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MRCPsych Part A > Clinical Examination > Flashcards

Clinical Examination Flashcards

1
Q

Concepts to approach threatening topics

A

Normalizing questions
Symptom expectation and reduction of guilt
Symptom exaggeration
Familiar language when asking about behaviours

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2
Q

Purpose of normalizing questions?

A

Decrease patients embarrassment about feeling or behaviour

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3
Q

Purpose of symptom expectation?

A

Defuse admission of embarrassing behaviour

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4
Q

Purpose of symptom exaggeration?

A

Determine actual frequency of sensitive or shameful behaviour

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5
Q

Techniques to change topics?

A

Smooth transitions
Referred transitions
Introduced transitions

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6
Q

When to use smooth transitions?

A

To hint at something the patient just said

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7
Q

When to use referred transitions?

A

Hint at something mentioned earlier

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8
Q

When to use introduced transitions?

A

To pull a new topic from thin air

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9
Q

What are directive techniques?

A

Focused on seeking a particular answer or driven by motives of doctor.

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10
Q

Give e.g. of limit setting

A

I am going to interrupt you as there are a few things to cover.

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11
Q

Name some directive techniques

A 
Limit setting
Closed questions
Question rephrasing
Redirection
Transition
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12
Q

Describe confrontation

A

Point out to a patient something which the doctor thinks the patient is missing or denying

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13
Q

Give e.g. of suggestive question

A

These voices are not from your head. Am I right?

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14
Q

What is functional analysis?

A

Attempts to explain and predict functions of a phenomenon by examining any relationships to the outcome.

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15
Q

What medical intervention can confirm a panic disorder?

A

Lactate provocation
Hyperventilation
CO2 inhalation

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16
Q

What inhibits panic attacks triggered by sodium lactate?

A

Benzos

TCAs

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17
Q

In which psychiatric diagnosis is infusion of amobarital (narcoanalysis) helpful?

A 
Catatonia
Stupor
Muteness
Repression
Dissociation
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18
Q

What happens to organic conditions when infused of amobarbital?

A

They worsen

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19
Q

Why do non-organic conditions get better with infusion of amo-barbital?

A

Due to disinhibition, decreased anxiety or increased relaxation

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20
Q

What can be substituted for amo-barbital?

A

Benzos

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21
Q

Investigations for suspected encephalitis syndrome

A

NMDA receptor and voltage-gated K+ channel receptor auto-antibodies (IgG0

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22
Q

Investigations for porphyria

A

Spot urine sample for porphobilinogen during acute attack and 24 hour urine for porphyrins, porphobilinogen and delta-aminolevulinic acid

