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1
Q

Anterior cranial fossa

A

Formed by frontal bone, ethmoid, sphenoid bone

Anterior: Inner surface of frontal bone

Posterior - lesser wing of sphenoid/anterior clinoid process

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2
Q

Content of anterior cranial fossa

A

Contents:
Frontal lobes of cerebral hemispheres
Midline has attachment for falx cerebri
Anterior clinoid process which give attachement to tentorium cerebelli (seperates cerebellum from occipital lobes)
Olfactory Bulb
Crista galli

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3
Q

Middle cranial fossa

A

Anteriorly: Lesser wing of sphenoid

Posteriorly: superior borders of petrous parts of temporal bones

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4
Q

Content of Middle cranial fossa?

A

Anterior to Posterior:

  • *Optic canal** tramsmits the optic nerve and opthalmic artery.
  • *Superior orbital fissure** transmits the lacrimal, frontal, trochlear, oculomotor, nasociliary, abducent nerves with the sup. opthalmic vein
  • *Foramen rotundum:** Maxillary nerve to pterygopalantine fossa
  • *Foramen ovale:** Large sensory root and small motor root of mandibular nerve
  • *Formaen Spinosum:** MMA & vein (from the infratemporal fossa into the cranial cavity)
  • *Foramen lacerum:** Carotid artery

Medial part of MCF - sphenoid bone.

  • *Sulcus chiasmatis** related to optic chiasm and lead sto optic canal on either side
  • *Sellae Turcica** lodges the pituitary gland
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5
Q

Posterior cranial fossa

A

Anteriorly: Superior border of petrous part of temporal bone

Posterior: internal surface of suamous part of occipital bone.

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6
Q

Content of posterior fossa

A

Cerebellum, Pons and medulla oblongata

Fossa:
Foramen Magnum:Occupies central area of floor, transmits the medulla oblongata, the spinal portion of CNXI and the two vertebral arteries
Hypoglossal canal: hypoglossal nerve
Jugular foramen: CN IX, X & XI and sigmoid sinus (NB Sigmoid sinus becomes the internal jugular vein)
Internal acoustic meatus: Transmits the vestibulocochlear nerve and motor + sensory roots of the facial nerve.

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7
Q

Infratemporal fossa

A

Deep to the masseter muscle

Lateral - ramus of mandible

Medial - lateral pterygoid plate of the sphenoid

Anterior - posterior surface of maxilla

Posterior - carotid sheath

Inferior - medial pterygoid muscle

Superior - skull base, sphenoid (foramen ovale/spinosum)

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8
Q

Content of infratemporal fossa

A

Muscles - lateral/medial pterygoid

Nerve - CN5iii (mandibular branch of Trigeminal), Chorda tympani (CN7), Otic ganglion (parasympathetic nerve)

Artery - maxillary

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9
Q

List the cranial nerve nuclei in each constituent part of the brainstem?

A

Originate from the brainstem:

Medulla oblongata, Pons, Midbrain

CN I-IV originate above the Pons:

  • CN I + II are above the midbrain
  • CN III + IV are in the midbrain.

CN V-VIII orignate in the Pons

CN IX-XII originate in the Medulla

Think rule of 4’s

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10
Q

Pterygopalatine fossa

A

Anterior - posterior wall of maxillary sinus

Posterior - pterygoid process of sphenoid bone

Inferior - palatine bone and palatine canal

Superior - inferior orbital fissure

Lateral - pterygomaxillary fissure

Medial - perpendicular plane of the palatine bone

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11
Q

Content of pterygopalatine fossa

A

Foramen rotundum opens into pterygopalantine fossa

Contents are CNVii (Maxillary)

Maxillary artery

Pterygopalatine Ganglion

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12
Q

Pterion

A

H shaped area where 4 bone meets

Frontal, parietal, temporal and sphenoid it is the weakest part of skull

Anterior division of MMA & MMV run behind

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13
Q

Orbit

A

Pyramidal cavity: base anterior and apex posterior

Orbital margin:
Frontal bone - Sup
Frontral and zygomatic bones - Lateral
Process of the maxilla and the frontal bone - Medial
Zygomatic bones and maxilla - Inferior

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14
Q

Extraocular muscles

A

Levator palpebrae - raises eyelid. CN III

Rectus x4

Oblique x2

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15
Q

Why does infection spread to the skull

A

Connection of venous drainage from facial vein.

Ophthalmic vein to cavernous sinus

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16
Q

Bones in the ear

A

Malleus, incus, stapes

Stapes has stapedius muscle

Malleus has Tensor Tympani (motor division of mandibular nn.)

