THE REQUIREMENTS OF THE NEUROANATOMY EXAM FOR DENTISTRY STUDENTS (Set up by dr. Tibor Hollósy, approved by dr. Pál Tóth) 2012

THE CENTRAL , MACROSCOPY

Students must

1. be able to match the development of the (neural tube, primary and secondary brain vesicles) with the macroscopic organization of the brain (important to recognize all parts of the brain and their cavities), 2. know all branches of all the 12 cranial along with their fibre composition and function, 3. be able to identify most of the gyri, sulci, fissures (listed below), and localize the primary cortical areas, 4. know and recognize the vessels (arteries, bigger veins and dural sinuses) and the area they supply, 5. know the circulation of CSF, 6. be familiar with the macroscopy of the eye and the ear.

Embryology: - recapitulation of neurulation, the placodes, the neural crest and their derivatives, - the structure of the neural tube, the development of the , the primary brain vesicles and their derivatives, the development of and the peripheral nervous system (ganglia and the autonomic nervous system).

Major brain divisions: - the derivatives of the secondary brain vesicles and their cavities, - prosencephalon = telencephalon (lat. ventricles) + (3rd ventricle), - mesencephalon = mesencephalon (cerebral aqueduc), - rhombencephalon (4th ventricle) = metencephalon (, ) + myelencephalon = .

Cranial nerves: - with all the minor details: nuclei, fibre composition, exit from the brain, the dura and the skull, all the branches (with the coresponding opening of the skull), course and function, - identification of cranial nerves belonging to the pharyngeal arches, - meanings of somatomotor, somatosensory, visceromotor and viscerosensory innervations, - autonomic ganglia of cranial nerves (position, the origin {} and route of preganglionic fibres, course of postganglionic fibres, effectors), - sensory ganglia of cranial nerves (topography, area of supply, the nucleus in which they terminate).

Blood supply: - with all the details. - veins: only the int. and great cerebral veins (about the others: all are directed to the closest dural sinuses).

Spinal cord: - ability of drowing cross section of SC and of identifying its components, - anterior median fissure, funiculi, ant., post. and lat. horns, central canal, cervical and lumbar intumescences, conus terminalis, cauda equina, - ventr. and dors. roots., spinal , ventr. and dors. rami, their course and fibre composition, spinal (intervertebral or dorsal root) , - definition of a spinal segment, the number of them, the level of termination of SC, - blood supply with all the details, - meninges: spinal dura mater (endorachis can be omitted, the level of termination of the dural sac is needed), arachnoid, pia mater, denticulate lig., spaces (epi- and subdural, subarachnoid) and their content.

Medulla oblongata: - pyramis, olive, med. and lat. parolivary sulci, inf. cerebellar peduncle, rhomboid fossa, 4th ventricle.

Pons: - base and tegmentum, middle cerebellar peduncle, rhomboid fossa, 4th ventricle. - Mesencephalon: - cerebral aqueduct, tectum, sup. and inf. colliculi tegmentum, sup. cerebellar peduncle, , interpeduncular fossa,

Cerebellum: - hemispheria, vermis, tonsilla, flocculus, nodulus, fastigium, - cerebellar peduncles, 4th ventricle.

Diencephalon: - , epi- (pineal body), meta- (lat. and med. geniculate bodies, brachium of sup. and inf. colliculi) and hypothalamus, - 3rd ventricle, - posterior commisure.

Telencephalon: - surfaces (convex, inf. and medial), lobes with the borders, - longitudinal and transverse fissures, - sulci: lateral, central, pre- and postcentral, parietooccipital, calcarine, olfactory, collateral, hippocampal,

2 - gyri: precentral, postcentral, sup., middle and inf. frontal, cuneus, cinguli, sup., middle and inf. temporal, parahippocampal, angular, supramarginal, transverse temporal gyri, location of primary cortical areas (no numbers of corresponding areas of Brodmann), - corpus callosum and parts of it, and parts of it, ant.commissure, - definition of commissural, association and projection fibres, - recognition of (caudate and lentiform nuclei and their parts, claustrum), - , names of its parts and tracts, external and extreme capsules, - lateral ventricle, its parts and walls.

4th ventricle and rhomboid fossa: - median sulcus, medial eminence, facial colliculus, trigones of vagus and hypoglossal nerves, area postrema, vestibular area, - median and lateral apertures of the 4th ventricle, - sup. and inf. medullary vela, fastigium, choroid plexus and its function.

3rd ventricle: - walls and its connections, - choroid plexus - to be omitted: recesses of the ventricle, role of stria medullaris thalami and of habenules.

Lateral ventricle: - walls and its connection, - choroid plexus, - to be omitted: embryological origin of lamina affixa, role of stria terminalis, dentate gyrus.

