Easy and Interesting Approach to

HUMAN NEUROANATOMY
(Clinically Oriented)
 Easy and Interesting Approach to
HUMAN NEUROANATOMY
(Clinically Oriented)

SAMAR DEB MS
Professor of Anatomy
Agartala Government Medical College
Agartala, Tripura
India

Formerly
Academic Director and Professor of Anatomy
Katihar Medical College, Katihar
Bihar, India

Principal and Professor of Anatomy

College of Medicine and JNM Hospital, Kalyani, Nadia,
West Bengal, India

Dean and Professor of Anatomy

North Bengal Medical College, Sushrutanagar, Darjeeling,
West Bengal, India

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Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

First Edition: 2014

ISBN 9789350909409

Printed at ? ? ?
 Dedicated to
My parents
who trained me to face and to overcome
all kinds of hardship in life

and

My teachers
who gave me the direction to achieve
the success in life.
 PREFACE
Just to Justify the Birth of First Edition

During the long journey of my teaching experience for more than 40 years, I had the opportunity to notice the
metamorphosis of my subject, Anatomy. I still remember my memorable days as a student of 1st professional
MBBS (1st MBBS) course, when my esteemed and respected teachers, as stalwarts in the field of anatomy,
used to be satisfied only after getting answers of the questions like, what are the structures passing through
canaliculus innominatus (not foramen ovale!) or what are the structure punctured, in order from superficial
to deep, if a deep pin-prick is made at the apex of femoral triangle. I have experienced that while asked
in examination, marks were divided for enumeration of the structures related to lateral aspect of palatine
tonsil starting from paratonsillar vein (of great clinical significance) up to ramus of mandible(!). My learned
renowned teachers had been very caring to teach all these details to us. But it was the time when Anatomy
used be taught as only Anatomy.
Since the beginning of my teaching profession, as time rolled on, I observed revolution in the subject of
anatomy. Gradually, the subject became more and more delicious when we achieved the techniques to bite
through the dry and hard cortex to enjoy the taste of juicy marrow of the subject through its more horizontal as
well as vertical integration and clinical orientation, of course, with omission of unnecessary details. I believe,
all anatomists like me, are thankful and grateful to Medical Council of India and Anatomical Society of India
who have been pioneer to bring this revolution.
My present submission, Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented),
is an attempt to follow the revolutionary path. Avoiding further details, I can only say, the title of the book,
through its every word, of speaks of its aims and objectives.
About the subject Neuroanatomy, it is well-known to all that, this branch of anatomy is characterized
by various negative adjectives such as, rough and tough, difficult, less important, not much required at
undergraduate level, etc. Undergraduate students are usually in a habit of ignoring or being away from it
as very often they are scared of. But they must know that this branch of anatomy can never be avoided in
professional life. Because Neuroanatomy deals with the study of nervous system which, being the master
system, regulates bodily functions performed by all other systems of body.
An effort has been made to deliver this subject through this book to the doorstep of readers of all levels in
easiest, simplest, and most interesting form.
It is not only the appreciation, if any, but also comments and criticisms are expected from anybody, anytime,
anywhere, its next edition.

Samar Deb
 ACKNOWLEGDMENTS

My Hats off to:

My beloved students, undergraduates as well as postgraduates, of all the times and all the places, for taking
keen interest for the classes for all the times in my life, which enabled me to present any topic in most
palatable and interesting way, even for one of them sitting in the backbench.
My honorable teachers, of all the times and all the places, from whom I gathered many stones to build an
approach road through which I have been able to reach the destination of art and quality of a good teacher.
My special tribute to Prof Shamer Singh, Prof GC Sen Sharma, Prof PR Roy, Prof NH Keshwani, Prof Samar
Mitra, Prof NG Das, and Prof SM Sen.
My cordial colleagues, senior and junior, and professional friends of all the times and all the places, including
those of my recent institutions, Agartala Government Medical College and Katihar Medical College. Special
mention is needed for those of my IMS, BHU days, namely Prof Shyamal Kumar Basu, Prof SN Samal, Prof.
Mandavi Singh, Prof JD Singh, Prof SK Pandey and Prof Gajender Singh.
Prof DN Choudhury, Prof. Swarup Kumar Dey, Prof KL Talukdar, Prof BK Khan, Prof Parthapratim
Pradhan, Prof. Kalyan Bhattacharya, Prof Hasi Das Gupta, Prof Karabi Baral and Prof Soumya Bhattacharya
from whom I have learnt something to flourish my creative ideology.
Prof CR Maity, Ex-director of Medical Education, Government of West Bengal, my inspiration in professional
life.
Prof Sibani Mazumdar and Dr Seikh Ali Amam, my colleagues and Dr Ansuman Ray, Dr Sudipa Biswas,
Dr Maitreyee Kar, Dr Hironmoy Roy, Dr Saif Omar and Dr Ananya Biswas, my bright postgraduate students
who constantly insisted me for writing this book.
All the eminent personalities in field of anatomy of the country whom I met sometime and somewhere
through which I have been able to enrich my knowledge.
All concerned authorities of Medical Council of India and Anatomical Society of India who brought the
revolution in teaching of anatomy to make it more interesting and integrated.
All the dignitaries, officials, and staff of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India
for giving the valuable opportunity to my creation to find the light of the earth.
Dr Malay Chakrabarty, famous neurosurgeon of Eastern India for giving necessary advanced information
on clinical relevance.
Shams Jamal Hashmi, for his untiring, meticulous and sincere work beyond his usual official job hours, in
connection with all computer works. Sri Ashok Sharma (Uprety), for his very caring technical assistance time
to time.
Paromita, for her heartful help to give final shape of the production.
Ghazi Danish Ahmad, System Engineer, Information and Technology Section, Katihar Medical College for
his technical assistance in connection with my work.
SZ Khan, Chief Librarian, Katihar Medical College and all his associates for all kinds of help from the
beautiful and very enriched library where I spent many hours for many days.
Madhubanti, my daughter, as she used to admire whenever she came close to my working table during
the late hours of the days, while at home. All my family members and all other near and dear, for their moral
support.
 CONTENTS

Chapter 1.
Introduction to Human Neuroanatomy 1
Principles of Functions of Nervous System 1

Chapter 2.
Nervous System in Brief 20
Central Nervous System 20
Brainstem26
Cerebellum28
Peripheral Nervous System 35
Chapter 3.
Peripheral End Organs 44
Receptors44
Receptors Other Ways of Classification 51
Motor End Organs (Effectors) 51
Motor Unit 53
Nerve Ending Related to Exocrine Gland Acini 56
Chapter 4.
Spinal Cord 57
Definition and Situation 57
Role of Spinal Cord as a Part of Central Nervous System 57
Extent57
Important Notes in Connection with Termination 57
Parameters of Spinal Cord 57
Regional Classification of Spinal Cord Segments 58
Exit of Spinal Nerves from Vertebral Foramen 59
Correlation of Spinal Cord Segments with Vertebral Level 60
Enlargement60
Surface Features 60
Coverings (Meninges) and Spaces Around the Spinal Cord 61
Internal Structure of Spinal Cord 63
Formation of Different Zones of Spinal Cord 64
Formation of Different Functional Cell Groups 65
Peripheral Outflow of Spinal Cord 66
Internal Structure of Spinal Cord 66
Internal Structure of Spinal Gray Matter 69
Various Cell Groups of Spinal Gray Matter 69
Cell Groups in Posterior Gray Column 69
Cell Groups in Intermediate Area of Spinal Gray Matter 70
Cell Groups in Anterior Gray Column 70
Cell Groups Around Central Canal 71
Rexeds Lamination of Spinal Gray Matter 71
Internal Structure of Spinal White Matter 72
Rubrospinal Tract 80
Tectospinal Tract 81
Vestibulospinal Tracts 82
Reticulospinal Tract 83
Olivospinal Tract 83
Hypothalamospinal Tract 83
Solitariospinal Tract 83
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Chapter 5.
Brainstem 94
Medulla Oblongata 124
Pons125
Midbrain126
Traumatic Lesion 126
Chapter 6.
Cerebellum 128
Introduction128
Position and Relations 128
Principle of Functions 129
Gross Anatomy 129
Primary Fissure and Lobes of Cerebellum 130
Phylogenetic Classification of Cerebellum 131
Internal Structure of Cerebellum 132
Structural detail of Cerebellar Cortex 134
Mechanism of Cerebellar Cortical Circuit 134
White Matter of Cerebellum 135
Nuclei of Cerebellum 135
Relationship Between Cerebellar Nuclei and Mediolateral Subdivisions of Cerebellar Cortex 136
Cerebellar Peduncles 136
Impaired Function of Paleocerebellum 138
Impaired Function of Neocerebellum 138
Chapter 7.
Fourth Ventricle of Brain 139
Chapter 8.
CerebrumCortical Gray Matter 144
Introduction144
Cerebral Hemispheres 145
Medial Surface 153
Tentorial Surface 155
Orbital Surface 155
Some Important Points about Cerebral Cortex 155
Types of Neurons in Cerebral Cortex 155
Layer of Cerebral Cortex 156
Functional Areas of Cerebral Cortex 157
Functional Areas in Frontal Lobe 157
Functional Areas in Parietal Lobe 160
Functional Areas in Occipital Lobe 161
Functional Areas in Temporal Lobe 162
Chapter 9.
Cerebrum White Matter 163
Classification 163
Internal Capsule 172
Chapter 10.
Basal Ganglia 176
Chorea183
Ballismus183
Athetosis183
Parkinson Disease 183

xii
 Contents
Chapter 11.
Lateral Ventricle of Brain 185
Chapter 12.
Diencephalon  192
Thalamus193
Metathalamus198
Epithalamus200
Paraventricular Nuclei of Epithalamus 202
Habenular Nucleus and Habenular Commissure
(Consult Figures of Commissure in Chapter of White Matter of Brain) 202
Subthalamus203
Chapter 13.
Third Ventricle of Brain  211
Tela Choroidea and Choroid Plexus 214

