurosurgery. Chaim has made an attempt to make life simpler by incorporating small quanta of knowledge on flashcards accompanied by clear and simple illustrations. The user may review as few or as many cards as his/her time will allow. Although not meant to be substitutes for standard comprehensive texts and atlases, these cards help to refresh the information learned from the bedside, operating room and standard books. Each card represents a mini-examination with instant access to appropriate answers. This is a fun way to recall neurosurgical information especially before an upcoming test. Setti S. Rengachary, M.D. Department of Neurological Surgery
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Physician Contributing Authors
Rivka R. Colen, MD Department of Radiology The Massachusetts General Hospital Harvard Medical School Boston, Massachusetts Doha Itani, MD Department of Pathology WSU School of Medicine Detroit, Michigan Mahmoud Rayes, MD Department of Neurological Surgery WSU School of Medicine Erika Peterson, MD UT Southwestern, Department of Neurological Surgery Dallas, Texas

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Contributing Medical Students
Darmafall, Kristyn Wayne State University School of Medicine Class of 2012 Davis, Naomi Wayne State University School of Medicine Class of 2011 Dub, Larissa Wayne State University School of Medicine Class of 2012 Faulkiner, Rodney Wayne State University School of Medicine Class of 2012 Galinato, Anthony Wayne State University School of Medicine Class of 2012 Gotlib, Dorothy Wayne State University School of Medicine Class of 2009 Kozma, Bonita Wayne State University School of Medicine Class of 2008 Lai, Christopher Wayne State University School of Medicine Class of 2010 Larson, Sarah Wayne State University School of Medicine Class of 2012 Martinez, Derek Wayne State University School of Medicine Class of 2011 Matthew Smith Wayne State University School of Medicine Class of 2011 Matto, Shereen Wayne State University School of Medicine Class of 2012 ©™

Contributing Undergraduates
Jeffrey P. Kallas Wayne State University Class of 2010 Abhinav Krishnan Wayne State University Class of 2010 Peter Paximadis Wayne State University Class of 2008

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Q?

Neurology

This patient most likely sustained damage to which of the following structures? A. Bilateral hypoglossal nuclei B. Left hypoglossal nerve C. Left hypoglossal nucleus D. Left upper motor neuron to the hypoglossal nucleus E. Right vagal nucleus

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2

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Neurology

BOARD FAVORITE!

The correct answer is D, left upper motor neuron to the hypoglossal nucleus. Damage to the left hypoglossal nucleus (or nerve) would cause tongue deviation to the left (ipsilateral). However, as depicted in the photo, damage to the upper motor neurons (which cross), would cause tongue deviation to the right (contralateral).

Midstokke S, Hess SJ, Saini T, Edwards PC. Unilateral tongue atrophy. Gen Dent. 2006 Nov-Dec;54(6):425-7.

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Q?

Neurology

The function of the superior olive is: A. Sound localization B. Proprioception C. Vestibular localization and function D. Visual gaze control

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Neurology

BOARD FAVORITE!

The correct answer A, sound localization. The superior olivary nucleus (or superior olive) is a small mass of gray substance situated on the dorsal surface of the lateral part of the trapezoid body. The superior olivary nucleus’ primary input is bilateral and from the bushy cells of the anterior ventral cochlear nuclei (AVCN). This input occurs primarily via the ventral acoustic stria. Its output is to the lateral lemnisci. The superior olivary nucleus is the first point where binaural input is combined.

Superior and Inferior colliculi

Superior Olivary nucleus Cochlear nucleus Nucleus gracilis Nucleus cuneatus

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Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 606.

Q?

Neurology
45 23 6 7

The function of the superior olive is demonstrated by which waveform: A. 1 B. 2 C. 3 D. 4 1 E. 5 F. 6 G. 7

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Neurology

BOARD FAVORITE!

The correct answer C, 3. Brainstem auditory evoked responses test the integrity of the auditory pathway. Wave 1 –auditory nerve Wave 2 –Cochlear nuclei (pons) Wave 3 –Superior olivary complex Wave 4 –Lateral lemniscus Wave 5 –Inferior colliculus Wave 6 –Medial geniculate nucleus Wave 7 –Auditory radiations (cortex) Damage to one of the structures will result in an increased latency! (e.g. acoustic neuroma will show increased latency of 1-3).

45 1 23 6 7

KNOW THESE WAVEFORMS WELL! BOARD FAVORITE!

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Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 606.

Q?

Neurology

Match the following statements with the correct answer: 1. Lateral vestibulospinal tract 2. Rubrospinal tract A. B. C. D. Extensor tone Flexor tone Both Neither

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9

A.

Neurology

BOARD FAVORITE!

1. The correct answer is A, extensor tone. The lateral vestibulospinal tract regulates extensor tone through the lateral vestibular nucleus. • The vestibulospinal tract arises from the lateral vestibular nucleus (i.e. Deiter’s nucleus) and descends bilaterally in the anterior part of the lateral funiculus. 2. The correct answer is B, flexor tone. Flexor activity is regulated by the rubrospinal tract from the red nucleus. • The rubrospinal tract arises from magnocellular neurons in the red nucleus and crosses at the ventral tegmental decussation. Stimulation of the red nucleus leads to excitation of contralateral flexor alpha motor neurons and inhibition of extensor alpha motor neurons.

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Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 668.

Q?

Neurology

Which brainstem nuclei release serotonin? A. Raphé nuclei B. Vestibular nuclei C. Hypoglossal nuclei D. Nucleus cuneatus E. Nucleus gracilis

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A.

Neurons in the dorsal raphé nucleus produce serotonin, they have long projections (green arrow) that carry the neurotransmitter to the orbital prefrontal cortex.

