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Colen Publishing

www.colenpublishing.com

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Colen Publishing, L.L.C.PO Box 36536Grosse Pointe Woods, MI 48236Author 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.Printed in ChinaColen Flash-Review: Neurosurgery, 2nd EditionISBNVolume 1: 1-935345-01-X Volume 2: 1-935345-02-8 2 Volume Set: 1-935345-00-1

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-------------------------------------------------- 1PREFACE------------------------------------------------------ 1HOW TO USE THIS CARD REVIEW-------------------- 1CONTRIBUTORS-------------------------------------------- 4GLOSSARY--------------------------------------------------- 1NEUROSURGERY------------------------------------------ 110NEUROLOGY ------------------------------------------------ 86NEUROPATHOLOGY-------------------------------------- 238NEUROANATOMY----------------------------------------- 57NEUROCRITICAL CARE---------------------------------- 80NEURORADIOLOGY--------------------------------------- 73NEUROBIOLOGY------------------------------------------- 64 BONUS BIOSTATISTICS---------------------------------- 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 EditorChaim B. Colen, M.D., Ph.D.Department of Neurological SurgeryWayne State University School of MedicineDetroit, Michigan

Assistant EditorRoxanne E. Colen, M.S., PA-CColen Publishing, LLCGrosse Pointe, Michigan

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AcknowledgementsI 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

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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 FAVORITEquestions 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 SurgeryWayne State University School of MedicineDetroit, Michigan

Setti Rengachary, MD Associate Chairman Department of Neurological SurgeryWayne State University School of MedicineDetroit, Michigan

William, J. Kupsky, MDDepartment of Neuropathology Wayne State University School of MedicineDetroit, Michigan

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• 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

Forward

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Physician Contributing Authors

Mahmoud Rayes, MDDepartment of Neurological Surgery WSU School of Medicine

Erika Peterson, MDUT Southwestern,Department of Neurological Surgery Dallas, Texas

Rivka R. Colen, MDDepartment of RadiologyThe Massachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Doha Itani, MDDepartment of PathologyWSU School of MedicineDetroit, Michigan

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Contributing Medical Students

Darmafall, KristynWayne State UniversitySchool of MedicineClass of 2012

Davis, Naomi Wayne State UniversitySchool of Medicine Class of 2011

Dub, LarissaWayne State UniversitySchool of MedicineClass of 2012

Faulkiner, RodneyWayne State UniversitySchool of MedicineClass of 2012

Galinato, AnthonyWayne State UniversitySchool of MedicineClass of 2012

Gotlib, DorothyWayne State UniversitySchool of MedicineClass of 2009

Kozma, BonitaWayne State UniversitySchool of MedicineClass of 2008

Lai, Christopher Wayne State UniversitySchool of MedicineClass of 2010

Larson, SarahWayne State UniversitySchool of MedicineClass of 2012

Martinez, DerekWayne State UniversitySchool of MedicineClass of 2011

Matthew SmithWayne State UniversitySchool of MedicineClass of 2011

Matto, ShereenWayne State UniversitySchool of MedicineClass of 2012

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Contributing Undergraduates

Jeffrey P. KallasWayne State UniversityClass of 2010

Abhinav KrishnanWayne State UniversityClass of 2010

Peter PaximadisWayne State UniversityClass of 2008

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• Match the following statements with the correct answer:

1. Neuromuscular junction2. Botox3. Renshaw cell4. Blocks Renshaw cell

neurotransmitter5. Curare

NeurobiologyQ?

A. Acetylcholine releaseB. Acetylcholine receptorC. 5 subunits: 2α subunits, a β, a δ and either

a γ or an ε.D. StrychnineE. Glycine

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NeurobiologyA.

• The corrects answers are the following: 1 - C, 2 - A, 3 - E, 4 - D, 5 - B. • Neuromuscular junction- the neuromuscular junction contains the nicotinic receptor

(an acetylcholine receptor subtype (nAChR)) There are 2 types of nAChRs; autonomic and neuromuscular. The autonomic nicotinic receptor has 5 subunits: 3α and 2β. The neuromuscular nAChR also consists of 5 subunits:2α subunits, a β, a δ and either a γ or an ε subunit.

• Botox –botulism toxin decreases Ach release (at neuromuscular junction and autonomic nerve terminals: both sympathetic & parasympathetic) by binding to synaptotagmin, while curare (δ-tubocurarine) blocks the Ach receptor. Botox has actually become useful for cosmetic purposes and dystonias.

• The Renshaw cell neurotransmitter is glycine; an aminoacid and whose channel is blocked by strychnine.