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17
Q

Sternocleidomastoid

A

origin - mastoid process

insertion - 2 heads - manubrim, clavicle

innervation - CN11

action - rotation of head

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18
Q

Trapezius

A

origin - occipital protuberance/nuchal ligament, T4-T12

insertion - acromion, clavicle, spine of scapula

innervation - CN11

action - elevation of scapula

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19
Q

Pathway of spinal accessory nerve

A

upper third posterior border of SCM to lower third of anterior border of trapezius

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20
Q

Hypoglossal nerve

A

Motor - extrinsic and intrinsic muscles to the tongue genioglossus, hyoglossus, styloglossus

medulla - hypoglossal canal

Joins the C1/C2 nerve root plexus

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21
Q

Extrinsic muscles of the tongue

A

Genioglossus

Hyoglossus

Styloglossus

Palatoglossus (innervated by vagus nerve)

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22
Q

Muscles of mastication

A

temporalis

Masseter

Lateral/Medial pterygoid

Developed from 1st pharyngeal arch

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23
Q

temporalis

A

origin - temporal fossa

insertion - Coronoid process of mandible

innervation - CN5iii

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24
Q

masseter

A

origin - maxillary process of zygomatic bone, zygomatic arch of temporal bone

insertion - ramus of mandible

innervation - CN5iii

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25
Q

lateral pterygoid

A

origin - greater wing of sphenoid and lateral pterygoid plate of sphenoid

insertion - neck of mandible

innervation - CN5iii

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26
Q

medial pterygoid

A

origin - greater wing of sphenoid and lateral pterygoid plate of sphenoid

insertion - ramus of mandible

innervation - CN5iii

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27
Q

Temporomandibular joint

A

Articulation between 3 surface - mandibular fossa, articular tubercle and head of mandible

Separated by articular disc

3 Ligaments - lateral, stylomandibular, sphenomandibular

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28
Q

Submandibular gland

A

Allocated in submandibular triangle

anterior and posterior belly of digastric muscle and mandible

In relations to mylohyoid muscles Hypoglossal (deep), lingual, marginal mandibular nerve

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29
Q

Sublingual gland

A

almond shaped under the tongue, laterally on mandible, medially by genioglossus muscle around lingual frenulum

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30
Q

Parotid gland

A

Superior & deep gland separated by facial nerve, ECA

Superior - zygomatic arch

inferior - inferior border of mandible

posterior - external ear/SCM

anterior - masseter

Stensen duct - 2nd upper molar

Sensory nerve - CN9, otic ganglion

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31
Q

What are the relations to the common carotid artery and branches?

A

Anterolaterally: skin, fascia, SCM, sternohyoid

Posteriorly: Transverse processes of 4 cervical vertebrae, prevertabral muscles, sympathetic trunk

Medially: Larynx and pharynx, lobe of throid gland

Laterally: IJV
Posterolateral - vagus nerve

Branches are Internal carotid artery and External carotid artery

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32
Q

External Carotid artery

A

Bifurcates from CCA at C4

She Always Likes Friends Over Papa, Mama and Sister

  • *S**uperior thyroid
  • *A**scending pharyngeal
  • *L**ingual
  • *F**acial
  • *O**ccipital
  • *P**osterior auricular
  • *M**axillary
  • *S**uperficial temporal
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33
Q

What are the relations to external carotid artery?

A

Anterolaterally:
At beginning anterior border of SCM
Superiorly by skin and fascia
Crossed by the hypoglossal nerve
Within the parotid gland is crossed by the facial nerve

Medially:
Internal Carotid artery
Glossopharyngel nerve and pharyngeal branch of vagus pass inbetween ECA and ICA

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34
Q

Internal carotid artery

A

Bifurcates from CCA at C4 no extracranial branch enters via carotid canal

Calming Voices Make Intra-Operative Surgery Pleasurable And Almost Memorable

C: caroticotympanic artery (C2)

V: Vidian artery (C2)

M: meningohypophyseal trunk (C4)

I: inferolateral trunk (C4)

O: ophthalmic artery (C6)

S: superior hypophyseal artery (C6)

P: posterior communicating artery (C7)

A: anterior choroidal artery (C7)

A: anterior cerebal artery (C7)

M: middle cerebral artery (C7) - forms circle Willis

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35
Q

What are the relations of the internal carotid artery in the neck

A

Anterolaterally:
Below the digastric: lie the skin, fascia and anterior border of SCM
Above the digastric: stylohyoid, stylopharyngeus, glossopharyngeal nerve, pharyngeal branch of the vagus, parotid gland

Posteriorly:
Sympathetic trunk
Transverse process of upper three cervical vertebrae

Medially:
Pharyngeal wall and sup laryngeal nn.

Laterally:
IJV and vagus nerve

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36
Q

Vertebral artery

A

Arises from the Subclavian artery, passes through foramen transversarium of C6

Gives off anterior & posterior spinal arteries

Enters via foramen magnum

Gives off PICA

Forms the basilar artery

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37
Q

Basilar artery

A

gives off AICA, pontine arteries, Superior cerebellar artery, labyrinthine artery

Forms Circle of Willis

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38
Q

Dural sinus system

A

Superior sagittal sinus

Inferior sagittal - straight sinus

Confluence of sinus - Transverse sinus

Carvernoous sinus - Superior/Inferior petrosal sinus Sigmoid sinus IJV

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39
Q

CSF drainage system

A
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40
Q

Ascending tract

A

Dorsal column

Spinothalamic

Spinocerebellar

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41
Q

Dorsal column

A

Medial lemniscal pathway

Fasciculus cuneatus - upper limb
Fasciculus gracilis - lower limb
Decussate in medulla (2nd order neurones)