Chapter 14.
Meninges of Brain and Cerebrospinal Fluid  215
Dura Mater 215
Arachnoid Mater 221
Pia Mater 223
Cerebrospinal Fluid 224
Chapter 15.
Blood Supply of Brain and Spinal Cord 228
Blood Supply of Brain 228
Variations of Circle of Willis 232
Cortical Branches Supplying Different Surfaces of Cerebral Hemisphere 234
Venous Drainage of Brain 236
Blood Supply of Spinal Cord 237
Venous Drainage of Spinal Cord 239
Blood-brain Barrier 240
Chapter 16.
Reticular Formation 245
Chapter 17.
Limbic System 253
Chapter 18.
Autonomic Nervous System 260
A component Parallel to Somatic Nervous System 260
Autonomic Nervous System and Endocrine system Jointly Maintain Internal Environment of body 260
Composition of Autonomic Nervous System 260
Subdivision of Autonomic Nervous System Sympathetic and Parasympathetic 261
Sympathetic Part of Autonomic Nervous System 264
Parasympathetic Part of Autonomic Nervous System 274
Injuries to Autonomic Nervous System 282
Diseases Involving Autonomic Nervous System 283
Combined Sympathetic and Parasympathetic Lesion Causing Urinary Bladder Dysfunction in Spinal Cord Injury 284
Disrupted Motor Functions of Bladder 284
Visceral Pain 285
Stomach Pain 286
Appendicular Pain 286
Renal Pain 286
Ureteric Pain 287

xiii
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Chapter 19.
Cranial Nerves 288
Olfactory Nerve and Olfactory Pathway 288
Optic Nerve and Visual Pathway 291
Optic Nerve 293
Optic Chiasma 293
Optic Tract 293
Lateral Geniculate Body (Third of Neurons) 294
Macular Vision 294
Clinical Examination of Retina 296
Detachment of Retina 297
Various Kinds of Loss of Visual Field 297
Argyll Robertson Pupil 298
Cranial Nerves Arising From Brainstem 299
Oculomotor Nerve 299
Postganglionic Branches of Ciliary Ganglion 302
Roots of Communication to Ciliary Ganglion 303
Trochlear Nerve 304
Trigeminal Nerve 305
Ophthalmic Nerve 308
Maxillary Nerve 311
Sphenopalatine Ganglion 312
Mandibular Nerve 313
Lingual Nerve 315
Inferior Alveolar Nerve 315
Auriculotemporal Nerve 316
Abducent Nerve 317
Facial Nerve 319
Vestibulocochlear Nerve 326
Vestibular Pathways 326
Cochlear Component of Vestibulocochlear Nerve 330
Last Four Cranial Nerves 334
Glossopharyngeal Nerve 334
Vagus Nerve 337
Accessory Nerve 343
Hypoglossal Nerve 347
Index 349

xiv
 Introduction to Human Neuroanatomy
Human Neuroanatomy is the division of Human Anat-
omy which deals with of Human Nervous System.
The Nervous System is defined as the Master of all
Systems or the Master System of the body, because
it controls or regulates all bodily functions performed
by other systems of the body, for example locomotor
system, gastrointestinal system, respiratory system.
PRINCIPLES OF FUNCTIONS OF NERVOUS
SYSTEM (FIG. 1.1)
When nervous system exerts its action over the other
systems of body, most simplified form of its action is
manifested basically as
1. Contraction of muscles.
2. Secretion of exocrine glands.
It may be noted here that the secretion of endocrine
glands is mostly under the hormonal control.
The muscles, whose contraction is regulated by
nervous system, may be voluntary (striated or skeletal)
or involuntary (nonstriated or smooth). Contraction of
the voluntary muscles results in movement of a joint.
The involuntary muscles may be in the wall or in the
substance of viscera, which are specifically called
Visceral muscle, e.g. in the wall of the gastrointestinal
tract, or tracheobronchial tree or in the substance of
any solid viscera. Again, the involuntary muscle may
be in the wall of the cardiovascular channel, e.g. in the
wall of the heart (myocardium) or in the wall of blood
vessel (tunica media). It may be also in the dermis of
the skin named the Arrectores pili.
1
The exocrine glands influenced by the activity of
the nervous system may be single and solitary like
any salivary gland or the lacrimal gland, or it may be
multiple and minute, like the mucous glands of the
wall of GI tract, or respiratory tract.
So result of functions of nervous system may be
summarized as follows
1. Contraction of voluntary muscle(s): Resulting
movement of a joint. It may result movement of
some organs, like tongue, eyeball.
2. Contraction of involuntary muscle(s) present in:
a) Viscera: It is called visceral muscle.
b) Wall of the cardiovascular system: Myocardium
of heart or smooth muscle in the wall of the
blood vessels.
c) Dermis of skin called Arrectores pili: It is
attached to the root of hair follicle.
3. Secretion of exocrine glands like:
a) Salivary glands or lacrimal gland: Large and
solitary.
b) Mucous secreting glands: In the wall of GI tract
or respiratory tractmany and minute.
But it is to be noticed that the functions of nervous
system do not mean only the effects as mentioned
above, but, in gist it also performs the followings:
(Fig. 1.1).
1. It receives and carries different information from
its periphery to center, which are related to change
in external and/or internal environment.
2. It perceives or acknowledges the informations at
its center.
3. It analyzes, integrates and coordinates the infor-
mations or inputs.
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
4. It commands for some effect after reception and,
integration or coordination of informations.
5. It stores the informations for the memory, intelli-
gence, learning and emotion of an individual.
SUBDIVISIONS OF NERVOUS SYSTEM (FIGS 1.2 AND 1.3)
A. Topographical Subdivision
1. Central: Part situated in the central axis of the
body, known as Central Nervous System. These
are Brain and Spinal cord. Brain is the proximal
expanded part situated inside the cranial cavity.
Distal, narrow, tubular and elongated part is the
spinal cord which is lodged in the upper two-third
of the vertebral canal. Grossly brain is divided into
three partsForebrain, Midbrain and Hindbrain.
Spinal cord is divided into 31 segments, which are
Sensory information
Received
and
Perceived
Sensory information
Carried from undermentioned
receptors
Due to change in
external/internal environment
Exteroceptor Proprioceptors
Touch Sensation from
Pressure muscles and tendons
Pain Sensation from
Temperature joints
Inputs
Fig. 1.1 Diagrammatic representation of principles of function of nervous system
2
classified regionally as Cervical-8, Thoracic-12,
Lumbar-5,Sacral-5 and Coccygeal-1.
2. Peripheral: This is known as Peripheral Nervous
System. This is peripheral outflow or peripheral
extensions from Central Nervous System in the
form of peripheral nerves. The peripheral nerves
are divided into two groups as
a) Proximal (Cranial): Cranial nerves, 12 pairs
arising as outflow from brain.
b) Distal (Caudal): Spinal nerves, 31 pairs, each
pair arising from each segment of spinal cord.
Central Nervous System may be compared as the
Director of an office, and Peripheral Nervous System
as the Field Staff. Like the Director, Central Nervous
System gathers information from and gives direction
to the Peripheral Nervous System, whose duty is to
convey information and also to carry out the order from
its Director, i.e. Central Nervous System, for action.
Stored for
Memory
Intelligence
Learning
Emotions
Analyzed Command
Integrated or
and directions
Coordinated given
Motor effect
Produced in the
form of
Contraction of
Contraction of involuntary muscles
voluntary muscles Secretion of
exocrine glands
Outputs

Midbrain
Brain
Brainstem Pons
Medulla oblongata
Spinal
cord
Fig. 1.2 Central nervous system
n Fundamental difference between the Cranial
and Spinal nerves:
All the spinal nerves contain sensory (incoming) fibers
carrying impulse (information) towards the central
nervous system and motor fibers (outgoing) carrying
impulse (directions) away from the central nervous
system to the effector organ, that is why all the spinal
nerves are mixed nerves. But some cranial nerves are
mixed like spinal nerves and some are either purely
motor or purely sensory.
B. Functional Subdivision
It is already understood that nervous system controls
various bodily functions. The simplified form of fun-
ctions controlled by nervous system are the follow-
ings:
Introduction to Human Neuroanatomy
Cerebrum
Brain
Cerebellum
Spinal nerves
Lower spinal
nerve forming
cauda equina
Filum terminale
i. Contractions of voluntary muscles to move the
joints or to move some organs like tongue, eyeball.
ii. Contractions of involuntary muscles like
a) Visceral muscles.
b) Smooth muscles in the wall of cardiovascular
channel.
c) Smooth muscles in the root of hair follicle of
skin, known as Arrectores pili.
iii. Secretions of exocrine glands which may be either
single, large, solitary, e.g. Salivary glands or
tiny innumerable, for examplemucous glands of
gastrointestinal and respiratory tract.
Out of these different functionsThe contractions
of voluntary muscles is controlled or regulated as per
ones own desire and is known as voluntary function,
whereas others are not under ones own control, called
involuntary function.
3
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

A cranial nerve among 12

pairs may be

Motor* Motor fibers of cranial nerves

carry out command or effects
BRAIN
Sensory*
Sensory fibers of cranial
or Mixed*
nerve carry sensory
information

