[BLANK_AUDIO]. Welcome back to Medical Neuroscience. I wanted to spend just a few minutes with you today giving you a sense of how to prepare for our final examination that we have in Medical Neuroscience. it is a comprehensive examination. It is an attempt to stretch both your learning and your application of that knowledge in more of a clinical direction than where we've gone this far in the course. So I think it would be helpful if I spoke to you for a few minutes to prepare you for this last learning experience in the course. So what to expect on our final examination? Well, in terms of the logistics, you can expect there to be 43 multiple-choice questions. that number may change a little bit as we finalize things, but that's The way it's shaping up at the present time. So ti will be a multiple choice examination. Now, what's going to be a bit different than most of the assessments you've seen so far in the course is that these questions will be organized around clinical case vignettes. yes, in our unit quizzes, we have had opportunity to think about clinical cases and challenge your understanding of functional neuroanatomy and we've done that in the neuroanatomy exam as well. But here in this exam, my goal is to ask you a series of questions that really can pertain to just about any aspect of the content of the course we've covered so far, but as they pertain to a particular case history. So I want you to recognize the questions I'm asking you pertain to the description of this person and the neurological issues that they present. So just be prepared to think that way and I'll give you some guidance in just a few minutes as to how to begin to mobilize your knowledge and put it into more of these kinds of clinical contexts that I think will really help you apply the learning that you've done throughout the course. And the questions that I present for you will be organized around our six major themes. These are the themes that are represented in the units of medical neuroscience. of course there will be functional neuroanatomy but not at the same level of detail and emphasis that I asked you about in the neuroanatomy exam. my goal there was to probe more thoroughly your knowledge of functional human neuroanatomy. but of course we, we cannot have a comprehensive examination. And we cannot have a cogent discussion around clinical cases without also having a clear neuroanatomical framework that helps you understand what might be going on in that patient. So functional neuroanatomy will be an important component of this examination. We'll have questions that pertain to neural signalling and plasticity of synapses and circuits. Of course, there will be emphasis on sensory systems and the basis of sensory perceptions. likewise, there will be significant content pertaining to motor systems and the control of movement and we'll have some questions in some of the cases that pertain to your understanding of the associative functions of the cerebral cortex among other more complex brain functions. Now I'd like to tell you a little bit about my approach to managing this examination. So, first of all, I want you to understand that I see this as not just a final examination but I see this as first and foremost the final learning experience that we get to share together in medical neuroscience. Now I understand, of course, as you do that this examination is essentially a take home examination. You have multiple attempts at it. So this gives me just a little bit of license to try to craft it less as an assessment of fact and detail, and more of an opportunity to mobilize your knowledge and apply it in a context that, I think, will be meaningful to you. After all, this is medical neuroscience. We have been emphasizing the foundational neuroscience that underlies clinical practice. But this examination is an opportunity to begin to move that knowledge more towards the clinical context. So, I want you to learn while you do this examination. You might want to plan on having at least a couple of attempts at this examination, so that you can improve your learning as you go. I want this examination to require integrative thinking. I want you to be confronted with a clinical case that requires you to think about the basis of synaptic transmission in the brain and potentially the consequences when synaptic transmission goes awry. And I want you to be able to think at a very large scale level in terms of the whole patient and the potential functional impairments that one might find when a patient is, let's say, experiencing a stroke or seizure or some other kind of disorder or dysfunction of brain activity. So, I want you to think in an integrative way, across the scales of organization that we've discussed in this course. From the cellular and synaptic level, right on up through the level of human behavior. And, of course, I want to emphasize again the importance of having an accurate functional neuroanatomical framework for understanding what's going on in your patient. And in the diagnoses that are common when presented with a patient with neurological injury or dysfunction, your principal aim is to localize the lesion. Because once you have an anatomical picture of where the lesion is localized, then that leads you towards appropriate intervention. for example it, it, it, does matter, it should matter, whether the lesion that produces weakness in one side of the body is localized to the spinal cord, and may be a neoplasm or that this weakness is attributable to a more acute event up in the cerebral cortex. And our approach to how we treat such a patient, how we promote rehabilitation and optimization of health status and functional ability is going to depend upon having that accurate neuroanatomical framework. And I'll just encourage you and remind you that great neurology, great clinical neuroanatomy has been in practice many, many decades prior to the invention of the magnetic resonance imaging machine. one of my concerns for our modern education of practitioners in the medical sciences, is that we rely perhaps a bit too much on imaging without first relying on our capacity to take a history, to acquire a physical examination findings, and then to build an anatomical framework that helps us understand