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42
Q

Spinothalamic tract

A

Anterior Crude touch & pressure

Lateral - pain and temperature

Decussate at level of spinal cord

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43
Q

Spinocerebellar tract

A

Proprioception anterior and Posterior

cerebellar - lower limbs rostral and cunecerebellar - upper limbs

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44
Q

Descending tract

A

corticospinal tract - cortex - internal capsule - crus cerebri Corticobulbar - CN7 and CN12 contralateral innervation Pyrimidal - medullary pyramids Extrapyrimidal - involuntary movement - vestibulospinal/reticulospinal tract

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45
Q

layers of SCALP

A

Skin

Connective tissue epicranial

Aponeurosis

Loose connective tissue

Periosteum (at sutures lining bones the periosteum from the outside is continuous with the periosteum on the inside)

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46
Q

Pituitary gland

A

On sella turcica:

Anterior - FSH/LH, GH, ACTH, TSH

Posterior ADH, Oxytocin

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47
Q

Describe the clinical features of a sub arachnoid haemorrhage, and the most common cause?

A

A sudden onset severe headache (peak pain almost immediately).

Worst headache ever.

Usually in the occipital region.

May be focal neurology and meningisms*

Most commonly due to a ruptured berry aneurysm in teh circle of willis.

*Neck stiffness, photophobia and headache.

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48
Q

Describe the vascular abnormalities which may predispose a patient developing a SAH?

A

Berry aneurysms: congenital weakness in the elastic lamina of aa, often develop at weak branch points in the circle of willis.

Arteriovenous malformations: Congenital defect in which there are abnormal anastomoses between the arterial and venous system without capillaries due to the abnormal pressure difference these are more likely to bleed.

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49
Q

Which aa are most commonly have berry aneurysms?

A

Berry aneurysms: congenital weakness in the elastic lamina of aa, often develop at weak branch points in the circle of willis.
40% occur at the ant. communicating aa
30% occur at the middle cerebral artery bifurication
20% occur at the posterior communicating aa origin

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50
Q

Describe how a suspected SAH haemorrhage should be investigated?

A

CT scan without contrast as soon as possible, high sensitivity within the 1st 24hrs.

Lumbar puncture can be done if history is suggestive but CT scan is negative as it CT can give a false negative rate in 2% of cases.

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51
Q

Describe the acute management of sub arachnoid haemorrhage?

A

Initial management of SAH aims to prevent further bleeding and reduce the risk of complications.

A-E assessment

Transfer to a specialist neurosurgical unit is needed. Patients will often need an ITU bed also and may be intubated and NG fed. Maintaining BP, electrolytes and BMs in a normal range is important.

Rebleed rates are high and devastating therefore neurosurgical intervention is needed either by:

  • a craniotomy and clipping (placing clips around the neck of the aneurysm)

OR

  • coiling performed through femoral catherisation (platinum coils obliterate the aneurysm by forming a coil inside)

Nimodopine (Ca antagonist) is used to prevent secondary vasopspasm

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52
Q

What are the complications of SAH?

A
  • Raised ICP due to blood spreading through the arachnoid space.
  • Vasospasm in response to the bleeding causing secondary ischaemia.
  • Rebleed risk.
  • Permanent neurological defect due to infarction at the site of rupture.
  • Death.
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53
Q

What are the predisposing factors which make people vulnerable to suffering subdural haemorrhage?

A

Infants and the elderly.

Anything increasing bleeding risk:

  • Anticoagulants
  • Liver failure
  • Alcoholism (poor clotting and brain atrophy)
  • Inherited haemophilias
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54
Q

What is the clinical presentation of an acute subdural haemorrhage?

A

Acute: Usually presents shortly after a moderate to severe head trauma.

There may be a loss of consciousness.

There may be a lucid period of a few hours where the patient seems relatively well before deteriorating and losing consciousness as a haematoma forms.

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55
Q

Where exactly does a subdural haemorrhage occur?

A

It is a haemorrhage that occurs between dura and arachnoid mater.

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56
Q

What is the clinical presentation of a chronic subdural haemorrhage?

A

Chronic: Usually presents 2-3 weeks after the trauma, which may have been relatively uneventful (think of this in groups with a high bleeding risk)

Often a hx of progressive symptoms including: Anorexia, nausea and vomiting.

Focal neurology such as limb weakness, speech difficulties, confusion or personality change.

May be a progressively worsening headache (should really raise suspicion)

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57
Q

Describe the following CT scan and the likely pathology?

A

Right sided acute SDH

Unilateral. Hyperdense (brighter) therefore acute. Cresenteric appearnce contiunous with outline of the brain.

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58
Q

Describe the following CT scan and the likely pathology?

A

Chronic left sided SDH

Hypodense (darker) therefore chronic

59
Q

Describe the CT scan appearance of a subdural haemorrhage?

A

Subdural haemorrhages are typically unilateral (85%) and follow a crescent-like distribution around the periphery of the brain. They can cross suture lines.

In acute bleeds haemorrhage appears hyperdense (brighter)

Overtime (chronic subdurals) haemorrhage may dissapear leaving behind a hypodense (darker) area.

60
Q

Describe the management of a patient with a subdural haemorrhage?

A

A-E assessment and stabilisation

Consider mannitol if intercranial pressure is raised

Referral to neurosurgery treatment is emergency craniotomy and clot evacuation.

61
Q

Which structural lesions which predispose to intracerebral haemorrhage?

