BRT | ANATOMY

Neuroanatomy

May 4, 2015

NEUROANATOMY
(for questions 1-4) A 25 year old male presents to the ER with a severe
contusion to the right side of the forehead. On examination, he has
diminished sensation to the forehead and cannot raise the upper eyelid.
Further examination shows that he cannot move the eye upward or in a
lateral direction. Radiographic studies show some displacement of the bony
structures of the orbit.
1.

Which is the site into which the bone has been displaced, resulting in all
of the described symptoms?
a. Mental foramen
b. Supraorbital foramen
c. Infraorbital foramen
d. Superior orbital fissure
e. Inferior orbital fissure

ANSWER: D

V1, CN III, IV, VI all pass through superior orbital fissure which explains
decreased sensation (V1), loss of ability to raise eyelid (levator
palpebrae superioris: III), and move eye upward (inferior oblique and
superior rectus: III) and laterally (lateral rectus: VI).

3.

Muscle

Primary Action

Medial Rectus
Lateral Rectus
Superior Rectus
Inferior Rectus
Superior Oblique
Inferior Oblique

Adduction
Abduction
Elevation
Depression
Intorsion
Extorsion

Secondary Action

CN

Intorsion
Extorsion
Depression
Elevation

III
VI
III
III
IV
III

Which nerve is involved in the patients inability to move the eye in a

lateral direction?
a. Trochlear
b. Oculomotor
c. Abducens
d. Supratrochlear
e. Infraorbital

ANSWER: C

Abducens nerve supplies the lateral rectus muscle, allows for

lateral gaze.

Trochlear nerve supplies the superior oblique muscle, not involved

in the patients deficit since he is able to perform downward and
inward gaze.

LASOT: Lateral rectus Abducens; Superior Oblique Trochlear

2.

Which nerve is involved in the patients inability to look upward or raise

the upper eyelid?
a. Trochlear
b. Oculomotor
c. Abducens
d. Frontal
e. Ophthalmic division of trigeminal nerve (V1)

ANSWER: B

Superior division of oculomotor nerve supplies the levator palpebrae

superioris,superior rectus and inferior oblique muscles with motor
innervation

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4.

Sensory deficit is a result of injury to which nerve?

a. Zygomaticofacial
b. Zygomaticootemporal
c. First cervical spine nerve (C1)
d. Maxillary division of trigeminal (V2)
e. Ophthalmic division of trigeminal (V1)

ANSWER: E

Ophthalmic nerve supplies sensory innervation to the forehead and the

scalp as far as the vertex.

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Anatomy | Neuroanatomy
6.

5.

Where would a lesion resulting in a fluent (sensory) Wernicke aphasia

most likely be found?
a. Temporal lobe
b. Parietal lobe
c. Frontal lobe
d. Occipital lobe
e. Limbic lobe

A patient presents with gait unsteadiness. When standing with his feet
together, he is slightly unsteady. When he closes his eyes, he becomes
markedly unsteady and must be held in order to avoid falling. Where is
the disease located?
a. Dorsal column
b. Lateral spinothalamic tract
c. Anterior horn cells
d. Lateral corticospinal tract
e. Anterior white commissure

ANSWER: A

Dorsal column carries sensory perception (Rombergs sign)

Lateral spinothalamic tract carries pain and temperature

AHC final common pathway for muscle stimulation

Lateral CST innervate neurons for motor function (pyramidal tract)

Two of the five sensory modalities, pain and temperature, cross sides at
the anterior white commissure, reaching the contralateral side about
two vertebral levels rostral to their origin.

ANSWER: A

Specifically, posterior parasylvian temporal operculum

Parietal lobe sensory association areas; a lesion in this area will

produce hemineglect, apraxia, Gerstmann syndrome (dysgraphia,
dyscalculia, left/right disorientation, finger agnosia)

Frontal lobe personality, mood, insight

Occipital lobe primary visual area

Limbic basic human emotion; learning processes

Type of
Aphasia

Fluency

Understan
d

Repetitio
n

Namin
g

Brocas

Poor;
effortful

Good

Poor

poor

Wernickes

Good;
word salad

Poor

Poor

Poor

Conduction

Good;
poor
articulatio
n
Poor

Good

Poor

Poor

Good

Good

May
be
norma
l

Transcortic
al Sensory

Good

Poor

Good

Usuall
y
norma
l

Global

None or
scanty;
expletives
only

Very poor

Very
poor

Very
poor

Transcortic
al Motor

Location of
Leson
Left posterior
inferior frontal
operculum
Posterior
parasylvian
temporal
operculum
Posterior
parasylvian

Frontally and
superiorly
extending
inward
to
striatum
Parietal,
temporal
involving
thalamocortic
al unit
Entire
parasylvian

Legend. Gray matter: 1. Anterior horn; 2. Posterior horn; 3. Gray commissure. White
matter: 4. Anterior funiculus; 5. Lateral funiculus; 6. Posterior funiculus; 7. Anterior
commissure; 8. Anterior median fissure; 9. Posterior median sulcus; 10. Central canal;
11. Anterior root; 12. Posterior root; 13. Dorsal root ganglion

7.

