Discussion and Reference Manual 2019 Copyright Ownership AANI owns all copyright rights in the RITE® examination materials, including the examination questions, graphics manual, and the discussion-and-reference manual. If you are interested in receiving a license from AANI to create study materials based on the RITE discussion-and-reference or graphics manuals (or both), please contact Academy staff at [email protected]. Anatomy Question 5: Anatomy - Peripheral Nervous System Discussion: The parasympathetic nervous system governs pupil constriction, bronchoconstriction, detrusor contraction and sphincter relaxation, and penile erections. References: Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005. Question 6: Anatomy - Cortex and Connections Discussion: The orbitofrontal syndrome consists of socially inappropriate behaviors as well as poor impulse control with disinhibition. The lateral convexity syndrome is associated with dysexecutive symptoms. The mesial frontal syndrome is associated with amotivation. References: Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, 2003. Question 7: Anatomy - Cranial Nerves Discussion: This patient presents with a combination of optic nerve dysfunction and ocular motility deficits. The oculomotor, trochlear, and abducens nerves all traverse through the cavernous sinus and superior orbital fissure into the orbital apex. The optic leaves the orbital apex through the optic canal and does not run through the cavernous sinus. In this context, the combination of optic nerve dysfunction and ocular motility deficits localizes to the orbital apex. References: Wilson-Pauwels L, Akesson E, Stewart P. Cranial nerves: anatomy and clinical components. Toronto: BC Decker Inc, 1988. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002. Question 12: Anatomy - Basal Ganglia and Thalamus Discussion: Thalamic astasia is characterized by an alert and awake patient with normal strength who cannot stand and sometimes sit unassisted for several days after an acute stroke. The patient may have varying degrees of sensory loss. They typically fall backwards or to the side opposite of the lesion. Lesions of the subthalamic nucleus are typically associated with hemiballismus, and putaminal lesions are often associated with weakness and chorea. Injury to the vestibular nucleus typically results in nystagmus and a tendency to fall toward the side of the lesion. Cortical areas critical for gait include the medial frontal region, the paracentral lobule, and the supplementary motor cortex. References: Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2011. Question 21: Anatomy - Cortex and Connections Discussion: Fifty patients with elevations of serum cardiac troponin levels had strokes involving the right posterior, superior medial insula, and the right inferior parietal lobule. Among patients with right middle cerebral artery strokes, the insular cortex was involved in 88% of patients with elevated serum cardiac troponin but in only 33% of patients without the elevation. References: Ay H, Koroshetz WJ, Benner T, et al. Neuroanatomic correlates of stroke-related myocardial injury. Neurology 2006; 66: 1325- 1329. Question 29: Anatomy - Peripheral Nervous System Discussion: The biceps are innervated by the musculocutaneous nerve, which arises from the lateral cord of the brachial plexus. The pronator teres is innervated by the median nerve from axons that travelled in the lateral cord of the brachial plexus. The deltoid is innervated by the axillary nerve, which arises from the posterior cord of the brachial plexus. The brachioradialis is innervated by the radial nerve, which arises from the posterior cord of the brachial plexus. The rhomboid receives supply directly from the C5 root. The supraspinatus is innervated by the suprascapular nerve, which arises from the upper trunk of the brachial plexus. References: Preston DC, Shapiro BE. Electromyography and neuromuscular disorders: clinical-electrophysiologic correlations. 3nd ed. Philadelphia: Elsevier, 2012. Question 40: Anatomy - Basal Ganglia and Thalamus Discussion: The caudate and the putamen serve as the primary input nuclei for the basal ganglia. The globus pallidus, which projects to the ventral anterior nucleus of the thalamus, is the primary output nucleus. The substantia nigra pars compacta, located in the midbrain, sends dopaminergic fibers to the putamen. The subthalamic nucleus receives inhibitory input from the external part of the globus pallidus and sends excitatory input to the globus pallidus pars interna. References: Carpenter M, Sutin J. Human neuroanatomy. 8th ed. Baltimore: Williams and Wilkins, 1983. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002. Question 45: Anatomy - Cranial Nerves Discussion: This patient presents with a pupil-sparing third nerve palsy. The oculomotor nerve innervates the medial, superior, and inferior recti, the inferior oblique, and levator palpebrae muscles. In ischemic third nerve palsies, the pupil is typically spared, as is the periphery of the nerve, where the pupillomotor fibers course. In contrast, posterior communicating artery aneurysms typically cause third nerve palsies involving the pupil, as they compress the nerve, and therefore the peripheral pupillomotor fibers. References: Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002. Question 48: Anatomy - Brainstem/Cerebellum Discussion: This patient's eye movements are consistent with the "one-and-a-half" syndrome in which the ipsilateral eye has no horizontal movements and the contralateral eye is only able to abduct. The clinical findings are a combination of a left intranuclear ophthalmoplegia (which prevents the left eye from adducting on rightward gaze with end-gaze nystagmus of the abducting right eye) and a left abducens nuclear palsy (which produces an ipsilateral gaze palsy preventing the patient from looking left). The only horizontal eye movement still possible, then, is abduction of the right eye on rightward gaze. This lesion must involve the left medial longitudinal fasciculus and left abducens nucleus. References: Carpenter M, Sutin J. Human neuroanatomy. 8th ed. Baltimore: Williams and Wilkins, 1983. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002. Question 69: Anatomy - Cortex and Connections Discussion: Fibers in the inferior aspect of the retina detect vision in the superior quadrants. After synapsing in the lateral geniculate, those fibers enter the temporal lobe as Meyer's loop, and project to the occipital lobe. The superior visual fields project to the inferior lip of the contralateral calcarine sulcus. References: Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005. Question 82: Anatomy - Cranial Nerves Discussion: When the eye is abducted, the primary depressor is the inferior rectus. When the eye is adducted, the superior oblique and inferior rectus depress the eye. When the patient looks down and to the left, she is primarily using the right superior oblique and left inferior rectus. References: Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005. Question 89: Anatomy - Basal Ganglia and Thalamus Discussion: Cheiro-Oral Syndrome is a lacunar syndrome characterized by contralateral sensory deficits of the mouth and hand. It typically localizes to the VPM and VPL in the thalamus. References: Shirish Satpute, D.O., John Bergquist, M.S., and John W. Cole, M.D., M.S.. Cheiro-Oral Syndrome Secondary to Thalamic Infarction: A Case Report and Literature Review. Question 92: Anatomy - Spinal Cord Discussion: On the ipsilateral side of a spinal cord hemisection there would be an upper motor neuron syndrome, greatly impaired discriminatory tactile sense, and reduced muscle tone below the level of the lesion. Contralateral to the lesion there would be loss of pain and temperature due to interruption of the ascending spinothalamic tracts (which cross soon after entry) References: Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, 2002. Question 107: Anatomy - Peripheral Nervous System Discussion: The short head of the biceps femoris is the only muscle proximal to the knee innervated by the peroneal division of the sciatic nerve. Needle EMG abnormalities of this muscle would indicate that a lesion of the peroneal nerve would have to be proximal to the fibular head. References: Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005. Question 109: Anatomy - Brainstem/Cerebellum Discussion: Auditory fibers from the superior olivary nucleus ascend in the lateral lemniscus to reach the inferior colliculus. The electrical activation of the lateral lemniscus is reflected in wave 4 of a brainstem auditory evoked potential. The fibers in the trapezoid body arise from the ventral cochlear or the superior olivary nucleus and decussate to the contralateral side. References: Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, 1991. Question 111: Anatomy - Brainstem/Cerebellum Discussion: Palatal myoclonus or palatal tremor is characterized