A

Arteriovenous malformations. (abnormal anastomoses between arteries and veins)

Cerebral amyloid angiopathy: accumulation of amyloid in the tunica media and adventivia of vessels making them increasingly fragile. This is the major cause in lobar intrecerebral haemorrhage.

Tumours which are often highly vascular.

62
Q

Describe how sterotactic aspiration is performed?

A

A metal stereotactic frame with for pins (screws) is attached to he patients head. A CT scan is taken with the frame on allowing the surgeon to pinpoint the exact coordinates of the haematoma.

The surgeon drills a small hole directly into the the haematoma and the clot is aspirated with a needle.

63
Q

Which other factors predispose to intracerebral haemorrhage?

A

Hypertension: is the major cause in deep intracerebral bleeds

Anticoagulant therapy

Ilicit drugs: sympathomimmetics aka cocaine, amphetamine and ecstasy

64
Q

Which vessel is usually implicated in extradural haematoma’s?

A

Shearing of the middle meningeal aa just underlying the temporal bone. (inside the skull but outside the dura mater)

An associated skull fracture is present in 75% of cases.

65
Q

Describe the acute investigations and management of a suspected extradural haemorrhage?

A

Initial investigation should be a head CT which will demonstrate the haemorrhage.

Prognosis is usually good even in large haemorrhage as long as there is prompt evacuation of the clot by using burr holes.

In small haemorrhages they can be treated conservatively with monitoring. If there is worry about raised ICP mannitol can be given.

66
Q

Define intracerebral haemorrhage?

A

A bleed within to the brain itself it is classified as either:

Deep

or

Lobar (within the lobes)

67
Q

Describe the clinical presentation of a intracerebral haemorrhage?

A

The classic presentation of ICH is sudden onset of focal neurological deficit progressing over hours with accompanying headache, nausea, vomiting, altered consciousness, and elevated blood pressure.

68
Q

Describe the initial investigations and suspected immediate patient management in intracerebral haemorrhage?

A

CT angiography has the advantage over CT as it can be used to indicate still active bleeding.

Initial treatment: Resus, reduce ICP, prep for surgery.

Management is needed in an ITU setting.

A: Intubated

B: Hyperventialte to reduce ICP. CO2 causes vasodilation therefore low levels cause relative constriction therefore reduced cerebral blood flow and lower pressures.

C: Maintain euvolaemia.

Surgical management:

Insertion of a VP (ventricular peritoneal shunt) to reduce ICP and allow room for the haematoma to grow with out damaging brain tissue.

Main surgical aim is to remove the clot and stop further bleeding can be done by:

Stereotactic aspiration (preferred for large deep seated haematomas)

Or

Craniotomy (only when the bleed is more superficial)

69
Q

Describe the clinical presentation of an extradural haemorrhage?

A

Typically there is a clear history of head trauma with a potential transient loss of conciousness.

Following this there is usually a lucid period in which they regain consciousness but usually have an ongoing severe headache.

Over the next few hours a haematoma forms and cause a mass effect herniation which presents clinically as gradual loss of consciousness.

Abducens nn is first nerve affected on side of injury sec. to herniation

70
Q

Outline the visual pathway?

A

Optic nn
Optic Chaism
Optic tract (superior and inferior fibres together)
Lateral Geniculate nucleus
Optic Radiations

Visual cortex (Travels to the occipital lobe broadman’s area 17. )

71
Q

Name the location of the causative lesion in homonymous hemianopia?

A

Optic tract lesion.

If it is a left sided homomynous hemianopia then the lesion will be in the right optic tract.

Can’t see out the left as lesion is on the right posterior tract.

72
Q

Name the location of the causative lesion in bitemporal hemianopia?

A

Optic Chiasm

73
Q

Name the location of the causative lesion in a homoynous quadrantanopia?

A

The optic radiations of the geniculocalcarine tract.

If the visual loss is on the left then the lesion is on the right.

​PITS - Parietal Inferior, Temporal Superior

If it is in the upper visual field it is from the superior retinal fibres running through the Temporal lobe.

If it is in the lower visual field the lesion is from the inferior retinal fibres running through the Parietal lobe.

So if you have a left inferior homomynous hemianopia then the lesion will be in right parietal retinal fibres of the geniculocalcarine tract.

If the lesion was a right sided superior homomynous hemianopia then the lseion would be in the left temporal lobe retinal fibres of the geniculocalcarine tract.

74
Q

Describe the difference between UMN and LMN facial nn weakness.

A

The forehead is spared in UMN facial nn weakness. This is because there is bilateral cortical representation of the forehead muscles.

75
Q

Describe the general clinical features of UMN?

A

UMN:
Hypertonia
Hyper-reflexia
Upward babinski
Pyrimidal muscle weakness (A pattern of weakness in the extensors (upper limbs) or flexors (lower limbs), is known as ‘pyramidal weakness’)
Clasp knife reflex

Pronator drift (if arm pronates indicated lesion)

76
Q

Describe the general clinical features of a LMN palsy

A

LMN:
Hypotonia
Hypo-reflexia
Muscle Weakness
Muscle Wasting
Fasiculations

77
Q

List the cranial nerves and functions?

A

CN I Olfactory: sense of smell

CN II Optic: Vision

CN III Occulomotor: All the muscles moving the eye except for superior oblique and abducent also controls the muscle responsible for the eyelid.

