Neuroanatomy for psychiatrists
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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

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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


The last supper

THE LAST SUPPER


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


The lobes

The Lobes


Job allocation

Job Allocation


Division of labour

Division of Labour


Lobe function

Lobe Function


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


Neuroanatomy for psychiatrists

Conscious pain, temperature, crude touch & pressure

Lateral and an anterior tract

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


Neuroanatomy for psychiatrists

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


Neuroanatomy for psychiatrists

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


Neuroanatomy for psychiatrists

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


Basal ganglia and limbic system

Basal Ganglia and Limbic System


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


Papez circuit

Papez Circuit


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


Dopamine pathways

Dopamine Pathways

HT

VTA


Serotonin pathways

Serotonin Pathways


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


Serotonin and depression1

Serotonin and Depression


Serotonin and schizophrenia

Serotonin and 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


Some corrections

SOME CORRECTIONS

  • EMI -2


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