S
P
I Sensory fibers of cranial
N nerve carry sensory
Each of the 31 pairs of spinal A information
nerves L
is
mixed*
C Motor fibers of spinal nerve
O carry out command or effects
R
D

Peripheral nervous system

Central nervous system

Acts as director Acts as field staff

Receives information Carries informations inwards
Analyze it Carries out directions or orders
Sends command outwards

Fig. 1.3 Central and peripheral part of nervous system

With the help of this background knowledge, it is
to be noted that functionally the nervous system is
classified as Somatic and Autonomic (Figs 1.4A
and B).
A. Somatic Nervous System: It is that division
of nervous system which controls or regulates the
voluntary functions, i.e. functions which can be perfo-
rmed as well as controlled as per ones own desire. It
is contraction of voluntary or skeletal muscles.
B. Autonomic Nervous System: It is that division
of nervous system which controls or regulates invol-
untary functions, e.g. functions which can neither
be preformed nor can be regulated as per ones own
desire. These are contraction of involuntary or smooth
muscles and secretion of exocrine glands.
4
Two parallel components of autonomic nervous
system:
They are called sympathetic and parasympathetic
nervous system. These two systems have anta-gonistic
actions on the same target organ, e.g. Parasympathetic
nervous system contracts the muscles in wall of
hollow viscera like GI tract (peristaltic movements),
but relaxes the sphincters; whereas the sympathetic
nervous system causes the opposite action on the same
target organ. Again in some cases either of them has
the influence, e.g. mucous glands of respiratory or
alimentary tract are under control of parasympathetic
nervous system, whereas secretion of sweat glands are
controlled by sympathetic system.
 Introduction to Human Neuroanatomy

Somatic
peripheral
outflow

Central nervous system

Exteroceptive brain and spinal cord
sensory fibers Somatic nervous system
Pain Temperature
Pressure Touch
Centers:

Proprioceptive sensory fibers Brain

from muscles and tendons and
spinal cord
[31 segments]

Motor fibers
To the effector organ, i.e. the
voluntary muscles

Fig. 1.4A Schematic representation of somatic nervous system (centers and outflow)

Autonomic
peripheral
outflow

Central nervous system

brain and spinal cord

Autonomic nervous system Sensory fibers

From all viscera

Centers:

Sympathetic motor
Sympathetic
T1 L2 (L3) segments of spinal
cord
G
Parasympathetic
Nuclei of 3rd, 7th, 9th, 10th
cranial nerves
C Para-
sympathetic
S24 segments of spinal cord motor

1. Motor fibers to involuntary

muscles
2. Secretomotor fibers to
exocrine glands

Fig. 1.4B Schematic representation of autonomic nervous system (centers and outflow) [G Autonomic ganglia Synaptic junction
between preganglionic and postganglionic neurons]
5
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
CENTERS OF NERVOUS SYSTEM
Center for somatic nervous system extend throughout
the whole length of brain and spinal cord, lying in
central axis of body.
Thats why it is called Central nervous system.
Centers for sympathetic and parasympathetic co-
mponents of autonomic nervous system are situated
in some of the levels of brain and spinal cord.
a) Sympathetic center is located in first to twelfth
thoracic and first and second lumbar (T1L2)
segments of spinal cord.
b) Center of parasympathetic system situated
partly in brain in the form of nuclei of some
cranial nerves (3rd, 7th, 9th, 10th). Again
part of its center is occupied in 2nd, 3rd, 4th
sacral segments of spinal cord (S24). These
centers for sympathetic and parasympathetic
components of autonomic nervous system
are of course, finally controlled by posterior
and anterior parts of hypothalamus of brain
respectively.
COMPOSITION OF NERVOUS SYSTEM
Nervous system is composed of very delicate and
sensitive tissue known as nervous tissue. In general,
it is known that a tissue is composed of cells and
intercellular substance. The intercellular substance
may be little or minimum as in epithelial tissue, or
Dendrites
Axonhillock
Nissl bodies
Nucleus
Neurofibrils
Fig. 1.5 A typical neuron
6
may be maximum as in connective tissue. But every-
where it is noncellular.
The structural and functional units of nervous
system are cells, known as Neuron. It is noteworthy
that in the nervous system, the intercellular substance
is not noncellular, rather made up of cells called
Neuroglia. The neuroglia, proportionately more in
number and primarily acting as supporting element
occupying the interstitial spaces between neurons.
NEURONS
The structural as well as functional units of nervous
system is Neuron.
It has two special properties
1. Irritability It is the power of a cell(neuron) by
which it is able to respond or react to change in
the environment (known as stimulus),which may
be external or internal (outside or inside the body).
2. Conductivity It is the power of a cell (neuron)
by which the excited state (known as impulse) is
propagated from the site of stimulus for a distance
to get the desired effect through hand to hand
contact of threadlike protoplasmic processes of
chain of neurons.
Structure of a Typical Neuron (Fig. 1.5)
A typical neuron is composed of
i. Cell body: It is known as Soma or Perikaryon and
ii. Processes: Thread- like protoplasmic prolongations.
Axon
terminal
Axon

Processes
The processes are of two types known as Dendrites
and Axons. Dendrites are the processes through
which impulse is transmitted towards the cell body.
Axons transmit impulse away from the cell body. So,
when an impulse passes through a chain of neurons,
it passes from axon of one neuron to the dendrite of
the next neuron of the chain (Fig. 1.6).
Number of processes in a neuron A neuron
always posseses at least one process, which is axon,
the number of which is always single. A neuron may
or may not have the Dendrites. If it is present, it may
be one or multiple (Fig. 1.7).
Cell body
It is the main expanded mass of cell with a centrally
placed nucleus containing a prominent nucleolus.
Cytoplasm has following unique characteristics:
a) Nissl bodies (Nissl granules/Nissl substance):
These are nothing but large aggregations of pro-
minently stained rough endoplasmic reticulum.
These are concerned with synthesis of enzymes
which are required for productions of chemical
substances known as neurotransmitters. Nerve
impulse is transmitted over the junction of
Dendrites
Axodendritic
Junction
(Synapse)
Fig. 1.6 Chain of neurons transmitting impulse (excited state of neurons) to target organ (e.g. skeletal muscle)
Introduction to Human Neuroanatomy
adjacent neurons (synapse) through those neuro-
transmitters. Nissl substances are absent not only
in the axons but also in the base of axons known as
axon-hillock.
b) Neurofibrils: These are ultramicroscopic thre-
adlike or fibrillar structures homologous to micro-
filaments of other cells. Neurofibrils are concerned
with maintenance of architecture of neuron and
acts as a storehouse of protein called Tubulin.
l Dendrites: They are fibrillar protoplasmic exten-
sions of neuron with the following characteristics
1. These are the processes through which impulse
travels towards the cell body.
2. Narrower in width.
3. Highly branched.
4. Branching of the dendrites are short known as
Dendrite Tree.
5. Terminal ends of dendrite tree are known as
Dendrite Spines.
6. Dendrites may be absent, if present it may be
single or multiple.
l Axon: It is the fibrillar protoplasmic extension of
neuron with following characteristics
1. These are the processes through which impulse
travels away from the cell body.
Axons
Target organ
(Skeletal muscle)
7
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

d d
d

C
d d d D

Figs 1.7 A to D Neurons showing variable number of processes

A One process Axon, B Two processes One axon and one dendrite,
C Three ProcessesOne axon and two dendrites, D Many processes One axon and many dendrites

2. Basal end is conicalknown as axon-hillock.
3. Wider in breadth.
4. It has no terminal branching, but from the middle
of the axon branching at right-angle may takes
place known as Collaterals.
5. Terminal end is expanded known as Telodendria
showing knob-like or button-like endings called
axon terminals or Terminal buttons.
6. Number of axon in neuron is always constantly
one.
It is important to notice that dendrites and axons
cannot be differentiated by their relative length. Some
neurons may have long axon. Again some may have long
dendrite. Fibers of median or ulnar nerve supplying
small muscles of hand are example of long axon. Wher-
eas fibers of saphenous nerve carrying sensation from
skin of foot are the example of very long dendrite. In
both the cases cell bodies are located in or very close to
spinal cord.
Neuronal (Axonal) Transport
Chemical substances synthesized in the neuronal
cell body are required to be transported through the
axon at its distal end. This is known as Orthograde
8
transport (Fig. 1.8A). These chemical substances
are either concerned with the nerve conduction,
when these pass through the interneuronal junction
(synapse) or these may be concerned with desired
function of nerve impulse when these reach the
effector organ. Sometimes chemical substances (may
be neurotoxins) liberated at the tissue level, absorbed
by axon terminals, are carried back towards the cell
body of the neuron. This is known as Retrograde
transport (Fig. 1.8B).
Classification of Neurons
1. According to number of processes (polarity)
(Figs 1.9A and B)
It is to be noted that, at one initial phase of
development, neurons used to have no process. How-
ever, this phase is followed by gradual appearance of
number of processes which will classify the neurons
as follows:
a. Unipolar neurons
These are developmentally primitive variety of neu-
rons with single process which is the axon. It is devoid
of any dendrites.
 Introduction to Human Neuroanatomy

Dendrite
Axon

Neurotransmitter

Fig. 1.8A Orthograde transport

Neurotransmitter passing from cell body of neuron to axon to neuronal junction (Synapse) to dendrite of next neuron

Toxin

Cell body Axon Tissue

Fig. 1.8B Retrograde transport, toxins liberated in tissue pass in opposite direction through axon toward cell body