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23
Q

Investigations for Wilsons Disease

A

Serum ceruloplasmin

24 hour copper excretion test

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24
Q

Investigations for lysosomal storage disease

A

Skin biopsy
Genetic tests
Detection of serum alpha-galactosidase enzyme

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25
Investigations for Homocystinuria?
Homocysteine in urine and blood | Molecular genetic testing
26
Investigations for metachromatic leukodystrophy
Arylsulfate A enzyme activity in WCCs or in cultured skin fibroblasts
27
Investigations in malnourishment
``` Serum homocystine and folate Vitamin B12 Niacin Trytophan Nicotinamide adenine Dinucleotide (NAD) and NADP ```
28
Difference between AIP and porphyria?
AIP does not present with rash
29
Onset of porphyria
18-40 years of age
30
What triggers AIP?
Oestrogens Barbituates Benzos Diclofenac
31
Treatment for AIP
Haemin - reduces haem synthesis
32
important receptors involved in autoimmune encephalitis
``` Voltage gated K+ channel complex - LGI1, CASPR2, contactin-2 NMDA AMPA receptor GABA-B Glycine receptor ```
33
How do anti-NMDA receptor antibodies work?
Titre-dependent destruction of synaptic NMDAR through crosslinking and internalisation
34
Gender variability in anti NMDAR encephalitis?
80% are female | 50% of women with it have underlying ovarian teratoma
35
How does psychosis with anti NMDAR first present usually?
Fever, headache, malaise
36
EEG in anti-NMDAR encephalitis?
Disorganized delta/theta activity
37
What to look for in MRI in anti-NMDAR encephalitis?
Medial temporal hyperintensity in hippocampi, frontobasal and insular regions in basal ganglia
38
How to confirm anti-NMDAR encephalitis?
CSF: lymphocytic pleocytosis, elevated protein and oligloclonal bands in 60%, anti-NMDAR antibodies.
39
Treatment of anti-NMDAR encephalitis
3 days of methylprednisolone PO/IV followed by PO prednisolone in association with 5 days of plasma exchange
40
Why must you not give antipsychotics in anti-NMDAR encephalitis?
Dystonic reactions and NMS-like syndrome can occur
41
What type of thyroid problem can cause cognitive impairment?
Low T4
42
When would EEG be required to diagnose dementia?
Rapid onset; may suggest CJD. | Need EEG and MRI
43
TFTs in patients with anorexia
Low T3 Low normal range T4 Normal TSH (low T3 syndrome)
44
GI effects of anorexia
Delayed gastric emptying Decreased colonic motility - secondary to chronic laxative misuse Acute gastric dilatation - rare, secondary to binge eating
45
Haematological signs of anorexia
Moderate normocytic anaemia Mild leucopenia with relative lymphocytosis Thrombocytopenia
46
Electrolyte result of laxative misuse
Metabolic acidosis Hyponatraemia Hypokalaemia
47
Brain abnormalities resulting in anorexia
Enlarged cerebral ventricles and external CSF spaces (pseudo atrophy)
48
BMI for obesity
30 or greater
49
Most specific and sensitive test for detecting heavy alcohol use over 10 days
Carbohydrate deficiency test
50
What is Marchiafava syndrome?
Corpus callosum damage often due to alcohol misuse
51
Normal QTc for men
440ms
52
Normal QTc for women
470ms
53
Which recreational drugs increase risk of QTc prolongation?
Stimulants
54
Method of testing drug use aside from urine
Specific gravity in urine
55
How long is alcohol present in urine?
Up to 12 hours
56
How long is amphetamine present in urine?
Up to 48 hours
57
How long is benzo present in urine?
3 days depending on half life
58
How long does cannabis last in urine if occasional use?
Up to 3 days
59
How long does cannabis last in urine if high daily use?
Up to 4 weeks
60
How long does cocaine last in urine?
6-8 hours
61
How long does cocaine metabolite last in urine?
2-4 days
62
How long does codeine stay in urine?
48 hours
63
How long does heroin last in urine?
1-3 days
64
How long does methadone stay in urine?
3 days or more
65
How long does morphine last in urine?
2-3 days
66
How long does PCP stay in urine?
8 days
67
Which recreational drugs are associated with renal disease?
Cocaine | Heroin
68
Common renal dysfunction in black patients with drug misuse
Segmental glomerulosclerosis
69
Common renal dysfunction in white patients
Membranoproliferative glomerulonephritis
70
Plasma and urine osmolality in diabetes insipidues
Plasma: High (>295) Urine: low
71
Plasma and urine osmolalities in psychogenic polydipsia?
Plasma: Low (<280) Urine: Low
72
Plasma and urine osmolalities in SIADH
Plasma: low Urine: high
73
At what Na level do symptoms of hyponatraemia occur?
Na <125
74
At what Na level can seizures and irreversible brain damage occur?
Below 110-115
75
Most common cause of Argyll-Robertson pupil