CN IV Trochlea: Superior oblique

CN V Trigeminal: 3 branches; opthalmic, maxillary and mandibular, sensation of the face and muscles of mastication.

CN VI Abducent: Controls lateral rectus muscle which pulls the pupil laterally (aka abducts)

CN VII Facial: 5 branches involving movements in the face. Temporal, zygomatic, buccal, mandibular, cervical. Taste to the anterior 2/3 of the tounge via the chorda tympani.

CN VIII Vestibulocochlea: hearing and balance

CN IX Glossopharyneal: Taste to the posterior 1/3 of the tounge. Sensation to the oropharynx.

CN X Vagus: Parasympathetic stimulation to most of the body including the heart and GI notably, test with gag reflex. Controls the movement of the palate.

CN XI Accessory: Motor innervation to SCM and trapezius.

CN XII Hypoglossal: Muscles of the tounge.

78
Q

Describe what you will see in a patient with the following palsies: CN III CN IV CN VI

A

CN III: The eye will be looking down and out, only the lateral rectus and superior oblique will be working. There will be a near complete ptosis and mydriasis.

CN IV: Patients present with vertical diplopia usually worse on downwards gaze.

CN VI: Usually occurs unilaterally one eye will not be able to look laterally and therefore will cause a binocular diplopia.

79
Q

Describe how you can tell if a facial nn palsy is a upper or lower motor neuron lesion?

A

UMN lesions are forehead sparing due to there being bilateral innervation.

This is

80
Q

In uvula and tounge deviation describe where the lesion is most likely to be?

A

Uvula deviates away from the lesion aka if uvula is deviated towards the left indicates a right sided CN IX & X palsy. Tounge deviates towards the lesion, aka a tounge deviated towards the left indicates a left sided CN XII palsy.

81
Q

Describe Rhine’s and Weber’s test and the clinical significance?

A

Rhine’s test: Twang a tuning fork and place it on the mastoid process, and then immediately in front of the ear. In a normal person it should be louder in front of the ear indicating that air conduction > bone conduction. If this is not the case the patient has a conductive hearing loss.

Weber’s Test A tuning fork is twanged and placed in the centre of the patients head and asked which ear the sound is loudest in, it should be equal. If the hearing deficit is conductive then it will be louder in the affected ear. If the hearing deficit is sensorineural then it will sound louder in the patients good ear. Without Rhine’s test you cannot tell the deficit in Weber’s test.

82
Q

What travels through the cribiform foramina in the cribiform plate?

A

Location: Anterior cranial fossa

Cranial bone: Ethmoid bone

Contents:

  • Olfactory nerve (CN I)
  • Anterior ethmoidal nerves
83
Q

What travels through the optic canal?

A

Location: Middle cranial fossa

Cranial bone: Sphenoid bone

Contents:

  • Optic nerve (CN II)
  • Opthalmic artery (located inferolaterally within the canal)
84
Q

What travels through the superior orbital fissure?

A

Location: Middle cranial fossa

Cranial bone: Sphenoid bone

Contents: Lazy French Tarts Sit Nakedly In Sexual Anticipation

  • Lacrimal nerve
  • Frontal nerve (branch of opthalmic nerve of trigeminal nerve (CN V))
  • Trochlear nerve (CN IV)
  • Superior opthalmic vein
  • Nasociliary nerve (branch of opthalmic nerve (CN V1))
  • Inferior division of the oculomotor nerve (CN III)
  • Superior dividion of the oculomotor nerve (CN III)
  • Abducens nerve (CN VI)

(+ A branch of the inferior opthalmic vein)

85
Q

What travels through the foramen rotundum?

A

Location: Middle cranial fossa

Cranial bone: Sphenoid bone

Contents:

  • Maxillary branch of trigeminal nerve (CN V2)
  • Artery of foramen rotundum
  • Emissary veins
86
Q

What travels through the foramen ovale?

A

Location: Middle cranial fossa

Cranial bone: Sphenoid bone

Contents: OVALE

  • Otic ganglion (inferior)
  • V3 cranial nerve (mandibular branch of the trigeminal nerve)
  • Accessory meningeal artery
  • Lesser petrosal nerve
  • Emissary veins
87
Q

What travels through foramen spinosum?

A

Location: Middle cranial fossa

Cranial bone: Sphenoid bone

Contents: MMA fighters break your SPINE

  • Middle Meningeal Artery
  • Middle Meningeal Vein
  • Meningeal branch of CN V3/Nervus Spinosus
88
Q

What travels through the internal acoustic meatus?

A

Location: Middle cranial fossa

Cranial bone: Petrous part of temporal bone

Contents:

  • Facial nerve (CN VII)
  • Vestibulocochlear nerve (CN VIII)
  • Vestibular ganglion
  • Labrynthine artery

EXTRA:

There are 4 regions within the IAM: anterio-superior/anterio-inferior/postero-superior/postero-inferior

…Seven UP, Coke DOWN

  • Facial nerve (CN VII) located superiorly
  • Vestibulocochlear nerve located inferiorly
89
Q

What travels through the jugular foramen?