A 60 year old man presents with sudden onset of speech arrest and
right-sided weakness. Examination shows 0/5 strength in the right arm,
3/5 strength in the right leg. Decreased right-sided sensation is also
present. This combination most likely represents
a. Left anterior cerebral artery infraction
b. Left middle cerebral artery infarction
c. Right middle cerebral artery infarction
d. Left lacunar infarction of anterior choroidal artery
e. Subarachnoid hemorrhage of right posterior cerebral artery

ANSWER: B

Speech area located at Brocas or dominant inferior frontal gyrus and

contralateral primary sensorimotor area are both supplied by left MCA.

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Anatomy | Neuroanatomy
8.

Which set of cranial nerves is closely related anatomically to the

corticospinal tract as it passes longitudinally through the brainstem?
a. CN III, IV, V
b. CN III, V, VII
c. CN III, VI, VIII
d. CN III, VI, XII
e. CN III, IX, X

ANSWER: D

Test-taking strat:
o The brainstem is comprised of the midbrain, pons and
medulla oblongata where cranial nerves III-IV, V-VIII and IXXII, respectively, are located.
o The pyramidal tract runs through the entire brainstem until it
decussates; thus options A, B, C (no cranial nerve located at
the medulla oblongata) and E (no cranial nerve located at the
pons)
9.

The history and physical exam of a patient indicate a meningioma

within the tentorium cerebelli. You visualize this tumor as residing:
a. Between the right and left cerebral hemispheres
b. Within the operculum of the frontal lobe
c. In the cisterna magna
d. At the cerebellopontine angle
e. Between the occipital lobe and the cerebellum

ANSWER: E

Between the right and left hemispheres falx cerebri

The cisterna magna (or cerebellomedullary cistern) is one of three

principal
openings
in
the subarachnoid
space between
the arachnoidand pia mater layers of the meninges surrounding the
brain.

The landmark tentorium cerebelli helps localize brain tumors in terms

of type, frequency, etc. Pediatric brain tumors are most commonly
found infratentorially whereas most adult tumors are supratentorial in
location.

Although vision loss is a relatively uncommon sequela of an ICA

aneurysm, compression of the optic nerve by an aneurysm can cause
visual field loss, decreased visual acuity, or both.

11. A 64 year old man diagnosed with permanent speech disorder (Brocas
aphasia) from CVA which most likely involves:
a. ACA
b. MCA
c. Lenticulostriate arteries
d. PCA
e. PICA
ANSWER: B

MCA supplies left frontal lobe operculum which contains Brocas

speech center
12. Where is the barrier between the blood and brain parenchyma?
a. Leaky ependymal (epithelial)
b. Tight ependymal (epithelial)
c. Capillary endothelium
d. Neuronal membrane
e. Fenestrated endothelium
ANSWER: C

Capillary endothelium provides the most significant barrier to

substances having free access to the extracellular space of the cells
within the brain

A, B ependymal cells provide the lining of ventricular spaces

13. Which region begins closure of the neural tube?
a. Cranial end
b. Caudal end
c. Cervical region
d. Lumbar region
e. Sacral region
ANSWER: C

The closure of the neural tube occurs first in the cervical region, and
progresses cranially and caudally simultaneously.

Failure of the neural tube to grow results in a variety of congenital

anomalies, including spina bifida

10. An aneurysm near the bifurcation of ICA into the anterior and middle
cerebral artery which deficit would most likely be associated with the
lesion?
a. Olfactory
b. Optic
c. Oculomotor nerve
d. Trigeminal
ANSWER: B

The majority of intracranial aneurysms arise from the internal carotid

artery (ICA) circulation.

The proximity of cranial nerves II to VI to the pathway of the internal

carotid artery make them susceptible to damage from an ICA
aneurysm, which may cause a variety of neurologic effects.
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14. An attending physician hands the intern a tuning fork and asks him to
test the perception of the vibratory modality in the individual that the
physician is checking. Which system is tested using this instrument?
a. Spinothalamic (anterolateral) system
b. Posterior spinocerebellar pathway
c. Dorsal column-medial lemniscus system
d. Tectospinal pathway
e. Rubrospinal pathway
ANSWER: C

The dorsal column-medial lemniscus system carries the sensory

modalities of two-point discrimination, vibration, and conscious
proprioception

The spinothalamic (anterolateral) system evaluates temperature and

sharp pain

The posterior spinocerebellar pathway is a sensory modality for

unconscious proprioception

The tectospinal pathway observes change in the position of the neck,

shoulders, upper trunk, visual and auditory stimuli

The rubrospinal pathway observes muscle tone, and coordination of

proximal appendicular muscle groups
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Anatomy | Neuroanatomy
15. A 35-year old male patient, who has previously been aggressive and
assaultive, injures his head in a boating accident. After the accident, the
nurses report that although he is very easy to deal with, he constantly
masturbates and often makes sexually suggestive gestures toward
them. What is the most likely site of his brain injury?
a. Basal ganglia
b. Hippocampus
c. Amygdala
d. Parietal lobes
e. Frontal lobes

d.
e.