Meninges: - dura mater: falx cerebri and cerebelli, tentorium of cerebellum, innervation and blood supply, dural sinuses (sup. and inf. sagittal, strait, transverse, sigmoid, confluens of sinuses, cavernous, sup. et inf.petrosal - why dura must form their walls?), emissary veins in general, what are they? - arachnoid, - pia mater, - spaces, possible origin of their hemorrhages, - productios of CSF, direction of its circulation (the only cisterns to be known are the cerebellomedullary and the interpeduncular), resorption (arachnoid granulations).

Brain slices: - the structures listed above are to be recognized on the CT and MRI images, - ability of putting the slices in correct order.

3 PERIPHERAL NERVOUS SYTEM, MACROSCOPY

A.) Somatic nervous system:

Students must know:

1. the definition of all nerve plexuses, their branches (except the cutaneous nerves), 2. the nerves innervating different groups of muscles, 3. the course of the nerves and their accompanying vessels (easyer way of learning), 4. skin innervation: important to know the nerve the branches of which are responsible for the innervation of a certain area of skin, e.g. anterior surface of the forearm - medial fascicle of brachial plexus + musculocutaneus nerve; dorsal surface - radial nerve, 5. the depth in which the cutaneous nerves (without their names) - frequently accompanied by superficial veins - are found (= subcutanous connective tissue).

Cervical plexus (C1-C4): - great auricular, lesser occipital, transverse cervical, supraclavicular, phrenic nerves, inferior root of ansa cerviacalis.

Brachial plexus (C5-Th1): - trunks on the neck, branches of the superior trunk: dorsal scapular, long thoracic and suprascapular nerves, - med., post. and lat. fascicules in the armpit, their branches (not important to know the rearrangement of trunks into fascicles), - ulnaris, radial, median nerves: their course and motor functions (groups of muscles are enough), - axillary n.: deltoid and teres minor muscle, - thoracodorsal n.: latissimus dorsi muscle, - subscapular: subscapularis and teres major muscles - which fascicules give cutaneous nerves and to which areas, - cutaneous nerves on the palm are given by median and ulnar nerves (distribution), - dorsal cutaneous nerves of the hand are the branches of radial and ulnar nerves.

Lumbar plexus (Th12-L4): - femoral and obturator nerves: course and motor functions (groups of muscles are enough).

Sciatic plexus (L4-S3): - sciatic, sup. and inf. gluteal nerves: course and motor functions (groups of muscles are enough), - tibial, common-, superficial and deep peroneal (fibular) nerves: course and motor functions (groups of muscles are enough), - superficial and deep peroneal (fibular) nerves: skin innervation on the back of the foot,

4 - medial and lateral plantar nerves: groups of muscles + skin innervation on the sole.

Pudendohaemorrhoidal plexus (S1-S4): - pudendal nerve.

Intercostal nerves.

B.) Autonomic (vegetative) nervous system: 1. Sympathetic nervous system with all the details (location of preganglionic perikarya, course of preganglionic fibres, their in para- or prevertebral ganglia, course of postganglionic fibres in plexuses surrounding arteries). 2. Parasympathetic nervous system with all the details (as above), major emphasis to be put on the innervation of salivary glands and glandules.

REGIONAL ANATOMY OF HEAD and NECK

Students must know:

1. the skin innervation in full details, which branch of which (cranial or other) nerve, the precise course of them including related structures of the skull (till the end of semester the complete route of transmission of sensory information (includding nuclei and pathways) is to be traced up to the sensory cortex. 2. all the muscle groups and their innervation: muscles of mastication, of facial expression, supra- and infrahyoid muscles, other groups (muscles of tongue, pharynx, larynx and palate) are to be recapitulated, 3. the external carotid and subclavian arteries and all of their branches, superficial and deep veins, lymphatric drainage,. 4. the cranial nerves and their branches (those visible are to be showed!), for recapitulation: nuclei and fibre composition of cranial nerves. 5. the important structures learned in the previous semester (recapitulation of teeth, oral and nasal cavities, pharynx and larynx), 6. the laminae (layers) of cervical fascia (superficial, pretracheal and prevetrebral) and the structures ensheathet by them, 7. the parasympathetic innervation of salivary glands and glandules (lacrimal, nasal, palatine, submandibular, sublingual and parotid glands) with all the detals (see Autonomic nervous system above).

Not much ease on the head and neck can be given.