Diabetes
76
What is checker-board abdomen?
Multiple surgical scars in factitious disease
77
In which drug misuse is piloerection seen?
Opiate withdrawl
78
How can one rate Minor Physical anomalies?
Lane Scale
79
In what type of patients are Minor Physical Anomalies noted?
Developmental disorders
80
Which tuning fork is used to test auditory function?
512Hz
81
Which tuning fork is used to test peripheral neuropathy?
128 Hc
82
What type of diseases result in a positive Romberg test?
Polyneuropathies | Disease of dorsal column
83
Normal caloric testing result
On cold water testing, nystagmus noted to opposite side. | On warm water, nystagmus to same side
84
What are hard neurological signs?
Imapirments of basic motor and sensory functions that are localisable to pyramidal, extrapyramidal or cranial nerve systems.
85
what are neurological soft signs?
Non-localisable neurological findings thought to reflect neurodevelopmental aberrations when seen in psychiatric disorders.
86
Three groups of soft signs
Abnormalities of motor coordination, sensory integration and signs of cortical disinhibition
87
Signs of midline cerebellar dysfunction
Ataxic gait Difficulty in maintaining upright posture Truncal ataxia
88
What is the neocerebeullum?
Lateral cerebellar hemispheres
89
What does neocerebeullum control?
Movement of ipsilateral limb
90
What is the midline vermis involved in?
Control of truncal tone, speech and eye movements
91
What is the archicerebeullum?
Flocculonodular lobe
92
What does flocculonodular lobe do?
Vestibular functions
93
What part of the cerebellum controls vestibular functions?
Archicerebellum/flocculonodular lobe
94
How to test for ataxia
Tandem gait
95
Which type of tremor accelerates in pace on approaching the target
Intention tremor
96
What is dyssynergia?
Incoordination
97
What is dysmetria?
Past pointing
98
What is dysrhythmia?
Inability to tap and keep to a rhythm
99
What is dysarthria a sign of?
Diffuse involvement of cerebellum
100
What is the Brudzinski sign?
Flexion of hips and knees when you try to flex the neck
101
What is Kernigs sign?
Flexing one hip and knee and then extending knee with hip still flexed. If opposite knee flexes, this test is positive
102
What is another name of the straight-leg raising test?
Lasegue
103
Describe the straight leg raising sign
Passively flexing hip with knees straight while patient is in supine position. Limitation of flexion due to hamstring spasm or pain indicates local irritation of lower lumbar nerve roots
104
Describe reverse straight leg raise sign
Passively hyperextending hip with knees straight while prone; limitation of extension due to spasm or pain in anterior thigh muscle indicates local irritation of upper lumbar nerve roots
105
Functions of cortical sensory system
``` Kinaesthetic sensation Stereognosis Graphesthesia Tactile localization Tactile 2 point discrimination on both sides of body ```
106
Which type of fibrillations are visible?
TOngue
107
Describe myoclonus
Brief <0.25 second muscle jerk, generalized.
108
What is myoclonus associated with
Generalized epilepsy CJD Severe Alzheimers
109
What is athetosis
Slow writhing spasms along long axis of limbs or body itself.
110
What is chorea
Quasi-purposeful movements affecting multiple joints with distal preponderance.
111
What lesion is chorea associated with?
Caudate
112
What is hemiballismus?
Violent flinging of half of body
113
What area of the brain is hemiballismus associated with?
Lesion of subthalamic nucleus
114
Give examples of primary reflexes
``` Glabellar tap Rooting Snout Sucking Palmomental ```
115
What are primary reflexes?
Absent in adults
116
What does primary reflex in adult suggest?
Possible frontal lobe damage
117
What are superficial reflexes?
Responses that indicate integrity of cutaneous innervation and corresponding motor outflow
118
What are the superficial reflexes?
Corneal and conjunctival Abdominal Cremasteric Plantar
119
What controls corneal and conjunctival reflexes?
Afferent: 5th nerve Efferent: 7th nerve
120
What is the abdominal reflex/
Drawing line away from umbilicus in diagonals of 4 abdominal quadrants. Normal reflex draws umbilicus towards direction of line.
121
Describe cremasteric reflex
Scratching medial surface of thigh to elicit scrotal contraction or lift. Normal: elevation of ipsilateral testis.
122
What does lack of both positive and negative Babinski sign suggest?
Absence of cutaneous innervation in S1 or loss of motor innervation in L5
123
What is required for a deep tendon reflex?
Intact cutaneous innervation Motor supply Cortical input to corresponding spinal segment
124
Spinal roots of biceps reflex
C5, C6
125
Spinal roots of brachoradialis reflex