Arachnoid villi cisterna magna foramen of Magendie

foramen of Monro
Foramen of Monro cerebral aqueduct foramen of
Luschka arachnoid villi

ANSWER: E

ANSWER: C

Damage to amygdala results in Kluver-Bucy syndrome which is

characterized by docility and hypersexuality.

A Damage to basal ganglia results in movement disorder such as

Parkinsons

B damage to hippocampus is associated with memory deficits

D damage to parietal lobe is associated with intellectual processing

of sensory information

E damage to frontal lobe results to problem with mood,

concentration, and orientation
16. The pituitary gland is formed by the fusion of an evagination of the
third ventricle with an evagination of:
a. ectoderm that forms the roof of the stomodeum
b. endoderm that forms the roof of the pharynx
c. endoderm that forms the first branchial pouch
d. ectoderm that forms the first branchial cleft
e. mesoderm that forms the first branchial arch
ANSWER: A

The pituitary gland is derived from two sources: 1) from evagination of

the third ventricle forming the infundibulum of hypothalamus and 2)
posterior lobe of pituitary gland.

The anterior lobe and pars intermedia are formed by Rathkes pouch,
which is an evagination of the ectoderm that forms the roof of the
stomodeum or primitive oral cavity.
17. The occulomotor nerve passes between which pair of arteries?
a. Superior cerebellar artery and posterior cerebral artery
b. Posterior inferior cerebellar artery and anterior inferior
cerebellar artery
c. Posterior cerebral artery and middle cerebral artery
d. Labyrinthine artery and anterior inferior cerebellar artery
e. Posterior cerebral artery and posterior communicating artery
ANSWER: A

The oculomotor nerve emerges from the midbrain passing between the
two cerebral peduncles.

The nerve passes between posterior cerebral artery and superior

cerebellar artery before entering the dura of the lateral wall of the
cavernous sinus.

Aneurysm of any of these two arteries will compress the oculomotor

nerve
18. Which sequence best describes the path that a drop of cerebrospinal
fluid follows from the lateral ventricle to the superior sagittal sinus?
a. Foramen of Magendie cerebral aqueduct 4th ventricle
arachnoid villi
b. Formaen of Monro Foramen of Luschka 4th ventricle
cisterna magna
c. Septum pellucidum 3rd ventricle 4th ventricle
foramen of Luschka
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19. As a result of a unilateral lower motor lesion of the hypoglossal nerve

would result in:
ANSWER: Deviation of the tongue ipsilaterally

The genioglossus muscle is paralyzed on the side of the lesion in the

hypoglossal nerve.

When the tongue is protruded, the vector of fully innervated muscle is

unopposed by the muscles of the opposite side, thereby producing an
obvious deviation of the tongue from the midline.

Protrusion is still possible due to normal innervated side.

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Anatomy | Neuroanatomy
20. On angiography, which vessel follows the contour of the corpus
callosum
a. Middle cerebral artery
b. Vertebral artery
c. Posterior cerebral artery
d. Superior cerebellar artery
e. Anterior cerebral artery
ANSWER: E
RATIONALE:

A1 segment of anterior cerebral artery follows the contour of the

corpus callosum

A MCA would run laterally in the lateral fissure before purging

horizontally on the lateral brain surface

B Vertebral vessels would run along the ventral surface of the

medulla

C PCA passes along the region along the cerebral peduncles of the
midbrain and courses along the ventral surface of occipital lobes

D Superior cerebellar artery is similar to the PCA except under the

cerebellar artery the dorsal surface of the cerebellum

21. The lentiform nuclei consist of the

a. subthalamic nucleus and substantia nigra
b. caudate nucleus and putamen
c. putamen and globus pallidus
d. caudate nucleus, putamen and globus pallidus
e. ventral anterior and ventral lateral thalami
ANSWER: C

Lentiform nuclei consist of the putamen and globus pallidus. On cross

section these nuclei have a lense like appearance.

