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Neuroanatomy for Psychiatrists Dr Rohit Shankar MBBS, MD, MRCPsych, CCT, PGC Cl. Research Consultant in Adult Developmental Neuropsychiatry.

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Presentation on theme: "Neuroanatomy for Psychiatrists Dr Rohit Shankar MBBS, MD, MRCPsych, CCT, PGC Cl. Research Consultant in Adult Developmental Neuropsychiatry."— Presentation transcript:

1 Neuroanatomy for Psychiatrists Dr Rohit Shankar MBBS, MD, MRCPsych, CCT, PGC Cl. Research Consultant in Adult Developmental Neuropsychiatry

2 Why should we know any Neurology? Brain Behaviour connection Brain Behaviour connection Man made divide Man made divide 2000 years of togetherness 2000 years of togetherness Hippocrates (460-377BC) Humours theory and Triad of mental illness Hippocrates (460-377BC) Humours theory and Triad of mental illness Plato – divine inspired and physical inspired mental illness Plato – divine inspired and physical inspired mental illness Inter canon of the yellow emperor Inter canon of the yellow emperor Johann Christian Reil 1808 Johann Christian Reil 1808 Reintegration – biological underpinnings Reintegration – biological underpinnings

3 Golden Rules Adhere to the routine Adhere to the routine A good History is more useful than a good examination 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 Usually well practiced testing would take 20 minutes then come back to any areas of deficits Don’t ‘Scan’ before you ‘Can’ physically examine 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 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

4 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 Exam

5 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

6 THE LAST SUPPER

7 DETAILS LIE IN BEHOLDER’S OBSERVATIONS! Detail of the Da Vinci's The Last Supper by Giacomo Raffaelli

8 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

9 The Lobes

10 Job Allocation

11 Division of Labour

12 Lobe Function

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14 Frontal Lobe Dysfunction The primary motor cortex The primary motor cortex Contra lateral motor control Contra lateral motor control The medial frontal cortex The medial frontal cortex Arousal and motivation – Abulic (Apathy & inattention) Arousal and motivation – Abulic (Apathy & inattention) The orbital frontal cortex The orbital frontal cortex Modulate Behaviour -Labile, euphoric, facetious, vulgar Modulate Behaviour -Labile, euphoric, facetious, vulgar The left postero-inferior frontal cortex (Broca's) The left postero-inferior frontal cortex (Broca's) Language – expressive Aphasia Language – expressive Aphasia The dorsolateral frontal cortex The dorsolateral frontal cortex Working memory & dysexecutive syndrome Working memory & dysexecutive syndrome

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16 Parietal Lobe Dysfunction The primary somatosensory cortex The primary somatosensory cortex Integrates somesthetic stimuli for recognition and recall of form, texture, and weight - Contralateral astereognosis Integrates somesthetic stimuli for recognition and recall of form, texture, and weight - Contralateral astereognosis Posterolateral - Postcentral gyrus Posterolateral - Postcentral gyrus visual-spatial relationships and proprioception visual-spatial relationships and proprioception Midparietal lobe (dominant) Midparietal lobe (dominant) calculation, writing, left-right orientation, and finger recognition - Gerstmann's syndrome calculation, writing, left-right orientation, and finger recognition - Gerstmann's syndrome The nondominant parietal lobe The nondominant parietal lobe Contralateral environmental awareness, drawing – Anosognosia, Hemiasomatognosia, spatial Apraxia Contralateral environmental awareness, drawing – Anosognosia, Hemiasomatognosia, spatial Apraxia

17 Temporal Lobe Dysfunction Auditory perception, receptive components of language, visual memory, declarative (factual) memory, and emotion Auditory perception, receptive components of language, visual memory, declarative (factual) memory, and emotion Right temporal lobe lesions - interpret nonverbal auditory stimuli (e.g. music) 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 Left temporal lobe lesions interfere greatly with the recognition, memory, and formation of language medial limbic - emotional parts & TLE medial limbic - emotional parts & TLE

18 Occipital Lobe Dysfunction Primary visual cortex and visual association areas Primary visual cortex and visual association areas Anton Babinski Syndrome Anton Babinski Syndrome Occipital Seizures – C/L Visual Hallucination Occipital Seizures – C/L Visual Hallucination Prosopagnosia - Face blindness Prosopagnosia - Face blindness

19 Conscious pain, temperature, crude touch & pressure Lateral and an anterior tract Thalamus (all conscious sensations) projection to areas of the cerebral cortex