A

Location: Posterior cranial fossa

Cranial bone:

  • Anterior aspect= Petrous portion of temporal bone
  • Posterior aspect= Occipital bone

Contents: If someone hits you with a glass JUG call 9-11

  • Glossopharyngeal nerve (CN IX)
  • Vagus nerve (CN X)
  • Accessory nerve (CN XI)
  • Jugular bulb
  • Inferior petrosal and sigmoid sinuses
90
Q

What travels through the hypoglossal canal?

A

Location: Posterior cranial fossa

Cranial bone: Occipital bone

Content:

  • Hypoglossal nerve (CN XII)
91
Q

What travels through the foramen magnum?

A

Location: Posterior cranial fossa

Cranial bone: Occipital bone

Contents: Special Meninges Make A Special Vertical Sheath

  • Spinal cord
  • Meninges
  • Meningeal lympthatics
  • Accessory nerve
  • Sympathetic plexus on vertebral arteries
  • Vertebral arteries
  • Spinal branch of vertebral arteries
92
Q

Which strokes have the highest mortality rate and why?

A

Strokes involving the vertebral and basilar arteries have a high incidence of mortality due to affecting supply of the brainstem.

93
Q

What is lateral medullary syndrome?

A

Ischaemia in the lateral part of the medulla oblongata in the brainstem

Symptoms:

  • *Contralateral loss** of temp + sensation
  • *Ipsilateral loss** of pain and temp on face
  • *Dysphagia, hoarseness & loss gag reflex**
  • *Ipsilateral horners syndrome**
94
Q

What are the sutures of the skull?

A

Parietal bones articulate with each other in the midline via the saggital suture

Coronal suture divides the parietal and frontal bones

Lamboid suture is articulation between the parietal bones and the occipital bones

95
Q

What structure is in the midline of Occipital bone

A

External Occipital Protuberance gives attachment to the muscles and ligamentum nuchae

96
Q

Contents of cavernous sinus?

A

Directly related to side of body of sphenoid

Contents:
CNIII + IV + V1 & V2 of CNV + CNVI
Internal carotid artery

97
Q

How would a fracture of anterior cranial fossa present?

A

Damage to the cribiform plate of the ethmoid bone - leads to epistaxis and cerebrospinal rhinorrhea

Fractures involving the orbital plate of the frontal bone leads to haemorrhage beneath the conjunctiva into the orbital cavity causing exompthalus

98
Q

How would a fracture of the middle cranial fossa present?

A

Weakest part base of skull ergo common

Leakage of CSF and blood from EAM is common

3rd, 4th, 6th, 7th and 8th cranial nn may be damaged

Can also get blood and CSF leaking from nose

99
Q

Fracture of posterior cranial fossa?

A

Blood may escape down nape of neck deep to postvertebral muscles

In fractures involving the jugular foramen 9th, 10th and 11th cranial nerves may be damaged

100
Q

Classification of Maxillofacial fractures

A

Le Fort fractures:
Type 1: Transverse fracture through maxillary sinuses, lower nasal septum and pterygoid plates

Type 2: Floating maxilla (pyramidal)

Type 3: Floating space (transverse)

101
Q

What are the two layers of Dura mater called?

A

Endosteal layer: Periosteum covering the inner surface of bones of the skull

Meningeal layer: dura mater proper
Covers the brain and is continuous through foramen magnum with dura mater of spinal cord

Continuations of the dura mater include:

  • *Falx Cerebri:** sickle shaped fold of dura mater that lies in midline between the two cerebral hemispheres
  • *Tentorium Cerebri:** crescent fold of dura mater that roofs over the posterior cranial fossa. Supports the occipital lobes of cerebral hemispheres
102
Q

Arachnoid Mater - anatomical position

A

Lies between pia mater internally and dura mater externally

Seperated from Dura by a potential space - subdural space

Seperated from pia by Subarachnoid space - filled with CSF

NB the arachnoid bridges over the sulchi in certain areas

103
Q

What are arachnoid villi?

A

Where the arachnoid projects into venous sinuses - where CSF is reabsorbed into the blood stream

104
Q

Subdural haemorrhage presentation and clinical features?

A

Tearing of the sup. cerebral veins at their point of insertion into superior sagital sinus

Cause - usually a blow on front or back of the head

Blood begins to accumulate in the potential spaces between dura and arachnoid

105
Q

Subarachnoid haemorrhage presentation and clinical features?

A

Results from leakage / rupture of aneurysm at circle of Willis

Sudden onset, severe headache with stiffness of neck and loss of consciousness

106
Q

Cerebral haemorrhage presentation and clinical features

A

Usually caused by rupture of thin walled lenticulostriate artery - a branch of the middle cerebral artery

Haemorrhage involves the vital corticobulbar and corticospinal fibres therefore leading ti contralateral hemiplegia

107
Q

Venous sinuses

A
108
Q

Cavernous sinus

A

Lies on lateral side of the body of the sphenoid bone

Anteriorly the sinus receives the inferior opthalmic vein and the central vein of the retina.

Drains posteriorly into the transverse sinus.

109
Q

Movements of eyelid - opening & closis

A

Opening: Levator palpebrae superioris raises the upper eyelid & orbicularis oculi relaxes

Closing: Orbicularis oculi contracts and levator pa,pebrae contracts

110
Q

qqqLacrimal gland - parasympathetic supply

A

Derived from the lacrimal nucleus of the facial nerve. Zygomaticotemporal branch - gives rise to lacrimal nerve.