C6
126
Spinal roots of triceps reflex
C7
127
Spinal roots of patellar reflex
L2-L4
128
Spinal roots of Achilles reflex
S4
129
What type of lesion is a pseudobulbar palsy?
UMN lesion
130
What type of lesion is exaggerated jaw jerk?
UMN lesion
131
What type of lesion is bulbar palsy?
LMN
132
Which disease is frontal baldness associated with?
Myotonic dystrophy
133
Neurocutaneous signs of Tuberous Sclerosis
Dermatomal eruptions Ash leaf macules Ungual fibromas Café au lait spots
134
Neurocutaneous signs of Neurofibroma
café au lait spots | Axillary freckling
135
Describe spastic dysarthria
Strained, hoarse voice Hypernasality Slow, imprecise articulation
136
Cause of spastic dysarthria
Bilateral UMN lesions
137
Cause of flaccid dysarthria
LMN | XII nerve involved if tongue is small due to loss of tone
138
Cause of ataxic dysarthria
Cerebellar
139
What is ataxic dysarthria?
Excess loudness, tremor and irregular articulatory breakdowns (scanning speech)
140
What is hypokinetic dysarthria
Breathy monotone voice with reduced loudness and articulation leads it to be accelerated and imprecise
141
Damage leading to hypokinetic dysarthria?
Motor control circuit
142
Which type of speech is associated with basal ganglia damage?
Hyperkinetic dysarthria
143
Describe hyperkinetic dysarthria
Strained hoarseness and voice arrests
144
Describe mixed dysarthria
Similar to spastic, accompanied by wet sounding voice with rapid tremor, poor laryngeal and tongue movements and poor control of lips
145
What results in mixed dysarthria?
Damage to more than one motor control system
146
What happens in hysterical aphonia?
Sudden loss of voice but preserved vocal cord activity | Normal examination
147
What type of dysarthria results from bilateral UMN lesions
Spastic
148
What type of dysarthria results from LMN lesion?
Flaccid
149
What type of dysarthria results from motor control circuit?
Hypokinetic
150
What type of dysarthria results from multiple motor system damage?
Mixed
151
What disorder leads to hemiparetic gait?
Stroke affecting pyramidal system
152
How does hemiparetic gait present?
Clenched hand with extended knee and plantarflexed ankle. | Makes paralyzed leg appear longed than other. Results in circumduction of affected leg when walking.
153
What results in patient veering to one side with ataxic gait?
Unilateral cerebellar lesion - patient veers to side of lesion
154
What causes steppage gait
Chronic peripheral neuropathies e.g. drop foot and dorsal column disorders
155
What compensation occurs in proximal myopathy resulting in waddling gait
Forward curvature of lumbar spine adds to body swing.
156
What diseases result in waddling gait?
Proximal myopathy Congenital hip dislocation Near term pregnant women
157
What disease causes scissoring gait?
Spastic paraplegia
158
How does scissoring gait present?
Marked rigidity and excessive adduction of swinging leg together with plantar flexion of ankle and flexion at knee due to contractures of all spastic muscles leads to forced tip-toe walking with knees rubbing together and crossing like scissors.
159
What condition caused gait apraxia/magnetic gait?
Hydrocephalus
160
Conditions causing high stepping gait due to foot drop?
Neuropathic Polio Peripheral lesions in MS
161
What type of gait occurs in Huntingtons?
Lurching, chaotic gait
162
What conditions lead to pigeon gait?
Torsional abnormalities seen in hip dysplasia
163
What gait occurs with Carbon monoxide poisoning?
Propulsive
164
What conditions cause stiff, scissoring gait?
UMN lesions Cerebral lesions Cortical lesions in MS Stroke
165
What conditions cause stomping gait?
Friedreich's ataxia Pernicious anaemia Tabes Dorsalis (Syphilis)
166
What causes Trendelenburg gait?
Weakness of abductor muscles of lower limb, mainly gluteus medius
167
Conditions causing absent ankle jerks and upgoing plantars?
Subacute combined degernation cord Syphilitic taboparesis Friedrich's ataxia MND
168
Underlying pathology causing absent ankle jerks and upgoing plantars
Absence of absence jerk as spinal reflex pathway is affected (afferent) while UMN type damage still produces Babinski
169
What is anisocoria?
Pupil asymmetry
170
Which type of nervous system deficit leads to tonic pupil?
Parasympathetic dysfunction
171
What is Argyll-Robertson pupil?
Irregular and small | Doesn't react to light but does accommate
172
Damage leading to anosognosia
Right frontoparietal lesions resulting in left hemiplegia that patient denies
173
What is Beevor sign?
Upward deviation of umbilicus when patient tries to raise head and sit up from supine position
174
When is Beevor sign seen?
Bilateral lower abominal paralysis
175
Signs of lateral corticospinal damage