Dressler D, AdibSaberi F. New formulation of Botox: complete antibody-induced treatment failure in cervical dystonia. J NeurolNeurosurg Psychiatry. 2007 Jan;78(1):108-9Adams, M.E. and Olivera, B.M. Neurotoxins: overview of an emerging research technology. Trends Neurosci. 17:151-155. (1994).

BOARD FAVORITE!

Classification: Neurobiology, Neuromuscular junction, Receptor actions

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• Which of the following is the principle visceral nucleus of the brainstem?A. Nucleus ambiguusB. Raphe nucleusC. Nucleus solitariusD. Locus ceruleusE. Trigeminal nucleus

NeurobiologyQ?

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NeurobiologyA.

• The correct answer is C, nucleus solitarius.• Nucleus solitarius receives afferent visceral information from the heart, lungs, GI

tract, as well as for taste. The solitary nucleus and tract are neural structures in the brainstem that carry and receive visceral sensation and taste from the facial (VII), glossopharyngeal (IX), vagus (X) cranial nerves, as well as the cranial part of the accessory nerve (XI).

• Nucleus ambiguous gives rise to the efferent motor fibers of the vagus nerve (CN X) terminating in the laryngeal and pharyngeal muscles, efferent motor fibers of the glossopharyngeal nerve (CN IX) terminating in the stylopharyngeus and contains the preganglionic parasympathetic neurons for cardiac regulation.

Andresen MC, Doyle MW, Bailey TW, Jin YH. Differentiation of autonomic reflex control begins with cellular mechanisms at the first synapse within the nucleus tractus solitarius. Braz J Med Biol Res. 2004 Apr;37(4):549-58.

BOARD FAVORITE!

Classification: Neurobiology, Brainstem, Nucleus Solitarius

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• Choose the MOST accurate statement regarding the physiology of an action potential:A. Voltage-gated potassium channels (also called delayed rectifier potassium

channels) have a delayed response, such that potassium continues to flow out of the cell and initiate depolarization.

B. Hyperpolarization is caused by K+ influx into a cell.C. Closing of voltage-gated potassium channels is both voltage- and time-

dependent.D. Depolarization is caused by Na+ efflux from a cell.

NeurobiologyQ?

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NeurobiologyA.• The correct answer is C, closing of voltage-gated potassium channels is both voltage- and time-

dependent. As potassium exits the cell, the resulting membrane repolarization initiates the closing of voltage-gated potassium channels.

Hyperpolarization

Resting potential

0 1 2 3 4 5Time (ms)

Threshold

Stimulus

Peak

Mem

bran

e vo

ltage

(mV

)

40

0

-55

-70

Na+ influx

K+ efflux

• These channels do not close immediately in response to a change in membrane potential. Rather, voltage-gated potassium channels (also called delayed rectifier potassium channels) have a delayed response, such that potassium continues to flow out of the cell even after the membrane has fully repolarized. Thus the membrane potential dips below the normal resting membrane potential of the cell for a brief moment; this dip of hyperpolarization is known as the undershoot.

• Hyperpolarization is caused by K+ effluxfrom a cell.

• Depolarization is caused by Na+ influx into a cell.

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 128-33.Robbins and Cotran. Pathologic Basis of Disease, 6th Edition. W.B. Saunders Company. 1999. p.55-56.

BOARD FAVORITE!

Classification: Neurobiology, Neurophysiology, Action Potential

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• Neurotransmitter that is found in a postganglionic sympathetic nerve terminal:A. GABAB. SerotoninC. AcetylcholineD. NorepinephrineE. C + D

NeurobiologyQ?

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NeurobiologyA.

• The correct answer is E, acetylcholine (Ach) and norepinephrine (NE).• Both Ach and NE are found in postganglionic sympathetic fibers. • Ach- sweat, piloerectors, and vasculature, mediated by muscarinic receptors

(inhibited by pertussis toxin).• REMEMBER: sweating of the palms of the hands is parasympathetic NOT

sympathetic! (BOARD FAVORITE!)• NE- all others• Peripheral sympathetic pathway –TRAVELS WITH SKELETAL NERVES (sweat,

piloerectors, and vasculature) (BOARD FAVORITE!)• Head and Neck sympathetic pathway -TRAVELS WITH BLOOD VESSELS

(BOARD FAVORITE!)• All preganglionic fibers (both sympathetic and parasympathetic) use Ach.

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 1051-52.

BOARD FAVORITE!

Classification: Neurobiology, Neurophysiology, Sympathetic Nerve Terminal

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• Which of the following statements is true regarding the intracellular second messenger cyclic AMP.

A. It is involved with photoreceptionB. It is hydrolyzed by phospholipaseC. It synergistically activates protein kinase CD. It is increased with D1 receptor stimulation

NeurobiologyQ?