5 ORGANS OF SPECIAL SENCES

The eye: - the walls of the orbit (which part of which bone!), the connections of the orbit and the structures passing through them, - the content of the orbit: muscles, nerves, vessels, connective tissue systems (fasciae, septa), - extraocular muscles: name, origin/insertion, innervation, which muscles are responsible for a certain movement of the eye (ab- and adduction, elevation- depression), - the visual pathway: optic nerve, chiasma and tract, lateral geniculate body, optic radiaton, visual cortex (“lips” of calcarine sulcus), - the pupillary light reflex: way of visual signal till the pretectal area, nucleus of Edinger-Westphal (accessory nucleus of oculomotor nerve), oculomotor nerve, ciliary ganglion, sphincter pupillae muscle, - the accommodation: visual pathway, visual cortex, pretectal area, nucl. of Edinger-Westphal, oculomotor n., ciliary ggl., ciliary m. (with simultaneous addauction of both eyes of course, recti mediales muscles), - lacrimal apparatus, eyelids and conjunctiva, the innervation of lacrimal gland (see facial and trigeminal nerves).

The ear: - outer, middle and inner ears, - outer ear: auricle (with no details), external acustic meatus: catilagineous and bony (foreign objects), sensory innervation (CNs V, VII, IX. and X. + cervical plexus), - eardrum: umbo, mallear stria and prominence, ant. et post. mallear folds, pars tensa, pars flaccida, cone of light, sensory innervation (CNs V and X), - auditory ossicles: malleus, incus, stapes (in proper lateromedial sequence, no parts, no ligaments), tensor tympani and stapedius muscles (actions and innervations are required), - middle ear: tympanic cavity (connections: auditory tube, mastoid air cells), - epi-, mezo és hypotympanum, - walls of tympanic cavity: enough to know the direction, the important relations and/or connections of them, anterior wall - internal carotid a., auditory tube (musculotubal and carotid canals), inferior wall - internal jugular v., lateral wall - tympanic membrane, upper wall - tegmen tympani, middle cranial fossa (!), posterior wall - mastoid antrum, medial wall - labyrinth, vestibular (oval) and cochlear (round) windows, promontory, facial canal (nerve), - inner ear: position in the pyramid, - bony labyrinth: vestibule, oval and round windows, ant., post. and lat. semicircular canals, crura and ampullae, cochlea, - membraneous labyrinth: utricle and saccule, ant., post. and lat. semicircular ducts, crura and ampullae, ductus reuninens, cochlear duct, - auditory tube: spaces connected by it, its function, - for recapitulation: facial canal, facial nerve and its branches, tympanic nerve.

6 TRACTS, NUCLEI, SYSTEMS

Students must know:

1. the tracts belonging to systems, the proper sequence of them according to the way of information transmission (first, second, third order and the location of their perikarya), 2. the functions of ascending (sensory) systems (types of sensory information; for this classification of receptors is essential!) and their position at various levels of CNS (spinal cord, , internal capsule), 3. of descending (motor) systems the pyramidal sytem in detail (function, cells of origin, position at various levels of CNS and termination); the course of corticopontine tracts; in case of other descending tracts only the name of them (implying origin and termination) and their position in the spinal cord.

Spinal cord: - definition of a spinal segment, location of perikarya (with no laminae of Rexed), the fibre composition of roots, spinal nerves and their rami, definition of dermatomes and Head-zones, - components proprioceptive and nociceptive reflexes (receptor, afferent , central connections, efferent neuron, effector), their function, - divisions of the (funiculi), position of tracts within them.

Brainstem: - all the nuclei of all CNs (their location and function); in case of sensory nuclei - the cells of origin of their afferent fibres (which ganglion?); in case of somatomotor - muscles in which the efferent fibres terminate; in case of s visceromotor nuclei - the way of preganglionic fibres (CN and its branches), their termination (which ganglion?), the way of preganglionic fibres (which nerve?), effector, - nucleus gracilis and cunatus, vestibular and cochlear nuclei, - ascending tracts passing through or originating/terminating here: medial, trigeminal, dorsal trigeminal and lateralis lemnisci; spinothalamic, ventr. et dors. spinocerebellar tracts (only their name and main function), - descending tracts passing through or originating/terminating here: corticospinal, rubrospinal, tectospinal, vestibulospinal, reticulospinal, corticonuclear, frontopontine and occipito-temporo-parietopontine tractus, medial longitudinal fascicle (only their name and main function), - and the pontocerebellar tract.

Cerebellum: - white and gray matters, the three layers of the cortex, - : the five neuron types (Purkinje, granule, basket, Golgi and stellate cell), the layer the somata of them are located in, which of them are excitatory or inhibitory, course of their and , - origin and termination of climbing and mossy fibres,

7 - the possible termination sites of axons, - the list and function of afferent and efferent tracts, the type of their termination (see above!), - the cerebellar nuclei and their connections (dentothalamic, dentorubral and cerebellovestibular tracts).

Diencephalon: - the main groups of thalamic nuclei (anterior, medial, ventrolateral), thalamic radiations projecting from them and their terminations (the name of the telencephalic lobe in which they terminate is enough + their main function), - the main groups of hypothalamic nuclei (magno- and parvocellular), their connections (the hypophysial portal circulation, tracts to the posterior lobe, respectively), - mammillary bodies (together with the fornix), - suprachiasmatic nucleus: the center of rhythms.

