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Neuroanatomy for Psychiatrists. Dr Rohit Shankar MBBS, MD, MRCPsych, CCT, PGC Cl. Research Consultant in Adult Developmental Neuropsychiatry. Why should we know any Neurology?. Brain Behaviour connection Man made divide 2000 years of togetherness

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neuroanatomy for psychiatrists

Neuroanatomy for Psychiatrists

Dr Rohit Shankar

MBBS, MD, MRCPsych, CCT, PGC Cl. Research

Consultant in Adult Developmental Neuropsychiatry

why should we know any neurology
Why should we know any Neurology?
  • Brain Behaviour connection
  • Man made divide
  • 2000 years of togetherness
  • Hippocrates (460-377BC) Humours theory and Triad of mental illness
  • Plato – divine inspired and physical inspired mental illness
  • Inter canon of the yellow emperor
  • Johann Christian Reil 1808
  • Reintegration – biological underpinnings
golden rules
Golden Rules
  • Adhere to the routine
  • A good History is more useful than a good examination
  • Usually well practiced testing would take 20 minutes then come back to any areas of deficits
  • Don’t ‘Scan’ before you ‘Can’ physically examine
  • Hoof beats are usually more likely to be from horses as opposed to Zebras, Hemiparesis is more likely from a stroke as opposed to an unwitnessed seizure
the neurological exam
The Neurological Exam

Motor System –

Limb strength

spasticity, flaccidity and fasciculation

Abnormal movements – e.g.. Chorea and tremors

Reflexes –

DTRs – biceps, triceps, Quadriceps, Achilles

Pathological reflexes – Babinski, frontal release signs

Sensation –

Position, vibration, stereognosis, Pain

Cerebellar –

Finger – Nose, Heel – Toe, Rapid alternating movements, Gait

the neurological exam1
The Neurological Exam

Mental Status –

GCS, orientation, Language, higher intellectual functions (arithmetic)

Cranial Nerves –

I Smell

II Visual acuity, visual field, optic fundi

Ocular motility nerves:

III,IV,VI pupil size and reactivity, extra ocular motion

cerebello-pontine angle nerves:

V corneal reflex and facial sensation

VII upper and lower facial muscle strength, taste

VIII hearing

Others:

IX - XI articulation, palate movement, gag reflex

XII tongue movements

details lie in beholder s observations
DETAILS LIE IN BEHOLDER’S OBSERVATIONS!

Detail of the Da Vinci\'s The Last Supper by Giacomo Raffaelli

diagnostic pathway
Diagnostic Pathway

Be Ritualistic

The formulation:

Symptoms, Signs, Localization and Diagnosis

Localization:

Where is the lesion?

CNS, PNS or Muscles

What is the lesion?

Diffuse or Discrete

Diagnosis:

Common conditions arise commonly –

Hoof beats are usually more likely to be from horses as opposed to Zebras

Hemiparesis is more likely from a stroke as opposed to an unwitnessed seizure

frontal lobe dysfunction
Frontal Lobe Dysfunction
  • The primary motor cortex

Contra lateral motor control

  • The medial frontal cortex

Arousal and motivation – Abulic (Apathy & inattention)

  • The orbital frontal cortex

Modulate Behaviour -Labile, euphoric, facetious, vulgar

  • The left postero-inferior frontal cortex (Broca\'s)

Language – expressive Aphasia

  • The dorsolateral frontal cortex

Working memory & dysexecutive syndrome

parietal lobe dysfunction
Parietal Lobe Dysfunction
  • The primary somatosensory cortex

Integrates somesthetic stimuli for recognition and recall of form, texture, and weight - Contralateral astereognosis

  • Posterolateral - Postcentral gyrus

visual-spatial relationships and proprioception

  • Midparietal lobe (dominant)

calculation, writing, left-right orientation, and finger recognition - Gerstmann\'s syndrome

  • The nondominant parietal lobe

Contralateral environmental awareness, drawing – Anosognosia, Hemiasomatognosia, spatial Apraxia

temporal lobe dysfunction
Temporal Lobe Dysfunction
  • Auditory perception, receptive components of language, visual memory, declarative (factual) memory, and emotion
  • Right temporal lobe lesions - interpret nonverbal auditory stimuli (e.g. music)
  • Left temporal lobe lesions interfere greatly with the recognition, memory, and formation of language
  • medial limbic - emotional parts & TLE
occipital lobe dysfunction
Occipital Lobe Dysfunction
  • Primary visual cortex and visual association areas
  • Anton Babinski Syndrome
  • Occipital Seizures – C/L Visual Hallucination
  • Prosopagnosia - Face blindness
slide19