Flask-shaped
Pyramidal (cerebrum) Polygonal (spinal cord) (cerebellum)

Unipolar Bipolar Pseudounipolar Multipolar neurons

Fig. 1.9A Types of neurons Fig. 1.9B Types of neurons

9
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
b. Bipolar neurons
These are the fusiform or spindle-shaped neurons
with one dendrite and one axon arising from opposite
poles. These are specialized neurons found in the
pathways of special senses, e.g. Retina (visual path-
way), nasal epithelium (olfactory pathway) and in
the vestibulocochlear nerve (auditory pathway for
hearing and equilibrium).
c. Pseudounipolar neurons
These are neurons with round or oval shape with a
common short stem of process dividing into peripheral
(dendrite) and central (axon) limbs. These neurons
are called pseudounipolar because apparently they
seem to have two poles. Classical example of these are
the dorsal root ganglion cells of spinal nerve lying just
outside and close to the spinal cord carrying sensory
impulse from periphery towards the spinal cord.
d. Multipolar neurons
These neurons present single axon with multiple
dendrites. Their shape will vary from triangular or
pyramidal to polygonal depending upon numbers
of dendrites so also the polarity. For example, the
neurons of motor area of cerebral cortex are pyramidal
or triangular whereas the motor neurons of spinal
cord are polygonal and neurons of cerebellum are
flask-shaped.
2. According to length of axon (Figs 1.10A and B)
a. Golgi type I (Fig. 1.10A)
Axons of these neurons are long in comparison to their
multiple short dendrites, viz. Pyramidal Neurons of
motor area of cerebral cortex, Anterior horn cells of
spinal cord , Purkinje cells of cerebellum.
Axons of pyramidal cells of cerebral cortex form
long descending tracts passing through the spinal
cord. Axons of anterior horn cells of spinal cord form
long peripheral nerves supplying voluntary muscles.
Purkinje cells axons form efferent fibers from
cerebellar cortex to relay in cerebellar nuclei situated
in its white matter.
b. Golgi type II (Fig. 1.10B)
Axons of these neurons are short, similar to the
length of the dendrites. Classical example of these

Brain

Upper motor
neuron
(Golgi type I)
with long
axon Long
axon

Interneurons
of spinal cord

Spinal cord

Lower motor
neuron (Golgi type I)
with long axon

Stellate (star-shaped) neuron of

A cerebellum (Golgi type II with short axon) B

Figs 1.10A and B A. Golgi type I neuron (with long axon), B. Golgi type II neuron (with short axon)
10

Cerebrum
(Brain)
Tertiary sensory neurons
Thalamus (Brain)
Secondary sensory neurons
Spinal cord
Fig. 1.11 Types of sensory neurons
neurons are stellate cells of cerebellar cortex, which
have short axon and multiple short dendrites giving a
star-shaped appearance. It forms synaptic connection
with too many neurons.
It is important to note that some of the neurons
may have single long dendrite. For example, fibers
present in the sensory nerves carrying sensory imp-
ulse from the periphery are the long dendrites of
sensory neurons present in the posterior root ganglia
of spinal nerve.
3. According to function of neuron
a. Sensory neuron (Fig. 1.11)
These neurons carry sensory impulse from a receptor
(sensory end organ) through the dendrite towards
the center of nervous system finally through axon.
From the sensory end organ or receptor situated
at the periphery of the body, the sensory nerve
impulse needs to pass through a chain of neurons
as the relay system to reach the center of nervous
system. The participating neurons in this chain
are classified as primary, secondary and tertiary
neurons (Fig. 1.11).
n Primary sensory (First order) neurons: They
start from the receptor or sensory end organ to enter
Introduction to Human Neuroanatomy
Primary sensory neurons
(Posterior root ganglion cell)
Peripheral process from sensory end organ
the central nervous system. Their cell bodies are
situated outside the central nervous system. Only
exception is the cell group of mesencephalic nucleus of
trigeminal nerve, whose cell bodies lie inside central
nervous system.
n Secondary sensory (Second order) neu-rons:
They are situated at the level of spinal cord which
receive impulse from 1st order of neurons.
n Tertiary sensory (Third order) neurons: They
relay the sensation from the secondary neurons to the
final target, i.e. cerebral cortex. First group of these
neurons are situated in the thalamus. The second or
final group is situated in the sensory area of cerebral
cortex.
b. Motor neuron (Fig. 1.10A)
These neurons carry outgoing motor impulse from
central nervous system to the peripherally situated
effector organs which are either muscles or glands.
l Types of motor neuron:
In somatic nervous systemUpper motor neuron and
Lower motor neuron.
i. Upper motor neuron: These motor neurons are
situated in motor areas of brain above the level
11
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
of spinal cord and brainstem (Midbrain, Pons
and Medulla).
ii. Lower motor neuron: These motor neurons are
situated in spinal cord.
4. Classification of neurons in relation to neuronal
junction(synapse) (Fig. 1.12)
Functions of a neuron depends upon the transmission
of impulse through a chain of successive neurons. The
junction of neuronal chain is known as Synapse or
Ganglion (pl. Ganglia).When related to a particular
synapse, the neurons are classified as
a) Presynaptic (Preganglionic) neuron: Proximal
to a synapse
b) Postsynaptic (Postganglionic) neuron: Distal to
the synapse.
In somatic nervous system, both the pre and post-
ganglionic neurons are situated inside the central
nervous system except the first order of sensory
neuron which lies outside of central nervous system,
e.g. Posterior root ganglia cells of spinal nerve. But in
autonomic nervous system the preganglionic neuron
is situated inside the central nervous system and
postganglionic neuron is situated outside the central
nervous system.
NEURONAL JUNCTION (SYNAPSE) (FIG. 1.12)
It has already been noticed that, when a neuron
is stimulated due to change in the environment,
Presynaptic neuron
A. Axodendritic synapse
B. Axosomatic synapse
Fig. 1.12 Common varities of synapses
12
external or internal, impulse or action potential is
generated.But activity of nervous system depends on
transmission or conduction of nerve impulse or action
potential through a chain of neurons. In the chain
neurons are approximated or apposed closely to each
other. This site of apposition or contact between two
neurons is known as synapse. Though, it is simple to
understand, but in 1891, neuronal theory of Waldeyer
first established that at the synapse or neuronal
junction of two successive neurons are contiguous, but
not continuous to each other. It was then detected that
some chemical substances called Neurotransmitters
jump across the synaptic junction to carry the nerve
impulse or action potential of the neuronal chain.
Fundamental points to remember regarding the
synapse:
1. Two successive neurons are contiguous in the syn-
apse but not continuous.
2. Chemical substance released in the proximal
neuron (presynaptic neuron) passes to distal or
postsynaptic neuron, through which impulse is
transmitted.
3. Impulse under physiological condition travels thr-
ough the synapse in one direction only.
4. Single end of an axon, known as axon terminal
will form synapse with single dendritic spine.
5. Multiple end button of one presynaptic neuron
may form synapse with dendrites of multiple
neurons or multiple dendrites of single neuron.
Postsynaptic neuron
C. Axoaxonic synapse