Tracts and systems: 1. Fasciculi of Goll and Burdach – medal : - epicritic sensibility from areas supplied by spinal nerves, - receptors, , fasciculi (dorsal , ipsilateral), nucleus gracilis and cuneatus, (contralateral), thalamus, sup. (or middle) thalamic radiation, primary somatosensory cortex. 2. Spinothalamic system: - protopathic sensibility from areas supplied by spinal nerves, - receptors, dorsal root ganglion, in the dorsal horn, tract on the contralateral side (!) (lateral and ventral funiculi), thalamus, anterior and superior thalamic radiations, primary somatosensory cortex (+ prefrontal lobe and cingulate gyrus in case of sensation). 3. Dorsal (posterior) : - proprioceptív sensibility from areas supplied by spinal nerves from C8 to L2, - receptors, dorsal root ganglion, thoracic nucleus (of Clarke, C8-L2), tract on the ipsilateral side (!) (lateral funiculus), inferior cerebellar peduncle, vermis (mossy fibre). 4. Ventral (anterior) spinocerebellar tract: - proprioceptív sensibility from areas supplied by spinal nerves below L2, - receptors, dorsal root ganglion, interneurons in the dorsal horn, tract on the contralateral side (!) (lateral funiculus), superior cerebellar peduncle, vermis (mossy fibre). 5. : - protopathic sensibility from areas supplied by cranial nerves V, VII, IX, X., - receptors, trigeminal (CN V), geniculate (CN VII), sup. and inf. (CN IX), sup. and inf. (CN X) ganglia, nucleus of spinal trigeminal tract, lemniscus (contralateral), thalamus, anterior and superior thalamic radiations, primary somatosensory cortex (+ prefrontal lobe and cingulate gyrus in case of pain sensation). 6. Dorsal trigeminal lemniscus: - epicritic sensibility from areas supplied by CN V,

8 - receptor, trigeminal ganglion, principal sensory nucleus of trigeminal nerve, lemniscus (contralateral), thalamus, superior thalamic radiation, primary somatosensory cortex. 7. Mesencephalic trigeminal tract: - proprioceptive reflex of muscles of mastication!!!, - receptor, tract (ipsilateral), mesencephalic nucleus of trigeminal nerve, tract (ipsilateral) , motor nucleus of trigeminal nerve. 8. Frontopontine (of Arnold) and occipitotemporoparietopontine (of Türk) tracts: - from the corresponding lobes of telencephalon to the pontine nuclei, from there as pontocerebellar tract to the contralateral hemisphere of cerebellum (through middle cerbellar peduncle), termination by mossy fibres. 9. Anterior thalamic radiation: - anterior thalamic nuclei → cingulate gyrus (limbic system), - medial thalamic nuclei → prefrontal cortex (pain sensation). 10. Superior (middle) thalamic radiation: - ventrolateral thalamic nuclei → primary sensory cortex, parietal cortex (sensory integration) (+ primary motor and premotor cortices). 11. Acustic radiation: - medial geniculate body → posterior transverse temporal gyri. 12. Optic radiation: - lateral geniculate body → striate (visual) cortex (occipital lobe). (N.B.: 11. + 12. = posterior thalamic radiation!) 13. Medial longitudinal fascicle: - connection between the central eyefield (), the , the nuclei of extraocular eye muscles and the motoneurons innervating muscles of the neck. 14. Corticonuclear tract: - tract from the precentral gyrus and the somatomotor nuclei of cranial nerves, - components: corticomesencephalic (which CN nuclei are in the mesencephalon?) and corticobulbar (which CN nuclei are in the pons and the medulla?) tracts. 15. : - pre- and postcentral gyri (giant pyramidal cells of Betz), internal capsule (posterior crus!), cerebral peduncle (crus), pons, medulla oblongata (pyramis), most of the fibres cross to the contralateral side, lateral funiculus of the spinal cord, most of the fibres indirectly (through interneurons) innervate motoneurons (of muscles of limbs), - uncrossed fibres cross at the level of their termination, mostly indirectly innervate motoneurons (of muscles of trunk, shoulder and pelvic girdle). 16. Vestibulo-, reticulo-, tecto-, rubrospinal tracts: - origin and termination are enough (the name implies them, as it also does the function). 17. Dentorubral-, dentothalamic-, cerebellovestibular tracts: - origin and termination are enough.

9 Internal capsule: - position, borders, parts and blood supply, - anteror crus (or limb): frontopontine tract (of Arnold), ant. thalamic radiation, - genu: corticonuclear and corticorubral tracts, - posteror crus: corticospinal tract, superior thalamic radiation, parietotemporo- occipitopontine tract (of Türk), acustic (sublentiform position) and optic (retrolentiform position) radiations.

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