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NeurobiologyA.• The correct answer is D, it is increased with D1 receptor stimulation.• Hormones that utilize this system include: epinephrine and norepinephrine, glucagon

and TSH.• In a cAMP dependent pathway, the activated Gs alpha subunit binds to and activates

an enzyme called adenylyl cyclase which in turn catalyzes the conversion of ATP into cyclic adenosine monophosphate (cAMP). The intracellular second messenger cAMP activates protein kinase A (PKA).

• cAMP is decomposed to AMP by the action of the enzyme phosphodiesterase. This cAMP phosphodiesterase - has an activity opposite to kinase, therefore it dephosphorylates cAMP into AMP, reducing the cAMP levels.

• Deregulation of cAMP pathways (hyperactive) and an aberrant activation of cAMP-controlled genes is linked to the growth of some cancers

• Activation of conventional protein kinase C - requires DAG, Ca2+, and phospholipid.

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 230-36.

BOARD FAVORITE!

Classification: Neurobiology, Neurophysiology, Second Messenger Systems

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• Match the receptors with their action:1. Mu12. Mu23. Kappa4. Delta5. Sigma

NeurobiologyQ?

A. HallucinationsB. Opiate analgesic euphoriaC. Miosis D. Reinforcing behaviorE. Respiratory depression

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NeurobiologyA.• The correct answers are:

1. B, Mu1- Opiate analgesic euphoria2. E, Mu2- Respiratory depression3. C, Kappa- Miosis4. D, Delta- Reinforcing behavior5. A, Sigma- Hallucinations

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 483-6.Robbins and Cotran. Pathologic Basis of Disease, 6th Edition. W.B. Saunders Company. 1999. p.55-56.

BOARD FAVORITE!

Classification: Neurobiology, Pharmacology, Receptor Actions

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• Hexamethonium blocks which receptor?A. MuscarinicB. NicotinicC. Glycine D. Glutamate

NeurobiologyQ?

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NeurobiologyA.• The correct answer is B, nicotinic receptor.• Hexamethonium is a nicotinic Ach receptor antagonist, acts by preventing

acetylcholine from binding to the cholinergic receptor.• It has no effect on the muscarinic acetylcholine receptors, or mAChRs.

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science, 4th ed. McGraw-Hill, New York. 2000. p. 971.

BOARD FAVORITE!

Classification: Neurobiology, Pharmacology, Receptor Actions

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• A 37 year-old male presented with generalized seizure and expressive dysphasia. MRI is shown. Reoccurrence of this tumor as a high-grade is LEAST likely due to which genetic abnormality?

NeurobiologyQ?

A. P53 tumor suppressorB. Retinoblastoma geneC. Amplification of platelet

derived growth factorD. Amplification of epidermal

growth factor receptor

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NeurobiologyA.• The correct answer is D, amplification of epidermal growth factor receptor.• This MRI demonstrates a low-grade glioma. Recurrent progressive low-grade glioma is

associated with mutations in the tumor suppressor gene p53 with amplification of CDK4 or loss of Rb and amplification or overexpression of PDGF.

• There are 2 subtypes of glioblastoma– Older patients with de novo tumors

• Deletions in cell cycle related INK4a-ARF genes p16INK4A and p19/p14ARF• EGFR amplifications

– Younger patients with progressive low grade glioma• Mutations in the tumor suppressor gene p53 with amplification of CDK4 or loss of

Rb• Amplification or overexpression of PDGF

Berger MS, Pardos M,Textbook of Neuro-Oncology. Saunders, Philadelphia. 2005. p. 608-9.

BOARD FAVORITE!

Classification: Neurobiology, Genetics, Tumor Growth Factors

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• Match the following sensory receptors with their description. 1. Meissner capsule2. Merkel receptors3. Free nerve endings4. Ruffini corpuscles5. Pacinian corpuscles

NeurobiologyQ?

A. Rapidly adaptive, vibration, receptors B. Slowly adaptive, touch and pressure, receptorC. Slowly adaptive, heavy pressure, receptorD. Rapidly adaptive, touch, receptors E. Pain receptors

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NeurobiologyA.• The correct answers are….• To obtain the answer to this question and to view over 250 more comprehensive neurobiology

questions please purchase the full product here !

Guyton, Arthur C., John E. Hall. Textbook of medical physiology. W.B. Saunders Company; 10th edition, 2000. p. 521, 530-2

Ruffini and Merkel drink TONIC SLOWLY! (slowly adapting tonic receptors)

R M

BOARD FAVORITE!

Classification: Neurobiology, Neurophysiology, Touch Receptors