the localization of a lesion in the nervous system of a patient. Prior to the time that we then explored the anatomy of that patient with our modern imaging methods. So, obviously we need both. We need the clinical expertise, and we need the best technologies that can help us understand the nature of injury and disease that afflicts the nervous system. Now how to study and learn. Well, I'd like to just briefly remind you of some of my tips that I gave you right at the onset of the course. And hopefully, I can reinforce them just a bit now. And that will prepare you for making the most of this final learning experience. So my tip number one is to follow the path. So I've tried to give you a path. I've tried to lay out for you a coherent curriculum through the content of this course. you'll be the judge as to how successful I've been in laying out that path. like this beautiful path through the rainforest in the great Pacific Northwest of, of this continent sometimes the path is clear. sometimes it's it's, it's not quite so clear. and we have to blaze a trail forward. But nevertheless I have tried to give you a path to follow and I would encourage you to continue to follow that path through the conclusion of the course. And I'll give you some study tips. in just a moment that will give more detail to that path that I think will be most productive for you. But, tip number one is to get yourself organized for this journey even to the finish line at the end of the course and follow this path. My second tip is to visualize your knowledge. I've tried to encourage you to do that via our peer assessment opportunities in the course, but I certainly would encourage you to continue to improve your knowledge by making it visible. And I'll say more about that, also, in just a moment. I think we have wonderful opportunity to learn spatially. perhaps one of my regrets in this first iteration of medical neuroscience is that I've not encouraged you to do this more regularly throughout the course. And in future editions of medical neuroscience, I think I will exercise some of the spatial learning approaches that I use here on campus with my own students. But I just love this concept of letting our medial temporal lobe memory system not just manage semantic symbols, but do what it has evolved to do, which is to map our environment and our position within it. And I love the idea of making your knowledge fill the space around you, and physically move through that space as a way of building association and consolidating your learning. And I love this image from an art installation where myself and my son were embedded in this environment, this artistic creation. And it was such a wonderful illustration. For me of what it means to immerse oneself in the knowledge that defines your environment. Well my final tip for you is to learn socially. Now that's a challenge for, for many of us, I know, especially in our global learning community. But I am just so pleased to see so many of you come together in the discussion forum and really lend a helping hand to one another in a positive and encouraging way. I think that's the power of the learning community that we can build, even in an online course such as this. So I'm very grateful to all of you that have contributed so well and so constructively in that process. And encourage you all to continue that, and even to extend it to face-to-face encounters. I think it would be wonderful to share with your friends and family some of what you've been learning in medical neuroscience. See, if you can't explain to a loved one the ionic basis of the action potential or the mechanisms of synaptic plasticity that are responsible for learning, and memory in the nervous system. Or why a particular stroke involving a particular artery produces the functional impairments that we often see from a clinical point of view. So learn socially, and I think you'll be very productive. Well, I want to give a little bit more detail to my first tip. Follow the path. And what I want to do is to really focus on learning clinical neuroanatomy, which gives us a wonderful framework for synthesizing and integrating our knowledge of medical neuroscience. So, here's a bit of a strategy that I found to be successful personally, and I know many of my students on campus feel the same way. So let me just share with you some of these steps in a bit more detail, and maybe you can freeze frame and capture some of the specific tips that I'm about to provide for you as you organize yourself for preparing for this final. So step number one study the pathway. So know the essential elements of each pathway. And here is basically a list of the pathways that I want you to be able to represent in your knowledge and your drawings. I want you to be able to accurately depict the dorsal column medial lemniscal pathway. As well as the anterolateral pathways that subserve mechanical sensation and pain and temperature sensation for the post-cranial body. I'd love for you to be able to do the same for the face via our trigeminal system. the visual system has been very important, throughout this course, and it's very critical that you understand the connections from the retina on up through the visual cortical areas in the occipital lobe and into the parietal and temporal lobe, so be familiar with the retina-geniculate striate pathway that's responsible for visual perception. the pupillary light reflex is a very important diagnostic reflex to know how to evaluate, how to interpret, so familiarize yourself with that reflex. Now into the motor system. you certainly should be quite confident in your understanding of the lateral corticospinal tract. You should also be familiar with our medial spinal pathways. Those pathways that set the stage for the expression of skilled behaviors. You should be familiar with the pathways in and out of the cerebellum, as well as the direct and indirect pathways through the basal ganglia. Now I know this is a lot and this is a tremendous amount of detail to master. But if you can break it down into the systems level pathways that are responsible for sensation, for motor control and the integrative actions of the nervous system. Now I think you will be well on your way to mastering the essential