Neurology

The correct answer is A, raphé nuclei. The raphé nuclei are located in the brainstem.

CROSS SECTION

Dorsal raphé nuclei

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Dorsal raphé nuclei

Q?

Neurology

Lack of sensory loss, presence of a “pinch sign”, and hand weakness is characteristic of: A. Carpal tunnel syndrome B. Anterior interosseous syndrome C. Ulnar nerve entrapment D. Posterior interosseous syndrome

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A.

Neurology

BOARD FAVORITE!

The correct answer is B, anterior interosseous syndrome. The “pinch sign” often occurs when there is a complete anterior interosseous nerve (AIN) lesion. Attempts to pinch the tips of the terminal phalanges of the index finger and thumb results in an extension of the distal phalanges. Thus, the pulps rather than the tips of these two digits approximate.

NORMAL

PINCH SIGN
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Note the distinctive findings of a AIN syndrome on performing the pinch test. There is loss of function in the AINinnervated flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) muscles, leading to weakness in the distal phalanges of the thumb and forefinger. The left photograph shows the normal function when attempting this hand posture.
H. Richard Winn, M.D. Youman’s Neurological Surgery 5th Edition. Philadelphia, PA: Elsevier 2004. p. 3925..

Q?

Neurology

30 year-old female presents with a history of shunted pseudotumor cerebri and small ventricles, now complains of worsening headache. Fundoscopic exam is shown below. Which of the following statements is TRUE? A. It is best treated with Diamox. B. She likely has shunt failure and stiff ventricles. C. She has venous thrombosis. D. There is no cause for concern about this headache.

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63

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Neurology

The correct answer is B, she likely has shunt failure and stiff ventricles. A low index of suspicion should be present when evaluating a patient with shunted pseudotumor cerebri (PTC). Approximately 40% of shunts placed in children will fail in the 1st year and almost all children will require shunt revision at some point. In PTC, shunt malfunction may result in blindness. PTC is encountered most frequently in young, overweight women between the ages of 20 and 45. Headache, occurring in more than 90 percent of cases, is the most common presenting complaint. Dizziness, nausea, and vomiting may also be encountered, but there are typically no alterations of consciousness or higher cognitive function. It is defined clinically by four criteria: (1) elevated intracranial pressure, as demonstrated by lumbar puncture; (2) normal cerebral anatomy, as demonstrated by neuroradiographic evaluation; (3) normal cerebrospinal fluid composition; and (4) signs and symptoms of increased intracranial pressure, including papilledema.
Martin TJ, Corbett JJ: Pseudotumor cerebri, in Youmans JR(ed): Neurological Surgery, ed 4. Philadelphia: WB Saunders,1996, Vol 4, pp 2980–2997.

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Q?

Neurology

Based on the radiological features seen in this MRI, choose the most appropriate statement regarding this condition: A. They have no intervening brain tissue between the vascular spaces on histopathology. B. They do have intervening brain tissue between the vascular spaces on histopathology. C. There is no genetic association. D. The HOX gene is highly associated.

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79

A.
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Neurology

BOARD FAVORITE!

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The correct answer is A, they have no intervening brain tissue between the vascular spaces on histopathology. Cavernous malformations (i.e. angioma, cavernoma, or cavernous hemangioma) may be inherited or sporadic and consist of variable sized sinusoids or cavernous spaces between capillaries. Unlike arteriovascular malformations and capillary telangiectasias., they have no intervening brain tissue between the vascular spaces and have thus been described as “blood sponges”. MRI shows welldefined, usually rounded lesions with little or no mass effect and are without vasogenic edema (unless hemorrhage is present). There may be small areas of new or old hemorrhages shown as a rim of hemosiderosis around the cavernous angioma in the surrounding brain tissue. Genetics: more common in Hispanics. CCM1 (for cerebral cavernous malformation 1) -chromosome 7 at band 7q11.2-q21. It is also known as KRIT1, for the protein created by the gene. 40% of familial cavernous angiomas. CCM2 -band 7p15-p13, protein named malcavernin. 20% of familial cavernous angiomas. CCM3 identified as linked to familial cavernous angioma is on chromosome 3 at band 3q.
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Craig HD, Gunel M, Cepeda O, et al: Multilocus linkage identifies two new loci for a mendelian form of stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27. Hum Mol Genet 1998 Nov; 7(12): 1851-8.

Q.

Neurology

This fundus is MOST likely seen in which of the following patients? A. 25 year-old female B. 14 year-old diabetic male C. 75 year-old diabetic male D. 25 year-old obese male E. 25 year-old obese female

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Neurology

The correct answer is E, 25 year-old obese female. This ocular fundoscopic image demonstrates classic grade 2 papilledema most likely seen in a 25 yearold obese female with pseudotumor cerebri (idiopathic intracranial hypertension).

Grade II papilledema. The halo of edema now surrounds the optic disc.

Brazis PW, Lee AG: Elevated intracranial pressure and pseudotumor cerebri. Curr Opin Ophthalmol 1998 Dec; 9(6): 27-32.

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Q?

Neurology

In myopathic disorders the motor unit potentials on electromyography would most likely show which of the following? A. Increased amplitude B. Decreased duration C. Monophasic D. Few in numbers with decreased recruitment E. A and D

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A.
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Neurology

BOARD FAVORITE!

The correct answer is…. To obtain the answer to this question and to view over 300 more comprehensive neurology questions please purchase the full app here !

Polyphasic “giant wave” of reinnervation

Low amplitude wave of myopathy

Daube JR: The description of motor unit potentials in electromyography. Neurology 1978 Jul; 28(7): 623-5.

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