Mitochondria
Presynaptic vesicle containing
Neurotransmitter
Exocytosis
Receptor
Synaptic web
Fig. 1.13 Structure of a typical synapse
Types of Synapse (Fig. 1.12)
So far, it is already understood that axon of presy-
naptic neuron forms synapse with the dendrons of
postsynaptic neuron. But truly speaking axon of a
neuron may form synapse with any component of
another neuron, e.g. dendrite, cell body, even the axon
also. So, the synapses are grossly classified as
1. Axodendritic: Synapse between axon of presynaptic
and dendron of postsynaptic neuron.
2. Axosomatic: Synapse between axon of presynaptic
and cell body or soma of postsynaptic neuron.
3. Axoaxonic: It is considered as a lateral synapse.
In this type, axon of lateral neuron form synaptic
connection with axon of another neuron which is
lying in the regular neuronal chain.
Besides the above mentioned commoner types of
synapses, other types are somatodendritic, somato-
somatic and dendrodendritic.
Structure of a typical axodendritic synapse
(Fig. 1.13)
A typical axodendritic synapse is composed of follo-
wing three parts. These are
i. Presynaptic membrane of axon of proximal neuron.
ii. Synaptic cleft between axon and dendrite.
iii. Postsynaptic membrane of dendrite of distal neu-
ron.
Presynaptic Membrane
Thickened cell membrane of the axon terminal at
the site of synapse is called presynaptic membrane.
Introduction to Human Neuroanatomy
Neurofibrils
Axoplasm
Axon terminal
Presynaptic membrane
Synaptic cleft containing
fluid rich in polysaccharide
Postsynaptic membrane
Beneath this membrane the axoplasm shows some
specialized features. The cytoplasm is condensed with
presence of number of mitochondria. It also contains
many membrane bound vesicles which contain ch-
emical substances known as neurotransmitter.
The vesicles are very tiny, 4050 nm (nanometer)
in diameter. One mm (micrometer) is 1/1000 of a
millimeter and one nm (nanometer) is 1/1000 of a mm
(micrometer). During transmission of nerve impulse,
neurotransmitter is released from presynaptic vesic-
les into synaptic cleft by exocytosis to stimulate
postsynaptic membrane of the distal neuron.
Synaptic Cleft
It is the gap measuring 2030 nm between pre and
postsynaptic membranes. It contains interstitial
fluid rich in polysaccharides. Through the process of
exocytosis neurotransmitters are released across the
presynaptic membrane into synaptic cleft.
Postsynaptic Membrane
This is the thickened plasma membrane of dendrite
spine at the site of synapse. This membrane sho-
ws specialization known as receptors which are to
uptake neurotransmitters passing across the syn-
aptic cleft. The dense cytoplasm beneath postsy-
naptic membrane is segmented and known as syn-
aptic web which contains a network of filame-ntous
structure.
13
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Impulse Transmitted Across the Synapse
Nerve impulse transmitted through presynaptic neu-
ron causes release of neurotransmitter from pres-
ynaptic vesicles. Neurotransmitter passing across the
synaptic cleft act as chemical impulse to stimulate
receptors of postsynaptics membrane. Chemical imp-
ulse reaching synaptic web beneath postsynaptic
membrane is again converted into nerve impulse to
stimulate postsynaptic neuron.
Neurotransmitters
There are varieties of chemical substances acting as
neurotransmitter. Mostly found neurotransmitters
are Acetylcholine and Norepinephrine. Acetylcholine
is liberated as neurotransmitter in many synapses of
central and peripheral nervous system including those
of parasympathetic nervous system. Norepinephrine
is released in most of the synapses of sympathetic
nervous system. Glycine is the neurotransmitter
discharged in the synapses of spinal cord. Dopamine is
the transmitter found in basal ganglia and substantia
nigra. Serotonin and Gumma-amino-butyric acid
(GABA) are other examples of commonly known
neurotransmitters.
Deactivation or cessation of action of neurotransmitters
After desired effect, influence of neurotransmitters
is withdrawn in either of two different ways. In case
of Acetylcholine, it is broken down by the enzyme
Acetylcholinesterase at synaptic cleft. But in case
of transmitters like norepinephrine, its effect is
restricted by its reuptake back through presynaptic
membrane.
Neuromodulators
These are the chemical substances which enhance,
prolong, restrict or inhibit the effect of the neuro-
transmitter on postsynaptic membrane. They are
stored in separate presynaptic vesicles.
NEUROGLIA
Broadly, the neuroglia can be defined as group of
cells of nervous system which are other than the
neurons. So the cells of this family do not posses two
basic characteristics of neurons, i.e. irritability and
conductivity. That is why none of them can generate
and conduct the nerve impulse. Both in central as well
as peripheral nervous system fundamentally they act
as intercellular (interneuronal) supportive material.
In addition, each type of neuroglia is characterized by
its independent specific function.
14
Size of neuroglia is much smaller than neurons,
but their number is far more proportionately, may be
as many as 50 times the number of neurons. When the
number of neurons are fixed after birth, the neuroglia
can multiply throughout life. In case of injury or
disease of nervous tissue, area of damaged or dead
neurons, are occupied by multiplying neuroglia. This
process is known as replacement gliosis.
Types of Neuroglia
In central nervous system
1. Ependymal cell
2. Macroglia a) Astrocytes b) Oligodendrocytes
3. Microglia.
In peripheral nervous system
1. Schwann cells.
2. Satellite cells.
Ependymal cell (Fig. 1.14A)
These are single-layered cubical or columnar cells
lining the cavities (ventricles and central canal) of
central nervous system (brain and spinal cord). They
represent the original cells lining the neural tube of
embryonic life. The free surface of the cells present
ultramicroscopic finger-like prolongations which are
nonmotile in nature. These are known as stereocilia.
n Functions:
1. Stereocilia of free surface of ependymal cells
increase surface area, so help in absorption of
cerebrospinal fluid circulated in cavity of central
nervous system.
2. Specialized area of ependymal lining of ventricles
is also concerned with formation of cerebrospinal
fluid (CSF).
Astrocytes
These cells are so-called because they are star-shaped
with radiating cytoplasmic processes. Astrocytes are
of following two types.
Protoplasmic astrocytes (Fig. 1.14B)
The radiating processes of these types of astrocytes are
thicker containing more amount of cytoplasm inside.
Stereocilia
(Nonmotile microvilli)
Fig. 1.14A Ependymal cells

Capillary Protoplasmic astrocyte
found in gray matter
Fig. 1.14B Protoplasmic astrocyte
They are related in relation to cell bodies of neuron
(in gray matter of central nervous system). Terminal
ends of the processes present foot-like expansions
known as end-feet. These types of astrocytes are
intermediate in position between cell bodies of neuron
and blood capillary. End-feet come in contact in one
side with neuronal cell body and in another side with
wall of capillary, thus helping in selective transport of
substance like nutritive substance or metabolites from
blood capillary to neuron. This media may prevent
transport of some unwanted or toxic materials, for
which it is known as blood brain barrier, some drugs
having action on central nervous system posses the
ability to cross this blood brain barrier.
Fibrous astrocytes (Fig. 1.14C )
The cell bodies of these types of astrocytes are
smaller with thinner and more branching processes.
They are predominantly distributed inbetween
pro-cesses of nerve cells (in white matter of central
nervous system).
n Functions:
1. Astrocytes posses supportive function acting as
packing material of central nervous system.
Fibrous astrocytes
Fig. 1.14C Fibrous astrocytes
Introduction to Human Neuroanatomy
Neuron
2. Astrocytes transport nutritive materials from blo-
od capillaries to neurons.
3. It forms the blood brain barrier.
Oligodendrocytes (Fig. 1.15A)
These are smaller round or spherical cells with lesser
number of processes. They are found in white matter
of central nervous system where expanded end of their
processes wrap around the length of nerve fibers. This
wrapping (ensheathment) or insulation of nerve fibers
is known as Myelination. The myelination prevent the
nerve impulse to be dissociated to the surrounding
tissue and thus facilitate the full conduction of impulse
towards the destination.
n Functions:
1. Oligodendrocytes primarily provide supportive
functions around neurons of central nervous sys-
tem.
2. They form myelin sheath around nerve fibers
(processes of neurons) inside central nervous sys-
tem.
Nerve fibers of CNS forming white matter
15
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nerve
fiber
Cell body of
oligodendrocyte
Process of oligodendrocyte Myelin sheath
Fig. 1.15A Multiple processes of one oligodendrocyte form myelin sheath (for insulation) of many nerve fibers in central nervous system
Microglia (Fig. 1.15B)
Microglia are so-called because they are smaller
in size. The cells present finer tortuous processes.
Microglia are identified by following three characters
which are related to the letter M.
1. Microglia are Mesodermal in origin which develops
from circulating Monocytes of fetal blood.
2. Microglia function as Macrophages of central ner-
vous system to engulf toxic substances, micro-
organism and damaged CNS tissue debris.
3. For phagocytic function, microglia are Migratory in
nature. Many microglia, acting as scavenger cells
are localized at the site of damaged or degenerated
nerve tissue and may fuse together to form a
Multinucleated giant cell of central nervous system.
n Function: Microglia, as already stated above,
are phagocytic in nature to act as scavenger cells or
macrophages of central nervous system.
Fig. 1.15B Microglia Macrophage of CNS Surrounding
damaged tissue for scavenging. Migrating in nature
Mesodermal in origin
16
Schwann cells (Fig. 1.16)
These are the neuroglial cells found in peripheral
nervous system, related to peripheral nerve fibers.
The cells are flattened with adequate amount of cyto-
plasm surrounding nucleus. The surface of the cell is
invaginated by processes of neuron. The nerve fiber,
following invagination, undergoes spiral movement to
be finally wrapped by layers of Schwann cells which
finally acts as myelin sheath.
n Function: Many Schwann cells in a row, take part
in formation of myelin sheath of peripheral nerves
outside central nervous system.
Nerve fiber
Schwann cells
A
Mesoaxon
Schwann cells
Nerve fiber
Nerve fiber
B
Figs 1.16A and B Schwann cells the glial (supporting) cells of
peripheral nervous system
A. A Schwann cell is invaginated by a single nerve fiber to
form myelin sheath
B. A Schwann cell is invaginated by many nerve fibers, so
attempt for myelin sheath formation fails