111
Q

What does the Lacrimal nn supply and where does it travel?

A

Arrises from the opthalmic division of the trigeminal nerve

Enters through the superior orbital fissure and passes forward along the upper border of the lateral rectus muscle

Supplies sensory innervation to the lacrimal gland and conjunctiva.
Supplies skin of the lateral part of the upper lid.

112
Q

What are the openings of the orbit?

A

Orbital opening: Lies anteriorly
About 1/6 of the eye is exposed

Supraorbital notch
Infraorbital fissure
Supraorbital fissure

Optic canal:
Located posteriorly on lesser wing of sphenoid
Transmits optic nerve and opthalmic artery

113
Q

What does the Frontal nn supply and how does it arise?

A

Arises from the opthalmic division of the Trigeminal nerve

Enters orbit through the upper part of the superior orbital fissure

Further divides into the supratrochlear (skin of forehead) and supraorbital nn (mucous membrane of frontal air sinus)

114
Q

What is the ciliary ganglion?

A

Parasymp. ganglion

Situated in posterior part of the orbit

Receives its preganglionic parasympathetic fibres from the oculomotor nn via the nn to the inf obliue

Postganglionic fibres leave the ganglion in the short ciliary nn which enter the back of the eye and supply the sphincter pupillae (CONSTRICTED PUPIL) and the ciliary muscle

115
Q

What is the function of the ciliary muscle

A

Contraction pulls the ciliary body forward

This makes the lens more convew.

Innervation occurs from the parasympathetic fibres of the oculomotor nn.

116
Q

Where does the lymph drainage of the external ear go?

A

Superficial parotid, mastoid and superficial cervical lymph nodes

117
Q

Describe the route of the facial nerve?

A

Emerges on the anterior surface of the hindbrain between the pons and the medulla

Roots pass laterally into the posterior cranial fossa with the vestibulocochlear nn. and enter the internal acoustic meatus

At the bottom of the meatus the nerve enters the facial canal that runs lat in the inner ear

On reaching the medial wall of the inner ear the nerve swells to form the sensory geniculate ganglion.

The nerve descends behind the pyramid and emerges from the temporal bone through the stylomastoid foramen.

118
Q

Important branches of the facial nn?

A

Greater petrosal nerve (arises from nn at the geniculate ganglion. Secretomotor function of the lacrimal gland and glands of nose and palate)

Nerve to stapedius

Chordae Tympani (arises in the facial canal. Enters infratemporal fossa and joins the lingual nn. Contains parasymp. fibres to submandibular and sublingual salivary glands and taste to ant. 2/3 tongue.)

Posterior auricular

  • *Temporal (**ant. and sup. auricular muscles, frontal belly of occipito-frontalis)
  • *Zygomatic** (orbicularis oculi - sphincter muscles of eyelid)
  • *Buccal** (Buccinator muscle, muscles upper lip and nostril)
  • *Mandibular** (muscles lower lip)
  • *Cervical (**supplies platysma)
119
Q

Nerve supply of the scalp

A
120
Q

Lymph drainage of the scalp

A

Anterior scalp and forehead - drains into submandibular lymph nodes

Lateral part of the scalp above the ear - superficial parotid

Lymph vessels in the scalp above and behind the ear - mastoid

Vessels in the back of the scalp drain into occipital nodes

121
Q

What are the branches of the opthalmic nerve and what do they supply?

A

Lacrimal nerve:
supplies the skin and the conjunctiva of the lat. part of the upper eyelid.

Supraorbital nerve:
Skin on the forehead
Skin and conjunctiva over central part of eyelid

Supratrochlear nerve:
Skin and conjunctiva over the medial part of eyelid
Skin over lower part of forehead

Infrattrochlear:
Supplies the skin and conjunctiva on the medial part of the upper eyelid and adjoining part of the side of the nose

External nasal nerve:
Supplies the skin on tip of the nose

122
Q

What are the branches of the Maxillary nerve and where do they supply?

A

Infraorbital nerve: exits thru infraorbital foramen
Supply skin of lower eyelid & cheek
Side of nose and upper lip

Zygomaticofacial nerve:
Supplies skin over prominence of cheek

Zygomaticotemporal:
Supplies skin over the temple

123
Q

What are the branches of the mandibular nerve and how do they divide?

A

Mandibular nerve is both sensory and motor

Mandibular root (both sensory and motor branches) leaves the trigeminal ganglion at foramen ovale

Main trunk:
Meningeal branch
Nerve to medial pterygoid muscle

Anterior division:
Massteric nerve
Deep temporal nerves
Nerve to lateral pterygoid
Buccal nerve

Posterior Division:
Auriculotemporal nerve
Lingual nerve
Inferior alveolar nerve
Communicating branches

124
Q

Cutaneous nerve supply to post aspect scalp

A

Greater Occipital nerve:
Skin overlying trapezius muscle and back of the scalp as high as the vertex

Lesser occipital nerve:
Lateral occipital region and skin over medial surface of auricle

Great Auricular nerve (C2, 3):
Supplies skin over the angle of mandible
Parotid gland and both surfaces of the auricle

125
Q

What does the sup. thyroid artery supply and what structures accompany it

A

Accompanied by the external laryngeal nerve - supplies cricothyroid muscle

Sup thyroid artery supplies upper pole of thyroid gland

126
Q

What does the ascending pharyngeal artery supply and what is it a branch of

A

2nd branch of ECA

Supplies pharyngeal wall

127
Q

What does the lingual artery supply and what is it a branch of?