content that is a critical component to clinical practice, no matter what kind of a practitioner you may be or you may aspire to become. Well, that was more detail than will be shared in the following tips but as you've heard from me already. I'm a firm believer in creating your own visual representations, be it through drawings or some other means. I want you to be able to challenge yourself to make your conceptions visible, and as you've heard repeatedly from me, when it comes to drawing, the bigger, the better. Another tip. I think we spend way too much time sitting down in stable postures in front of fixed surfaces. I think our learning and our creativity is really mobilized when we move our body. So when you draw, I would suggest that you, you draw standing up, or you make your drawings sufficiently large that you simply have to move. And I think you'll find that this can be a tremendous assistance to your studying and learning, not just in this course but in whatever endeavors you may be pursuing. Well, step number three is to begin to push your knowledge and your representations into the social domain of our human relations. So discuss the pathways, verbalize orally your understanding. So, here are some questions that you can ask if you get a drawing in front of you that perhaps has neurons along a sensory or motor pathway. You can point to an axon, and you can ask yourself questions such as, where does this axon originate? Or in other words, where are the cell bodies that grew out theses axons? And this is one way to get to a level of detail that's critical for understanding functional neuroanatomy. One might ask the same kind of question in the intrograde direction. You may want to ask, where do the axons in question terminate? Where are the synapses made by the axon in question? Again, our focus will be on the level of detail that is essential for localizing lesions in the central nervous system. Now, one might also ask about cell bodies and begin there so one could identify a cell. Let's say, it's a dorsal root ganglion cell or perhaps a cell in oh, let's say the thalamus, and you might ask where are the axons terminating that grew out from these cells. Now, in all of these kinds of questions when you're talking about the anatomy of pathways, it's so important to understand decussation, that is, where is there a midline crossing. So one way to rehearse your knowledge of decussation is to be as specific as you can about addressing these questions. So for example, if you were to ask yourself or a study partner, where do the axons in the medial meniscus originate? A great answer would be the contralateral dorsal column nuclei. Okay? So the concept of contralateral there emphasizes that you understand that the decussation has happened. prior to the collection of axons that actually form the medial lemniscus. Okay. Step number 4 is to actually begin to explore the anatomy of the nervous system through our digital atlases, or perhaps you have some textbooks or paper atlases at your disposal. But actually find the pathways. Identify the pathways and cross sections through the brain and the spinal cord. So, identify the key elements of these pathways that you've depicted in your drawings. The locations of axons, the location of cell bodies and critical gray matter structures. Now I would again be very pleased if you were to use Sylvius4 for this exploration, but there are so many wonderful products out there. I'm really happy for you just to dive in to some accurate representation of the actual structure of the human brain as it's presented. either in histological atlas or a photographic atlas. And finally, my fifth tip is to begin to take your knowledge of these different systems and components and build it together into a framework [SOUND] that really defines the spaces and structures of the central nervous system. For example, I would want you to be able to ask questions, such as, well, what would happen if we had a stroke that involved the right vertebral artery, which supplies brain structures in the right ventral medulla and caudal pons? So you might want to think about well what comes together along the ventral and medial aspect of the medulla. And that should point you towards structures such as the medullary pyramid, the medial meniscus, maybe even a cranial nerve that is associated with that level of the nervous system. And then in that case, the cranial nerve in question would be the hypoglossal nerve. So, I want you to be able to really take advantage of your knowledge of the vascular system to put a focus on this exercise. So I want you to be able to discuss what happens when regions of the nervous system are injured. And a great way to do that is to appeal to the vascular anatomy that we've learned. And that anatomy would include knowing the distributions of the major cerebral arteries, the middle cerebral artery, the anterior cerebral artery, the posterior cerebral artery, including the branches of some of these that supply deeper structures, and more posterior structures, such as the brain stem. I'd want you to be able to understand the penetrating or circumferential branches of the basilar and vertebral arteries, the cerebellar arteries, and understand how they supply these sectors or wedges of the brain stem. And the same would be true for the spinal arteries, the posterior spinal artery and the anterior spinal artery. So I think with this path made a little bit more clear with this guidance, you will be successful in this final learning experience in medical neuroscience. not only might you pass the course with the honor of distinction, but you will be affirmed as having succeeded on, on really quite an arduous journey. I know it's been difficult or you to follow this path that I've laid out for you given the amount of information that I've tried to convey, and the challenge of consolidating it all. But I hope that you find this to be an affirming experience, as you take this journey to its end, as we approach our final event in medical neuroscience. So with that said, I look forward to seeing you on the other side of the final exam in one form or another. And I trust that you'll be successful. And that you're learning and your hard work will be validated and affirmed.