Fig. 1.17 Capsular or satellite cells surrounding cell body of posterior root ganglion neuron
Satellite cells (Fig. 1.17)
These are another variety of glial cells related to
peripheral nervous system. These cells are related to
surface of cell body of the neurons which are present
outside the central nervous system, e.g. neurons of
posterior root ganglia of spinal nerves and neurons of
sympathetic ganglia. The satellite cells are flattened
in shape and small in size. A good number of these
cells form an encapsulation around the surface of the
above mentioned neurons present outside the central
nervous system.
n Function: Satellite cells are also known as caps-
ular cells as they form a covering around the cell
bodies of neurons of peripheral nervous system.
Developmental Source of Neuroglial Cells
1. Ependymal cells: These represent the original
parent lining cells of primitive neural tube (ecto-
dermal).
Nucleus of Schwann cell
Nerve fiber
A
Myelin sheath
Nucleus of Schwann cell Internode
Nerve fiber
B Node of Ranvier
Fig. 1.18 Myelin sheath of peripheral nerves
Introduction to Human Neuroanatomy
Capsular (Satellite) cells
Posterior root ganglion cell
2. Macroglia (Astrocytes and oligodendrocytes):
from the spongioblasts of mantle zone of neural
tube (ectodermal).
3. Microglia: From the circulating monocytes of fetal
life (mesodermal).
4. Schwann cells and satellite cells: From cells of
neural crest (ectodermal).
MYELIN SHEATH (FIGS 1.15A, 1.16 AND 1.18)
A nerve fiber, either in peripheral or in central nervous
system carries nerve impulse towards destination.
This impulse must reach the destination to the full
extent with full velocity without being dissociated in
the surrounding tissue. For this, the nerve fiber needs
insulation (nonconductive coating). This insulation is
formed by formation of sheath around the fiber, known
as myelin sheath. In the nervous system, only the supp-
orting cells are available to form this myelin sheath.
In peripheral nervous system, the Schwann cells and
in central nervous system, the oligodendrocytes take
part in formation of myelin sheath.
Nerve fiber
Layers of plasma membrane of
Schwann cell made up of lipid-protein
Nerve fiber
17
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
In peripheral nervous system, many Schwann cells
come in relation to the length of a single nerve fiber
in a row. These many Schwann cells are invaginated
by a single nerve fiber. Due to invagination, Schwann
cell give rise to formation of mesoaxon (Fig. 1.16A).
Now the Schwann cell rotates around axon in a spiral
fashion. The mesoaxon turn around several times
around the fiber, thus squeezing out the cytoplasm
at the periphery of Schwann cell. The turns of cell
membrane of Schwann cell around nerve fiber form
the myelin sheath (Fig. 1.18A). The multiple layered
membranous sheath is white in color due to presence
of white lipid protein. More peripherally rim of
cytoplasm of Schwann cell form an additional sheath
which is known as Schwann cell sheath or neurilemmal
sheath. Intermittent gap between the segments of
myelin sheath formed by adjacent Schwann cells is
known as nodes of Ranvier (Fig. 1.18B). An unit of
sheath formed by a single Schwann cell, in between
nodes of Ranvier is known as internode.
Myelin sheath of central nervous system is formed
by oligodendrocytes. But it is important to note follo-
wing important points at this stage (Fig. 1.15A).
1. It is not the whole cell, but only the processes of
oligodendrocyte take part in formation of myelin
sheath.
2. Many processes of one oligodendrocyte take part
in the formation of myelin sheath of many nerve
fibers.
3. Again processes of many oligodendrocytes take
part in formation of myelin sheath of single nerve
fiber.
n Functions:
1. Myelin sheath helps in conduction of impulse
through nerve fiber to the full extent and with full
velocity to the destination.
2. Thus myelin sheath prevents dissociation of impu-
lse to the surrounding tissue.
3. It acts as a support to the nerve fiber.
4. It prevents ionic interchange between the cyto-
plasm of nerve fiber and the surrounding tissue.
CLINICAL ANATOMY
Tumors of Central Nervous System
A tumor is formed as a result of abnormal cell division
(mitosis) of a tissue. It is important to note at this
stage that nervous system is composed of neurons,
neuroglia as well as blood vessels and meninges
(covering of central nervous system made up of
connective tissue). Among these, only the neurons are
fixed in number as they do not multiply after birth.
18
So a tumor in nervous system cannot originate from
neuron. Tumors formed due to abnormal proliferation
or multiplication of neuroglia and cells of connective
tissue of meninges and cells of wall of blood vessels
are known as Glioma, Meningioma and Angioma
respectively.
Neuronal Damage or Injury
Injury may affect neuronal cell body and /or processes.
Initially it leads to loss of function. But ultimate effect
will depend upon serverity of the injury and duration
of action of injurious agents. It is important to note at
this stage that if neuronal death occurs quickly, within
a few minutes, no morphological changes are found.
But if the neuron manages to survive for 612 hours,
morphological changes are characterized by swelling
of cell cytoplasm and nucleus, and displacement of
Nissl granules to the periphery. This is followed by
recovery of the neuron.
When a nerve cell process (axon) is a cut or injured,
it will lead to change in nerve cell which is known as
axonal reaction or axonal degeneration. This change
is noticed within 2448 hours. The change is more
rapid if axon is injured close to cell body. Axonal
injury in peripheral nervous system is followed by
an attempt for repair in cell body. In central nervous
system, degeneration is not followed by regeneration.
Activities of Neuroglia Following Neuronal
Damage
Neurons show some stage of cell death. Initially they
are characterized by dark stained cytoplasm with ill-
defined nucleus. But the neurons finally get dissolved
passing through a stage of appearance of vacuoles in
cytoplasm and disintegration of cell organelles. By
this time microglia, being migratory in nature, rush
to the site of lesion to act as scavenger with their
phagocytic activity. Monocytes from the neighboring
bloodstream also join with the microglia to help in
scavenging activity. It is now the astrocytes which
undergo hyperplasia and hypertrophy to occupy the
space of disintegrated neurons. This procedure is
known as replacement gliosis.
Spread of Some Viral Infection Through
Neuronal Process
Rabies is a viral disease which causes acute attack
on central nervous system. The virus is transmitted
through the bite of rabied dog or some other wild
animal. From the site of bite virus spread centrally
towards central nervous system through retrograde
direction (retrograde axonal transport) via axoplasm.
Therefore, it is clear that onset of the disease will be
quicker if the site of the wound (due to bite) is more

close to central nervous system (i.e. in trunk or head
and neck) than if it is away (e.g. in distal part of
limbs).
Axonal transport also play important role in
spread of some other viral diseases affecting nervous
system, e.g. poliomyelitis, and herpes simplex and
herpes zoster.
Chemical Agents Acting on Synaptic
Transmission
Neurotransmitters jumping through synaptic cleft
from presynaptic neuron to postsynaptic neuron are
responsible for conduction of nerve impulse through
chain of neurons to the destination. Chemical agents
acting on autonomic ganglia may interfare with
neurotransmission is either of two ways. Some agents
like procaine, simply inhibit release of Acetylcholine
(neurotransmitter) from presynaptic neuron. The
other group, like nicotine, hexamethonium do not
give chance to Acetylcholine to act on postsynaptic
membrane, because these drugs occupy the receptor
site of postsynaptic membrane. Some drugs which
can cross the blood brain barrier, like atropine,
Introduction to Human Neuroanatomy
scopolamine, are able to act on synapses of central
nervous system. In myasthenia gravis there is a
profuse deficiency of synaptic transmission due to
absence of Acetylcholine in synaptic cleft.
Caffeine present in tea or coffee act as neuro-
modulator which enhance the activity of neuro-
transmitters stimulating central nervous system.
Multiple Sclerosis A Disease Causing
Demyelination
Multiple sclerosis is a degenerative disease of central
nervous system. Exact cause of the disease is not
known. Probable cause is the imbalance between some
viral infection and immune response of the individual.
Young adults between the age of 2040 years are
most commonly affected. Fibers of optic nerve, spinal
cord and cerebellum are affected usually. The myelin
sheath of nerve fibers are degenerated during active
phase of the disease. The myelins are scavenged by
microglia with subsequent formation of replacement
gliosis. The disease is sometimes typically charac-
terized by exacerbations and remissions.
19
 Nervous System in Brief*
2
*(This chapter should not be ignored but is to be read thoroughly. If the reader goes thoroughly, all the subsequent chapters will
be better understood)

CENTRAL NERVOUS SYSTEM
Central Nervous System is made up of (Fig. 2.1)
1. Brain: Proximal expanded part situated inside the
cranial cavity.
2. Spinal cord: Distal, narrow, tubular and elongated
part situated in upper two-third of vertebral canal.
Fundamental Subdivisions of Brain (Fig. 2.1)
Morphologically, the brain is composed of three comp-
onents which are further subdivided. Each of these
parts is having Latin names which are of clinical
significance.
Forebrain (prosencephalon)
It is most expanded part having
i. Diencephalon: Central midline part having rig-
ht and left identical halvesIt forms different
components of thalamus.

Cerebrum

Brain Midbrain
Pons Cerebellum
Brainstem
Medulla
oblongata

Spinal Spinal nerves

cord

Lower spinal nerve

forming cauda equina

Filum terminale

Fig. 2.1 Central nervous system

 Nervous System in Brief
Brain

Tree

Stem
Brainstem

Fig. 2.2 Brainstem is like stem of a tree

ii. Telencephalon: Two (right and left) lateral exten- Brainstem

sions, each of which looks like half of a sphere,
known as cerebral hemisphere. Both the cerebral
hemispheres are most expended parts of brain.
They overhang the diencephalon (thalamus) form
both sides and together form a sphere known as
It is the component like stem of a tree on which lies
the main mass of brain (Fig. 2.2). It is made up of
following parts of brain.
1. Midbrain

cerebrum.
Midbrain (mesencephalon)
It is shortest and simplest out of the three comp-
onents of brain.
Hindbrain (rhombencephalon)
It is subdivided into as many as 3 parts.
l Proximal(Metencephalon): Which is further subd-
ivided into two parts:
1. Ventral Pons 2. Dorsal Cerebellum
l Distal (Myelencephalon) 3. Medulla oblongata:
Which is distal most cylindrical part of brain. It is
continuous with the spinal cord below.
}
2. Pons
3. Medulla Two ventral components of hindbrain
oblongata
Long-axis of brainstem is oblique vertical directed
downwards and backwards (Fig. 2.3). 3 components
of brainstem namely midbrain, pons and medulla
oblongata are connected to cerebellum by 3 pairs of
compact bundles of white matter known as cerebellar
peduncles (Fig. 2.4)
l Superior cerebellar peduncle: Connecting midb-
rain.
l Middle cerebellar peduncle: Connecting pons.
l Inferior cerebellar peduncle: Connecting medulla
oblongata.