Conscious pain, temperature, crude touch & pressure

Lateral and an anterior tract

Thalamus (all conscious sensations) projection to areas of the cerebral cortex

slide20

This tract carries unconscious proprioception (muscle sense) to the cerebellum which is responsible for muscle coordinationThey innervate the cerebellum on the same side

slide21

Corticospinal tract cerebral cortex – Localised voluntary motor controlTwo branches, the lateral and the anterior The lateral crosses in the medulla at the ‘pyramids’ The anterior does not crossCommon signs: DTR abnormalities, Motor Paresis, Babinski

the basal ganglia
The Basal Ganglia
  • Located Sub cortically
  • Modulates the Corticospinal tract
  • Regulates muscle tone, motor activity and generates postural reflex
  • Confined to the brain, no role on LMNs or Spinal Cord
  • Caudate Nucleus, Corpus Striatum, Lentiform Nucleus (Globus Pallidus + Putamen), Subthalamic Nuclei, Substantia Nigra
slide23

IC (white matter) runs between the CN and the LN = Corpus Striatum

Artery of Stroke

Pure damage to Basal Ganglia = No corticospinal symptoms, No neuropsychological dysfunction, No cognitive Dysfunction, contra lateral

Result of biochemical not usually structural, B/L, slow progress

Cerebrum + BG = inv Mov + cognitive &/or psychiatric Sx

hippocampal formation amygdala
Hippocampal Formation & Amygdala
  • Hippocampal Formation

Dentate gyrus + the hippocampus proper + Subiculum

Memory, spatial navigation and attention

  • Amygdala

Via hypothalamus activates the ANS

Activation of Neurotransmitters

Emotional Learning – Conditioning

Memory modulation

Kluver Bucy Syndrome – Docility: diminished fear responses, dietary changes, Hyperorality, Hypersexuality, Visual Agnosia, Hypermetamorphosis: irresistible impulse to notice and react to everything, memory loss

function of the limbic system
Function of the Limbic System
  • Affective functions
  • Playful moods
  • Emotions and feelings, like wrath, fright, passion, love, hate, joy and sadness
  • self preservation
serotonin and depression
Serotonin and Depression
  • Serotonin transmission - Caudal raphe nuclei and Rostal raphe nuclei is reduced in depression
  • Increasing the levels of serotonin in these pathways, by reducing serotonin reuptake = treatment
serotonin in schizophrenia
Serotonin in Schizophrenia
  • Dorsal raphe nuclei - Substantia Nigra
  • Rostral raphe nuclei - cerebral cortex, limbic regions and basal ganglia
  • The up-regulation of Serotonin pathways leads to the hypofunction dopamine pathways = negative symptoms
  • The serotonergic nuclei in the brainstem that give rise to descending serotonergic axons remain unaffected in schizophrenia
brain stem
Brain Stem
  • Brain Stem: Midbrain, Pons, Medulla
  • Contains CNs, CS Tract and other ‘long’ Tracts
  • Positive evidence of localization and negative evidence of cerebral injury
  • Example – Diplopic but no effect on visual acuity or fields
  • Brain stem injures -Massive infarcts, Overdoses etc
  • Simultaneous damage of BS and Cerebrum RARE exceptions: MS, tumours etc
cerebellum
Cerebellum
  • Controls the coordination of movements/limbs – Ipsilateral
  • Muscle Hypotonia and Pendular DTRs
  • No obvious cognitive role
  • Intentional Tremor
  • Gait Ataxia, Scanning speech, tandem gait failure
  • Cognitive Impairment?
  • Alcohol – Thiamine, AIDS, toxins, Vitamin E, Phenytoin
psychiatry and neurology
Psychiatry and Neurology
  • Psychogenic Paresis and Hoover’s Sign
  • La Belle Indifference
  • MS
  • Sleep Disorders
  • Parkinsonism, Huntington, Wilson’s disease
  • Frontal Lobe issues, Dementia
  • Seizures of Non epileptic origin and NEADs, Sensory seizures
case study 1
CASE STUDY 1
  • An elderly man has left ptosis and a dilated and unreactive left pupil with external deviation of the left eye, right hemiparesis, right sided hyperactive DTRs and positive Babinski, no aphasia or hemianopia where is the lesion?
  • Cerebrum
  • Cerebellum
  • Pons
  • Midbrain
  • Medulla
  • None of the above
case study 2
CASE STUDY 2
  • A 20 year old woman reports having lost all vision in her right eye and right hemi-sensory loss. Pupil and DTRs are normal. She does not press down with her left leg while attempting to lift her right leg. where is the lesion?
  • Cerebrum
  • Cerebellum
  • Pons
  • Midbrain
  • Medulla
  • None of the above
case study 3
CASE STUDY 3
  • 50 yr old man with mild dementia has absent reflexes, loss of position and vibration sense and ataxia. Which areas are affected?
  • The CNS
  • The CNS and the PNS
  • The Cerebrum and the posterior columns
  • The ANS
case study 4
CASE STUDY 4
  • After having suffered from increasing severe depression for 3 years the psychiatrist finds the 55 year old woman to have right sided optic atrophy and left sided papilledema. Where is the lesion?
  • Occipital Lobe
  • Frontal Lobe
  • Parietal Lobe
  • Temporal Lobe
  • None of the above
question
QUESTION
  • Where is the primary damage in Wilson\'s disease, Huntington\'s Chorea and Choreiform Cerebral Palsy?
  • Extra pyramidal system
  • Pyramidal system
  • Entire CNS
  • Cerebellar outflow tracts
  • None of the above
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