A subthalamic nucleus and substantia nigra are the cephalic

components of basal ganglia

B caudate nucleus and putamen are referred to as striatum

D caudate nucleus, and globus pallidus are referred to nuclei of basal

ganglia

E Ventral anterior and ventral lateral thalami are thalamic specific

nuclei related to motor system
Case: A 29 year old man goes to the ER because of a severe headache.
The patient says that the headache, which seems localized to the area
behind the ears, has been intermittent but persistent since he was
involved in a beach volleyball game while on vacation. Shortly after he
returned from his vacation, he made an appointment with his family
physician because he was worried about the headache and the fact that
he had developed noticeable clumsiness. An avid fitness enthusiast, he
noted his performance was awkward and uncoordinated. When
questioned, he mentioned unusually frequent bouts of nausea and
vertigo.
Physical examination reveals an alert, oriented, thin man with mild
hoarseness and some difficulty swallowing oral secretions. The left side of
his face is affected by Horners syndrome, and he has pronounced
bilateral rotatory nystagmus in the primary position with all directions of
gaze. He has decreased sensitivity to light touch on the left side of his
face, flattening of the left nasolabial fold, and paresis of the left soft
palate. Finger to nose testing shows left sided dysmetria. Wen asked to
walk across the room, his gait is ataxic and he deviates to the left. There
is diminished pain and thermal sensation on the right side. Reflexes are
symmetric. There is no Babinski reflex, and the remainder of the motor
and sensory examination is normal.
22. The attending and resident physicians suspect a vascular occlusion or
rupture. Which one of the following vessels should be the primary
suspect?
a. Middle cerebral artery
b. Internal carotid artery at the cavernous sinus
c. Superior cerebellar artery
d. Posterior inferior cerebellar artery
e. Anterior communicating artery
ANSWER: D
The findings in this case suggest a lesion involving structures in the
lateral aspect of the brainstem medulla which is supplied by the PICA.
A,B, E involved in vasculature in cerebrum
C. Superior cerebellar artery supplies the midbrain

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Anatomy | Neuroanatomy

23. What is the most likely cause of the patients Horners syndrome?
a. Descending autonomic innervation from the hypothalamus
b. Parasympathetic dystonia
c. Compression of the sympathetic chain and superior cervical
ganglion in the neck as a result of torticollis
d. A reactive conjunctivitis caused by the sand in the patients
eyes
e. A hypothalamic cyst
ANSWER: A
Horners syndrome
o Triad: miosis, ptosis, and loss of hemifacial sweating.

Case taken as a whole indicates damage to the descending autonomic

system in the medulla
B, C, D, E no indications based on the history since this will only produce
very specific localized problems
24. Which brain stem pathway affected by the lesion is responsible for the
findings of diminished pain and thermal sensation on the right side?
a. Dorsal column-medial lemniscus
b. Anterolateral system (spinothalamic tract)
c. Dorsal spinocerebellar tract
d. Pontocerebellar tract
e. Periaqueductal gray pathway

Hoarseness and difficulty of swallowing indicates weakness of the

larynx and the pharynx respectively.
Motor innervation structures are primarily supplied by the vagus nerve.
Vagus cells responsible for efferent motor originates in nucleus
ambiguuus.
Nucleus ambiguuus resides in part of the medulla supplied by PICA
A glossopharyngeal nerve motor innervation is not enough to
influence primary movement in swallowing
B Innervates the tongue and not supplied by PICA
D no involvement sternomastoid and trapezius muscles
E Trigeminal nerve may be involved but involvement would manifest
as loss of pain and temperature sensation on the face

27. What is the most likely diagnosis?

a. Wernickes syndrome
b. Kluver-Bucy syndrome
c. Webers syndrome
d. Locked-in syndrome
e. Wallenbergs syndrome
ANSWER: E

Constellation of neural findings and involvement of the lateral aspect of

medulla indicates Wallenberg syndrome or lateral medullary
syndrome.

Affectation of the PICA in this case can be pointed out as the cause of
this syndrome

A involves parietotemporal lobe and is primarily a speech related

disorder

B involves amygdala and medial temporal lobe

C involves midbrain and oculomotor nerve palsy

D Involve pons

ANSWER: B
Located in the upper outer quadrant of the medulla.
Responsible for pain and temperature sensation from the opposite side of
the body and sites of the medulla supplied by PICA.
25. The lack of a Babinski reflex indicates that which one of the following
pathways is intact?
a. Anterolateral system (spinothalamic tract)
b. Pyramidal (corticospinal) tract
c. Dorsal column-medial lemniscus system
d. Auditory system
e. Olivocerebellar tract
ANSWER: B
Babinski sign indicates upper motor neuron damage. Since the patient
does not exhibit Babinski, then this means that the descending
corticospinal tract is intact
26. Involvement of which one of the following cranial nerves is responsible
for the findings of hoarseness and difficulty swallowing?
a. Glossopharyngeal nerve
b. Hypoglossal nerve
c. Vagus nerve
d. Spinal accessory nerve
e. Trigeminal nerve
ANSWER: C
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