A

3rd branch of ECA

Supplies the tongue

128
Q

What does the facial artery supply and what is it a branch of?

A

4th branch of ECA

Loops upward - lies deep the submandibular gland

Emerges and bends around lower border of the mandible

Supplies the tonsill, submandibular salivary gland, and muscles and skin of face

129
Q

What does the occipital artery supply and what is it a branch of?

A

Branch of ECA

Supplies the back of the scalp

130
Q

What does the posterior auricular artery supply and what is it a branch of?

A

Branch of ECA

Supplies the auricle and scalp

131
Q

What does the superficial temporal artery supply and what is it a branch of?

A

Branch of ECA

Accompanied by auricotemporal nerve and supplies the scalp

132
Q

What does the maxillary artery supply and what is it a branch of?

A

Branch of ECA

Enters pterygopalantine fossa of the skull

Branches supply upper and lower jaws, muscles of mastication, nose, palate and meninges inside the skull

133
Q

What is the course of the oculomotor nerve?

A

Emerges on anterior surface of the midbrain

Continues into middle cranial fossa in lateral wall of cavernous sinus

Enters orbital canal through superior orbital fissure

Supplies the extrinsic muscles of the eyes and the intrinsic muscles of the eye - enables eye movement and constriction of pupil

134
Q

How is the sensory supply of the mandibular nerve to the skin distributed?

A

Mental:
Supplies skin over lower lip and chin

Buccal:
Supplies skin over small area of cheek

Auricotemporal nerve:
Ascends from upper border of parotid gland
Supplies the EAM, skin of the auricle, outer surface of the tympanic membrane and the skin of the scalp above the auricle

135
Q

What are the branches from the anterior division of the mandibular nerve?

A

Masseteric nerve: masseter muscle

Deep temporal nerves: temporalis muscle

Nerve to lateral pterygoid

Buccal nerve: NB sensory branch only (does not supply buccinator muscle)

136
Q

What are the branches from the posterior division of the mandibular nerve?

A

NB sensory other than nerve to mylohyoid muscle (branch of inf. alveolar nn.)

Auriculotemporal nerve:
Supplies skin of auricle, EAM, TMJ and scalp

  • *Lingual nerve:**
  • *Sensation to ant 2/3 tongue and floor of mouth**

Inferior alveolar nn:
Supplies teeth of the lower jaw (enters through mandibular canal)

Communicating branch:
Runs from inf. alveolar nerve to lingual nerve.

137
Q

What is the otic ganglion

A

Parasympathetic ganglion located medial to mandibular nn

Post ganglion - parotid gland with secretomotor function

Innervated by the glossopharyngeal nn.

138
Q

What is the role of the glossopharyngeal nerve and which branches promote this?

A

Swallowing, salivation, control BP and HR and nn supply to post 1/3 tongue

Carotid branch:
Supply from carotid sinus

Pharyngeal branches

Lingual branches
Sensation to post 1/3 tongue

139
Q

What is the course of the vagus nerve

A

Anterior surface of medulla oblongata

Passes laterally through posterior cranial fossa and leaves skull through jugular foramen

Descends in neck alongside Carotid arteries and IJV in Carotid sheath

140
Q

What are the important branches of the Vagus nerve

A

Pharyngeal branch:
Supplies all of the muscles of the pharynx (except stylopharyngeus) and of soft palate

Superior laryngeal nn:
Divides into internal & external laryngeal nn
(Internal laryngeal: sensory to mucous membrane of piriform fossa and larynx as far down as the vocal chords
External laryngeal: motor and located close to sup thyroid artery - cricothyroid muscle)

Recurrent laryngeal nn:
Right side nerve hooks around first part subclavian artery ascends in groove between trachea and oesophagus

Left side nerve hooks around arch of aorta
Nerve is closely related to inferior thyroid artery and supplies all muscles of the layrnx (except cricothyroid), mucous membrane of layrnx below vocal chord and mucous membrane in upper part trachea.

141
Q

What is the origin of the accessory nerve?

A

Consists of a cranial root and a spinal root

Cranial root:
Emerges from the anterior surface of the medulla oblongata. Nerve runs laterally in post. cranial fossa and joins the spinal root

Spinal root:
Arises from anterior gray horn of upper five segments of teh cervical part of the spinal cord.
Nerve enters skull through foramen magnum

Cranial & spinal root leave skull through jugular foramen

Spinal root enters deep surface of SCM and crosses posterior triangle of neck to supply trapezius

142
Q

What is the lymphatic drainage of the tongue?

A

Tip: Submental lymph nodes

Sides of anterior 2/3: submandibular and deep cervical lymph nodes

Posterior 1/3: Deep cervical lymph nodes

143
Q

Which tongue muscle is not supplied by hypoglossal nerve and what is its action

A

Palatoglossus - supplied by pharyngeal plexus

Pulls roots of tongue upward and backward

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