Ipsilateral spastic paralysis below level of lesionn Babinski sign ipsilateral to lesion UMN type hyper-reflexia
176
Signs of posterior column damage
Ipsilateral loss of tactile discrimination, vibratory and position sensation below level of lesion
177
Signs of lateral spinothalamic damage
Contralateral loss of pain and temperature sensation, usually 2-3 segments below level of lesion
178
Describe Chvoestek sign
Tapping cheek at angle of jaw precipitates tetanic facial contractions
179
What does Chvoestek sign occur?
Hypocalcaemia
180
Describe Doll's eye maneuver?
Turning head passively with patient awake and fixated or patient in coma.
181
Result of Doll's eye maneuver in awake patient?
Eyes remain fixated at original focus when all gaze pathways normal
182
Result of Doll's eye maneuver in coma?
Eyes deviate in opposite direction with brainstem intact
183
What type of disease is Friedreich's ataxia?
Trinucleotide repeat
184
Signs in Friedreich's ataxia?
``` Pes cavus Kyphoscoliosis Cerebellar signs Impaired joint position/vibration Cardiomyopathy Optic atrophy ```
185
What is seen in Holmes Adie syndrome?
Benign tonic pupil | Absent patellar and achilles reflexes
186
Signs in Horner's syndrome
``` Ptosis Anhidrosis Miosis Enophtholmos Loss of cilospinal reflex ```
187
Describe Marcus Gunn pupil
Abnormal pupil dilates as light swings back from normal side.
188
Pathology underlying Marcus Gunn pupil
Afferent (optic nerve) pupillary defect
189
Describe mononeuritis multiplex
Painful asymmetric asynchronous sensory and motor peripheral neuropathy with isolated damage to at least 2 separate nerve areas
190
Causes of mononeuritis multiplex
``` Diabetes Vasculitis Amyloidosis Direct tumour involvement Autoimmune disorders Paraneoplastic ```
191
What is milkmaid's grip
Inability to maintain sustained grip
192
What pathology does Milkmaids grip occur in
Chorea
193
What is Myerson sign?
Continuing to blink with repeated glabellar taps
194
In which diseases does Myerson sign occur
Parkinsons, particularly those with bilateral frontal lobe dysfunction
195
Triad of optic neuritis
``` Loss of vision Eye pain Dyschromatopsia (70% unilateral) Spontaneous recovery ```
196
Describe Uhthoff symptom
Exercise/heat-induced vision loss - MS
197
Cause of subacute combined degeneratio
Vitamin B12 deficiency
198
Signs of subacute combined degeneration
Peripheral neuropathy | Posterior column signs with pyramidal signs below wait
199
Which types of patients show trombone tongue?
Patients with chorea
200
What is trombone tongue?
Unsteadiness of tongue when patient tries to protrude it outside mouth
201
Signs of UMN lesion
Rigidity Hypertonia Exaggerated reflexes Mild atrophy
202
Signs of LMN lesion
Atonia/hypotonia Loss of deep tendon reflexes Atrophic, wasted Fasciculations
203
Cause of bulbar palsy
LMN weakness of CN 9-12
204
Cause of pseudobulbar palsy
Bilateral supranuclear (UM) lesions of lower CN
205
Signs of Bulbar palsy
Wasted, fasciculating tongue Nasal speech Loss of jaw jerk and gag reflex
206
Diseases in Bulbar palsy
``` MND Polio Botutilism Myasthenia Gravis Muscular dystrophies ```
207
Signs of pseudobulbar palsy
Stiff tongue - wasting only in later stages Donald-duck speech Exaggerated jaw jerk, preserved gag reflex Emotional lability
208
Diseases in pseudobulbar palsy
MND MS Multiinfarch dementa Severe HI
209
In which type of lesion is there Donald Duck speech?
UMN
210
In which type of lesion is there loss of jaw jerk and gag reflex?
LMN
211
Who created the MMSE?
Folstein, 1976
212
How many points in MMSE
30
213
Cut off for dementia in MMSE
23/24 | 21/22 if less than 9 years formal education
214
What is MMSE insensitive to
Early decline
215
What does MMSE not pick up
Frontal executive defects
216
Items in MMSE
``` Orientation (10) Registration (3) and recall (3) Attention (5) Multistep command (3) Naming (2) Repetition language (1) Reading comprehension (1) Writing (1) Visual construction (1) ```
217
What does clock drawing test require
Verbal understanding Short-term memory Spatially coded knowledge Constructive skills and planning - executive function
218
Which subjects perform poorly in clock drawing test?
Low education Advanced age Depression
219
What can normal clock drawing ability reasonably exclude?
Cognitive impairment
220
Who created the Clock drawing test?
Watson
221
What is the clock drawing test scored out of?
7
222
Normal score for clock drawing test
0-3
223
How many digits is deemed to be correct in clock drawing test
Placing of any three digits in a quadrant
224
What does Addenbrookes test
``` Orientation Attention Memory Verbal fluency Language Visuospatial ability ```
225
What test helps to differentiate subtypes of dementia?