Cerebral peduncle

Superior cerebellar peduncle

Middle cerebellar peduncle

Inferior cerebellar peduncle

Fig. 2.3 Long-axis of brainstem passes downwards and backwards

21
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
central nervous system starts very early at the stage of
tri-laminar embryonic disk (plate). Midline ectoderm
on the dorsal aspect of embryonic disk (neuroectoderm)
becomes thickened on 16th day of embryonic life
which is called neural plate (Fig. 2.5A). By 20th day,
a cephalocaudal linear depression appears on neural
plate. It is called neural groove (Fig. 2.5B). Right
Cerebral
Superior cerebellar and left lips of neural groove gradually become more
Peduncle
peduncle and more elevated and prominent which are called
Middle cerebellar neural crest. On 25th day fusion of two neural crests
peduncle
starts from the middle of neural groove and proceeds
Inferior cerebellar
simultaneously towards both ends. Closure is almost
peduncle complete leaving temporarily openings at the cephalic
and caudal ends (Fig. 2.5C) called anterior (cephalic)
Fig. 2.4 Peduncles of brain
One cerebral peduncle
and posterior (caudal) neuropores. As soon as the
Three cerebellar peduncles neuropores are closed, a closed tube so far lined by
Cerebral peduncle Compact ventral part of midbrain single layer of neuroectodermal cells is formed by 30th
connecting brainstem with cerebrum (Fig. 2.4). day of intraembryonic life. It is called neural tube.
Within the period of 35th day, proximal (cephalic)
Gray and White Matters of Central Nervous dilated part of tube, which will form the brain, is
System with Embryological Background differentiated from the distal, narrow, elongated
Central nervous system so also the whole nervous part, the future spinal cord (Fig. 2.5D). By 35th day of
system is developed from ectoderm with the exception intrauterine life, the proximal dilated part is divided
of its blood vessels and some neuroglial cells (microglia) into three sacculations known as Forebrain, Midbrain
which are mesodermal in origin. Development of and Hindbrain Vesicles (Fig. 2.5D).
Neural plate

Neural groove
Ectoderm

Mesoderm B

Endoderm A
Telencephalon

FB
Diencephalon
MB Mesen cephalon

HB Rhombencephalon

Anterior
neuropore Posterior
neuropore

C D

Figs 2.5A to D Embryological background showing central nervous system develops from neural tube. A. Formation of neural plate
on ectodermal surface of 3 germ layered embroyonic disk, B. Formation of neural groove, C. Anterior and posterior neuropores,
D. Formation 3 brain vesicles
22
 Nervous System in Brief
Multiplication of Single Layered Cells of Neural Tube (Fig. 2.6)

A
A B

Single layered neuroectodermal Spongioblast

cells initially lining neural tube Neuroblast

Ependyma
Ependyma

Astrocytes

Neurons

C Neuroblast Spongioblast D Oligodendrocyte

Figs 2.6A to D Multiplication of single-layered neural tube cells. A. Single-layered neuroectodermal cells lining neural tube, B.
Following mitosis, newer cells pushed to the periphery are differentiated into neuroblast and spongioblast, C and D. Formation neuron
and neuroglia (astrocyte and oligodendrocyte) from neuroblast and spongioblast respectively

On 35th day, single layered neuroectoderm cells
(Fig. 2.6A) lining the neural tube start mitotic cell
division. The newer cells (daughter cells) are pushed
to the periphery (Fig. 2.6B). The original lining cells
form the inner lining of the cavity of neural tube called
Ependymal cells. The daughter cells pushed to the
periphery, are differentiated into two types known as
neuroblasts and spongioblasts (Fig. 2.6C) which will be
transformed into Neurons and Neuroglia (Astrocytes
and oligodendrocytes) respectively (Fig. 2.6D). The
microglia will be formed from the monocytes of blood
squeezed out through pores of capillaries. Outside the
ependymal cell lining, the cell bodies of neuron forms
a zone called Mantle Zone (Figs 2.7 and 2.8). This
zone also contains Astrocyte type of neuroglia.
Foot processes (end-feet) of astrocytes come in
contact, on one side with neuronal cell bodies and
on other side with the fenestrated (pored) wall of
capillaries. These astrocytes thus, help in nutritional
transport from capillaries to neurons. Besides, these
cells form a barrier between neuron and capillary
allowing selective transport of substance and prev-
enting transport of unwanted substance (toxic
materials) from capillary to neuron. This is known
as Blood Brain Barrier (Fig. 2.8). The processes of
neurons situated in mantle layer are pushed outside
forming another peripheral zone known as Marginal
Zone (Figs 2.7 and 2.8). Oligodendrocytes of neuroglial
cells are present in this zone which will ensheath
(myelin sheath) the neuronal processes. Microglia of
neuroglial cells are present in both mantle as well as
marginal zones (Fig. 2.8).
Initially relation of inner mantle zone and surro-
unding it, outer marginal zone exists althrough the
length of neural tube.
Gray and White Matters (Fig. 2.8)
Lipid material of myelin sheath of nerve cell process
(called nerve fiber) present in marginal zone of
developing central nervous system gives a Whitish
23
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Ependyma

Mantle zone

Marginal zone

Fig. 2.7 Cell division of neural tube leads to formation of layer of ependymal cells, mantle zone and marginal zone

appearance. That is why this zone is called White
matter of central nervous system. Inner mantle zone
made up of neuronal cell bodies presents grayish
appearance for which it is called Gray matter.
Variations of relationship between gray matter and
white matter
l In spinal cord, throughout the whole length,
gray matter presents its original central position
surrounding the central canal. White matter,
containing bundles of nerve fibers is peripherally
positioned.
l In brainstem (midbrain, pons and medulla oblo-
ngata) there is no separately demarcated zones
of gray and white matters. Both components are
intermingled.
l In parts of brain (cerebrum and cerebellum)
relationship of gray and white matter is reversed.
Gray matter becomes peripheral forming the
cortex and white matter forms the central core.
This alteration is due to following reasons:
i. Due to elongation of neuronal processes the
nerve cell bodies forming the gray matter is
pushed to the periphery (Fig. 2.9).
ii. Peripheralization of gray matter (cortex) of
cerebrum and cerebellum is further caused
due to need for increase in surface area of gray
matter through formation of foldings (gyrus).

Ependymal cell

Neuron
Astrocyte
Mantle zone Capillary
forming gray
matter Microglia

Marginal zone
M
forming white
matter
Oligodendrocyte
Forming
Myelin sheath

Fig. 2.8 Various cells of central nervous system with blood brain barrier (B) and formation of myelin sheath (M)
24
 Nervous System in Brief
White matter Spinal cord is made up of 31 segments which
are regionally subdivided from above downwards as
follows
Gray matter Cervical 8
Thoracic 12
Lumbar 5
Sacral 5
Coccygeal 1
A pair of spinal nerve (right and left) comes out
from each of the segments of spinal cord which are
numbered and named accordingly (Fig. 2.10). All
the spinal nerves are mixed nerve formed by union
of ventral (motor) outgoing and dorsal (sensory),
incoming nerve roots which are attached separately
to anterolateral and posterolateral aspects of each
segment respectively.
Fig. 2.9 Peripheralization of neuronal cell bodies due to Interior of spinal cord shows centrally situated H-
elongation of neuronal process, for which gray matter becomes
shaped area of gray matter. The central connecting
superficial to white matter
limb (gray commissure) is traversed by central canal
l Diencephalon (thalamus), the central, midline lined by ependymal cells and extensive throughout
portion of forebrain is made up of only gray matter. the whole length. Each lateral half of gray matter
of spinal cord presents a broader anterior horn and
l Basal ganglia are submerged collection of gray
narrower posterior horn. All the thoracic and upper
matter in the central core of white matter of two lumbar (T1 L2) segments of spinal cord present
cerebrum. additional lateral horn. Along the length of spinal cord,
respective horns are called anterior, posterior and
Different Parts of Central Nervous System in lateral gray columns. Neurons of anterior (ventral)
Brief horn are motor (efferent) or effector in nature. Their
axons, coming out through ventral nerve root, pass
Spinal cord is the caudal (distal), elongated, narrow, via spinal nerves and end in effector organs, like
tubular part of central nervous system situated in upper voluntary muscles (Fig. 2.11).
two-third of vertebral canal. It starts as a continuation Again neurons of posterior (dorsal) horn are
of medulla oblongata at upper border of 1st cervical sensory (afferent) or receptor in nature. These
vertebra and ends at the level of lower border of 1st receive sensory informations (inputs) carried from
lumbar vertebra. Sometimes it may extend upto 2nd peripheral sensory end organs through peripheral
lumbar vertebra. It is 18 inches in length. processes of pseudounipolar nerve cells of posterior
root ganglion of posterior roots of spinal nerves. These
Posterior pseudounipolar neurons of posterior root ganglia
root are developed from neural crest cells aggregated on
Dorsal ganglion dorsolateral aspect of neural tube. The neurons of
nerve Gray matter posterior horns (tract neurons) give out axons which
root
are pushed out to the peripheral white matter in the
form of compact bundle (ascending or afferent tract)
which carry sensory informations from periphery, via
Spinal nerve posterior (dorsal) nerve root upwards to the higher
Ventral
nerve root White matter sensory centers of brain (Fig. 2.11). The neurons of
intermediate or lateral gray horn (T1 L2 segments
only) form centers for sympathetic component of
autonomic nervous system. Peripheral white matter
also contains descending (efferent) or motor tracts
coming down as long axons of neurons of motor area
of brain (upper motor neurons) to relay on motor
neuron of anterior horns of spinal cord (lower motor
Fig. 2.10 A pair of spinal nerve arises from each of the segments
neurons). Each half of peripheral white matter
of spinal cord of spinal cord is divided into anterior, lateral and
25
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Tract neuron Posterior root Sensory nerve endings
ganglia cells carry impulse from
receptors

Ascending Efferent (motor) Motor nerve endings supply

(sensory) tract neuron effector organ (skeletal muscle)