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

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

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

23 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

24 Basal Ganglia and Limbic System

25 Hippocampal Formation & Amygdala Hippocampal Formation Hippocampal Formation Dentate gyrus + the hippocampus proper + Subiculum Dentate gyrus + the hippocampus proper + Subiculum Memory, spatial navigation and attention Memory, spatial navigation and attention Amygdala Amygdala Via hypothalamus activates the ANS Via hypothalamus activates the ANS Activation of Neurotransmitters Activation of Neurotransmitters Emotional Learning – Conditioning Emotional Learning – Conditioning Memory modulation 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 Kluver Bucy Syndrome – Docility: diminished fear responses, dietary changes, Hyperorality, Hypersexuality, Visual Agnosia, Hypermetamorphosis: irresistible impulse to notice and react to everything, memory loss

26 Papez Circuit

27 Function of the Limbic System Affective functions Affective functions Playful moods Playful moods Emotions and feelings, like wrath, fright, passion, love, hate, joy and sadness Emotions and feelings, like wrath, fright, passion, love, hate, joy and sadness self preservation self preservation

28 Dopamine Pathways VTA HT

29 Serotonin Pathways

30 Serotonin and Depression Serotonin transmission - Caudal raphe nuclei and Rostal raphe nuclei is reduced in 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 Increasing the levels of serotonin in these pathways, by reducing serotonin reuptake = treatment

31 Serotonin in Schizophrenia Dorsal raphe nuclei - Substantia Nigra Dorsal raphe nuclei - Substantia Nigra Rostral raphe nuclei - cerebral cortex, limbic regions and basal ganglia 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 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 The serotonergic nuclei in the brainstem that give rise to descending serotonergic axons remain unaffected in schizophrenia

32 Serotonin and Depression

33 Serotonin and Schizophrenia

34 Brain Stem Brain Stem: Midbrain, Pons, Medulla Brain Stem: Midbrain, Pons, Medulla Contains CNs, CS Tract and other ‘long’ Tracts Contains CNs, CS Tract and other ‘long’ Tracts Positive evidence of localization and negative evidence of cerebral injury Positive evidence of localization and negative evidence of cerebral injury Example – Diplopic but no effect on visual acuity or fields Example – Diplopic but no effect on visual acuity or fields Brain stem injures -Massive infarcts, Overdoses etc Brain stem injures -Massive infarcts, Overdoses etc Simultaneous damage of BS and Cerebrum RARE exceptions: MS, tumours etc Simultaneous damage of BS and Cerebrum RARE exceptions: MS, tumours etc

35 Cerebellum Controls the coordination of movements/limbs – Ipsilateral Controls the coordination of movements/limbs – Ipsilateral Muscle Hypotonia and Pendular DTRs Muscle Hypotonia and Pendular DTRs No obvious cognitive role No obvious cognitive role Intentional Tremor Intentional Tremor Gait Ataxia, Scanning speech, tandem gait failure Gait Ataxia, Scanning speech, tandem gait failure Cognitive Impairment? Cognitive Impairment? Alcohol – Thiamine, AIDS, toxins, Vitamin E, Phenytoin Alcohol – Thiamine, AIDS, toxins, Vitamin E, Phenytoin

36 Psychiatry and Neurology Psychogenic Paresis and Hoover’s Sign Psychogenic Paresis and Hoover’s Sign La Belle Indifference La Belle Indifference MS MS Sleep Disorders Sleep Disorders Parkinsonism, Huntington, Wilson’s disease Parkinsonism, Huntington, Wilson’s disease Frontal Lobe issues, Dementia Frontal Lobe issues, Dementia Seizures of Non epileptic origin and NEADs, Sensory seizures Seizures of Non epileptic origin and NEADs, Sensory seizures

37 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? 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 Cerebrum Cerebellum Cerebellum Pons Pons Midbrain Midbrain Medulla Medulla None of the above None of the above

38 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? 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 Cerebrum Cerebellum Cerebellum Pons Pons Midbrain Midbrain Medulla Medulla None of the above None of the above

39 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? 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 The CNS and the PNS The CNS and the PNS The Cerebrum and the posterior columns The Cerebrum and the posterior columns The ANS The ANS

40 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? 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 Occipital Lobe Frontal Lobe Frontal Lobe Parietal Lobe Parietal Lobe Temporal Lobe Temporal Lobe None of the above None of the above

41 QUESTION Where is the primary damage in Wilson's disease, Huntington's Chorea and Choreiform Cerebral Palsy? Where is the primary damage in Wilson's disease, Huntington's Chorea and Choreiform Cerebral Palsy? Extra pyramidal system Extra pyramidal system Pyramidal system Pyramidal system Entire CNS Entire CNS Cerebellar outflow tracts Cerebellar outflow tracts None of the above None of the above

42 SOME CORRECTIONS EMI -2 EMI -2

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