Addenbrookes
226
Cut off for dementia in Addenbrookes
82
227
Major area of scoring in Addenbrookes
Language
228
What determines CT image contrast?
Degree to which tissues absorb x-rays
229
Which structures are likely to be obscured in CT?
Those close to bone e.g. brainstem
230
Plane of rotation of CT?
One - axial
231
How can one visualise tumours and inflammation in CT?
Infusion of iodine-containing contrast agents; once in vascular compartments, iodinated compounds absorb more irradiation than brain tissue
232
What area of the brain does CT have poor visualization capacity for
Posterior fossa
233
What are MRI magnets rated in
Tesla units of magnetic field strength
234
What happens when atoms are placed in a magnetic field
Axes of all odd-numbered nuclei (i.e. H1) align with magnetic field This axis deviates away from magnetic field when exposed to pulse of radiofrequency electromagnetic radiation oriented at 90 or 180 degrees to magnetic field. When pulse terminates, axis of spinning nucleus realigns itself with magnetic field and emits its own radiofrequency signal. This is collected by MRI scanners
235
Planes of MRI
Axial Coronal Sagittal
236
What affects the realignment of H1 axis?
Immediate environment and degree of water content
237
Difference between hydrogen in fat and wat
Fat: realign rapidly Water: realign slowly
238
Describe pulses in T1 images
Brief
239
What is emphasised in T1 images?
Hydrophobic environments - i.e. fat is bright, CSF is dark
240
In which type of MRI is CSF dark?
T1
241
Which type of MRi scan closely resembles CT?
T1
242
Which MRI scan allows contrast enhancement with contrast agent gadolinium-DTPA?
T1 - these appear white
243
Pulses in T2
Four times as long as T1
244
What images are emphasised in T2?
Signal from hydrophilic areas - brain tissue is dark, CSF is whtie
245
What is revealed in T2 images?
Brain tissue with abnormally high water content - tumours, inflammation, strokes
246
What is protein density sequence in MRI helpful for?
Periventricular structures
247
What is fluid attenuated inversion recovery (FLAIR) in MRI?
When T1 image is inverted and added to T2 image to double contrast between gray and white matter
248
What is FLAIR in MRI images helpful for?
Detecting sclerosis of huppocampus caused by temporal lobe epilepsy Localizing areas of abnormal metabolism in degenerative neurological disorders
249
When are MRI scans contra-indicated?
PPM | Implants of ferromagnetic metals
250
Radiation in MRI?
None
251
Which scan has good sensitivity to early ischaemia?
MRI
252
How does infarct appear in T2 image?
Bright
253
How does infarct appear in T1 image?
Dark
254
How does infarct appear in CT?
Infarct
255
How does haemorrhage apear in T2?
Bright
256
How does haemorrhage appear in T1?
Bright
257
How do tumours appear in T2?
Bright
258
How do tumours appear in T1?
Dark
259
How do tumours appear in CT?
Dark
260
How does bone appear in T2?
Dark
261
How does bone appear in T1?
Bright
262
How does air appear in T2?
Dark
263
How does air appear in T1?
Dark
264
How does fat appear in T2?
Bright
265
How does fat appear in T1?
Bright
266
How does fat appear in CT?
Dark
267
How does white matter appear in T1?
White
268
What can MR spectroscopy detect?
Several biologically important nuclei with odd number of protons and neutrons
269
What is H1 proton spectroscopy useful for?
To quantify N-acetyl aspartate, creatinine and choline-containing molecules
270
What cannot be detected with MRS
Dopamine
271
What can phosphorus-31 MRS determine
pH of brain regions and concentrations of phosphorus-containing compounds i.e. metabolic activity of brain
272
Other indications of MRS
Measure concentration of psychotherapeutic drugs such as lithium, fluoxetine and trifluoperazine which contain fluorine-19
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What is blood oxygen level dependent technique?
Neuronal activity = local increase in o2 consumption, so local conc of deoxyhaemoglobin increases relative to oxyhaemoglobin. Oxyhaemoglobin is diamagnetic (weak magnetic contrast) Deoxyhaemoglobin is paramegnetic, producing MR signal detected in T2.
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What is fMRI based on?
Blood oxygen level dependent technique
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What is fMRI a measure of?
Proxy measure of tissue activity that depends on relative changes in perfusion
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Advantage of fMRI over PET and SPECT
No radioactive isotopes used
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Structures studied in resting fMRI
Brain regions with high levels of activity during rest: precuneus, lateral parietal regions and medial prefrontal cortex
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What are brain networks that show higher baseline activity at rest in fMRI called?
Default mode network
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What does SPECT stand for?
Single Photon Emission Computed Tomography
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How does SPECT work?
Uses radioactive compounds to study regional differences in cerebral blood flow in brain. This records patterns of photon emission from bloodstream which varies according to level of perfusion
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What does SPECT use?
Compounds labeled with single photon-emitting isotopes
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Name the three isotopes used in SPECT
Iodine-123 Technetium-99m Xenon-133
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What type of SPECT is referred to as the cerebral blood flow technique?
Xenon-SPECT
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How does Xenon-133 work in SPECT?
Enters blood quickly and is distributed to areas of the brain as a function of regional blood flow
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Limitation of Xenon-SPECT
Can only measure blood flow on surface of brain
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What do you need to use to assess blood flow in the whole brain?
Injectable tracers such as HMPAO
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How does HMPAO work in SPECT?
Attaches to highly lipophilic molecules that cross Blood brain barrier to enter brain cells. Once inside, ligands are enzymatically converted to charged ions, which remain trapped in cell. Over time, tracers concentrate in areas of high blood flow.
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Which compound is used to study receptors in SPECT?
Iodine-123-labeled ligands
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What can Iodine-123 ligands be used to study in SPECT?
Muscarinic Dopaminergic Serotonergic (occupancy and distribution)
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What compound is used to study D1/D2 receptors in SPECT?
Iodobenzamide
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What compound is used to study GABA-A receptors in SPECT?
Iomazenil
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What compound is used to study dopamine and serotonin transporters in SPECT?
Nor-beta-CIT
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What compound is used to study D2/D3 receptors?
Epidepride
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What can PET study?
Blood flow Receptor distribution Metabolic activity
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Difference between SPECT and PET
SPECT; single particle is emitted | PET: two particles are emitted, thus more precise location for event and better resolution of image
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What happens to isotopes used in PET?
Decay by emitting positrons with resolution closer to its theoretical minimum of 3mm
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Limitation of PET
Require on-site cyclotron
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Most commonly used isotopes in PET
Fluorine-18 Nitrogen-13 Oxygen-15
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Which isotope used in PET is not linked to another molecule?
Oxygen-15
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Advantage of fluorine-18 used in PET?
Gives direct information about neuronal metabolism
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PET ligand used in blood flow
C15/H215O
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PET ligand used for glucose metabolism
F18 deoxyglucose
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PET ligand used for D2 receptors
11C raclopride
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PET ligand used for ropamine neuron density
18F dopa | 18F metatyrosine
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PET ligand used for GABA-A receptors
11C Flumazenil
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PET ligand used for 5HT2 receptors
18F altanserin | Setoperone
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PET ligand used in striatal D2 and cortical 5HT2
11C methylspiperone
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What PET ligand is used for seretonin synthesis rate
11C methyltryptophan
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PET ligand used for muscarinic receptors
11C scopolamine
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What does DTI stand for
Diffusion tensor imaging
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How does DT1 work
Combines principle of nuclear magnetic resonance and molecular diffusion
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What is diffusion in DT1?
Random translational motion of molecules - Brownian notion - that results from energy carried by these molecules
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How does DT1 work
During random Brownian motion, molecules probe tissue structure at a microscopic scale beyond usual image resolution; direction of movement determines integrity and trace of white matter tracts
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Gradients allowed via DT1
16
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In which scan can Fractional Anisotrophy be calculated?
DT1
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What is Fractional Anisotrophy?
Index of integrity of white matter
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What is tractography?
Using principal direction of diffusion tensor to infer white-matter connectivity of brain
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Neuro-imaging findings in depression re metabolism
Decreased metabolism in prefrontal cortex, anterior cingulate and amygdala
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Brain volumes seen in depression
Decreased frontal and basal ganglia volumes
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Hyperintensities seen in neuroimagingin depression
Periventricular and deep white matter | Subcortical - thalamic and striatal
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Neuroimaging findings in treatment response for depression
Higher prefrontal metabolism (anterior cingulate) predict better treatment response
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Neuroimaging findings in patients with depression with higher dysfunctional negative thoughts
Higher 5HT2A receptor density
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Neuroimaging findings in women with depression
Increased MAO-A activity
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Neuroimaging findings in psychomotor retardation in depression
Elevated D2 binding in untreated depression
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Neuro-imaging findings in patients on therapeutic dose of SSRIs
80% of 5HT transporters occupied
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Neuro-imaging findings in schizophrenia
Ventricular enlargement | Loss of grey matter - insular cortex, anterior cingulate (medical prefrontal cortex) and medial temporal lobe
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Neuro-imaging findings in first few years of diagnosis?
Progressive loss of brain volume
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Neuro-imaging findingin schizophrenia linked with executive tasks
fMRI revealrs poor DLPFC activation
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MRS findings in schizophrenia
Decreased n-acetyl aspartate in PFC (neuronal loss)
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Findings in DT1 in schizophrenia
Widespread reduction | Fractional anisotrophy: frontal and corpus callosum - more in chronic treated patients
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Neuro-imaging findings in Alzheimers
Ventricular enlargement Loss of temporal lobe volume - hippocampus Decreased parieto-temporal fMRI activation and SPECT blood flow
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Neuro-imaging findings in OCD
Reduced and increases volumes of caudate nuclei noted (both) | Higher caudate blood flow - increased metabolism
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What neuro-imaging findings decrease with effective treatment of OCD?
Higher caudate blood flow reduces with treatment
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Neuro-imaging findings in childhood-onset schizophrenia
Ventricular enlargement at baseline and slower growth rates (right hemispheric) white matter also noted
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A non-invasive perfusion MRI methodology used to quantify cerebral blood flow is?
Arterial spin labelling
336
What is used in MRS to measure cellular metabolism?
R-31
337
What is used in MRS to quantify N-acetylaspartate, choline, glutamatate, lactate and creatinine?
H-1
338
What is used in MRS to study labelled drugs and deoxyglucose?
F-19
339
What is Gedankenlautwerden?
Thought echo
340
What is moria?
Tendency to be inappropriately euphoric
341
Who came up with the idea of autochthonous delusions?
Wernicke

MRCPsych Part A (22 decks)

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