Fig. 2.11 Destination of ventral and dorsal roots of a spinal nerve

posterior white columns. They are known as anterior,
lateral or posterior funiculus. (Pl- funiculi). Anterior
and lateral funiculi are composed of both ascending
(afferent or sensory) as well as descending (efferent
or motor) tracts. But posterior funiculus is made up
of only ascending (sensory) tracts.
Again in 2nd, 3rd and 4th sacral (S2, S3 and S4)
segments of spinal cord, neurons of intermediate
area (no lateral horn present here) form center for
parasympathetic component of antonomic nervous
system.
BRAINSTEM (FIGS 2.12 TO 2.14)
Brainstem is the short tubular stalk-like or pedu-
ncular component of brain which is composed of follo-
wing parts of brain from above downwards
1. Midbrain
2. Pons
3. Medulla oblongata }Ventral parts of
hindbrain
Cerebral peduncle is the ventral most part of mid-
brain composed of compact vertical bundle of nerve

Superior cut surface of midbrain

Cerebral peduncle of
midbrain
Midbrain

Pons

Cut surface of middle

cerebellar peduncle

Inferior cerebellar peduncle

Medulla oblongata

Fig. 2.12 Ventral (anterior) view of brainstem

26

Cerebral peduncle
Midbrain
Pons
Medulla oblongata
Fig. 2.13 Lateral view of brainstem
fibers by which brainstem is connected above to the
cerebrum (Figs 2.12 and 2.13).
Cerebellum is connected to the three components of
brainstem, i.e. midbrain, pons and medulla oblongata
through 3 compact bundle of fibers called Superior,
Middle and Inferior Cerebellar Peduncles. Superior
cerebellar peduncle is thinnest whereas middle is the
thickest. Again superior and inferior peduncles are
composed of both afferent as well as efferent fibers
of cerebellum, but middle is made up of only afferent
fibers to cerebellum (Fig. 2.13).
Medulla oblongata is narrower, cylindrical and
most caudal part of brainstem which is continuous
below with the cylindrical spinal cord. Pons presents
ventrally bilateral bulge known as basilar part. In the
midline, it presents a vertical sulcus known as basilar
Central canal (aqueduct)
of midbrain
Fourth ventricle
Central canal of lower part
of medulla oblongata
Fig. 2.14 Cavity of brainstem through sagittal section
Nervous System in Brief
Aqueduct (central canal) of midbrain
Superior cerebellar peduncle
Middle cerebellar peduncle
Inferior cerebellar peduncle
sulcus which lodges the basilar artery. Basilar part
of pons is continuous laterally and horizontally with
middle cerebellar peduncle. Ventral part of midbrain
presents compact cerebral peduncle. Dorsally mid-
brain presents two pairs of round bulge, upper is
known as superior colliculus and lower one is called
inferior colliculus (pl-colliculi).
Cavity of brainstem (Fig. 2.14) cavity of
midbrain is narrow and slit-like which is known as
aqueduct of Sylvius. Cavity of the central nervous
system opposite pons and medulla oblongata is dilated
which is known as 4th ventricle of brain. It is related
ventrally to the dorsal surface of pons and medulla
and dorsally to cerebellum. The 4th ventricle of brain,
cavity of hindbrain is continuous below with central
canal of spinal cord.
Inner white matter
Outer gray matter of
cerebellum
27
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Cerebral peduncle
Cerebellum

Midbrain Superior cerebellar peduncle

Middle cerebellar peduncle

Pons

Inferior cerebellar peduncle

Medulla oblongata

Fig. 2.15 Cerebellum related to three components of brainstem

Gray and White Matter of Brainstem
Brainstem is the part of central nervous system which
shows intermingling of white and gray matter. There
is no defined separate zones of white and gray matter
as found in the other parts of central nervous system.
n White matter:
1. Vertical fibers: These are present in the form of
ascending and descending bundles. Ascending
bundles are afferent or sensory fibers connecting
spinal cord or different centers of brainstem vert-
ically upwards to the higher centers of cerebellum
or cerebrum. Descending bundles of fibers are
efferent or motor passing down from higher centers
to the spinal cord.
2. Horizontal fibers: These are afferent to or efferent
form cerebellum passing through three cerebellar
peduncles.
n Gray matter:
1. Specific collection of nerve cells in a different parts
of brainstem forming nuclei, e.g.
i. In midbrain: Substantia nigra, red nucleus,
tectum.
ii. In pons: Pontine nucleus.
iii. In medulla oblongata: Olivary nuclei, nucleus
gracilis, nucleus cuneatus, arcuate nucleus.
2. Reticular nucleus extends throughout whole len-
gth of brainstem.
3. Nuclei of cranial nerves: Nuclei (motor and sen-
sory) of lower 10 (ten) cranial nerves (3rd12th)
are present at different levels of 3 components of
brainstem.
from which it is separated by the cavity of hindbrain,
the 4th ventricle of brain. It is connected to 3 parts of
brainstem by 3 pairs of cerebellar peduncles, superior,
middle and inferior.
Phylogenetically cerebellum is divided into follo-
wing 3 parts:
i. Archicerebellum Oldest (Vestibulocerebellum)
ii. Paleocerebellum Intermediate (spinocerebel-
lum)
iii. Neocerebellum Latest (Pontocerebellum).
Principle of Functions
Various sensory inputs are carried to cerebellum to be
analyzed and to be coordinated or integrated to give
directions for:
i. Maintenance of equilibrium (by archicerebell-
um).
ii. Maintenance of muscle tone and postural adjust-
ment of muscles (by paleocerebellum).
iii. Coordination of muscle movements (by neoce-
rebellum).
Midbrain
Superior cerebellar
peduncle
Vermis

CEREBELLUM (FIGS 2.14 TO 2.16) Cerebellar

hemisphere
Cerebellum, the Little Brain is dorsal part of Hind-
brain situated behind pons and medulla oblongata Fig. 2.16 Cerebellum viewed from above
28
 Nervous System in Brief
Superior
vermis
Fastigial
nucleus

Globose

Cerebellar
hemisphere
nucleus

nucleus
} Nucleus
Emboliform interpositus

Dentate nucleus

Inferior vermis

Fig. 2.17 Coronal section of cerebellum strowing cerebellar nuclei

Gross Anatomy the white matter of cerebellum. Central core of white

matter contains collections of gray matter called
Cerebellum presents superior and inferior surfaces.
cerebellar nuclei which are following from lateral to
Anteriorly, a notch is related forwards to the brain-
medial (Fig. 2.17).
stem. Cerebellum is divided grossly into i. Dentate nucleus
a) A midline part: Vermis, so called because it

looks like worm.
b) Two lateral extensions: Cerebellar hemisphe-
res.
Surface of both vermis as well as cerebellar hemi-
spheres show parallel fissures. Primary fissures
divide cerebellum into lobes. Secondary fissures divide
lobes into smaller units called lobules. Almost all the
lobules have vermis as well as corresponding lateral
extensions. Tertiary fissures in each lobule demarcate
adjacent narrow linear leaf-like components known as
Folia.
Fundamental Structure
Outer or peripheral portion of cerebellum is made up
of gray matter known as cerebellar cortex. Cortical
gray matter is thrown into narrow, linear leaf-like
parallel pleats called folia. Inner central portion is
}
ii. Emboliform nucleus
Nucleus Interpositions
iii. Globose nucleus
iv. Fastigial nucleus
Forebrain (prosencephalon) (Fig. 2.18)
It is the largest component of brain and subdivided into:
1. Telencephalon: It is right and left lateral exte-
nsion. Both jointly giving the appearance of a
sphere called cerebrum. Each half, right or left
half of sphere (cerebrum) is hemispherical called
cerebral hemisphere.
2. Diencephalon: It is the central component of fore-
brain which forms 5 components of thalamus.
Components of diencephalon is not visible in int-
act brain as it is overhung from either side by
cerebral hemispheres (Fig. 2.18). Diencephalon is
the inferomedial portion of forebrain.

Cerebral hemisphere Cerebral hemisphere

Thalamus

Diencephalon
{ Hypothalamus

Two cerebral hemispheres form

cerebrum (Telencephalon)

Fig. 2.18 Forebrain seen through coronal section

29
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
A B
Superolateral surface
Inferior surface
Figs 2.19A to C Three primary surfaces of cerebral hemisphere of left side
Cerebral hemisphere
Both the cerebral hemispheres present large number
of convolutions (foldings) on the surfaces. These
convolutions are known as gyri (singular = gyrus),
one gyrus is separated from adjacent gyrus by linear
depression called sulcus (Plural = sulci). Gyri on the
surfaces of cerebral cortex (superficial layer of gray
matter) increase the surface area of cortical gray
matter. In life, both the cerebral hemispheres are
inseperable from each other, as both are interconnected
by thick, compact, transversely passing band of white
matter called corpus callosum.
l Surfaces of cerebral hemispheres: Grossly, cerebral
hemisphere presents three surfaces (Figs 2.19A to C):
i. Superolateral
ii. Medial
iii. Inferior.
Superolateral surface is convex, but medial and
inferior surfaces are flat.
Lobes and Poles (Fig. 2.20A): Three (3) sulci called
primary sulci divide the cerebral hemispheres into
five lobes.
The sulci are (Fig. 2.20)
1. Lateral sulcus. 2. Central sulcus.
3. Parietooccipital sulcus.
Five lobes are the following:
1. Frontal lobe: Infront of central sulcus.
30
Medial surface
C
2. Parietal lobe: Between central sulcus and parieto
occipital sulcus.
3. Occipital lobe: Behind parietooccipital sulcus.
4. Temporal lobe: Below lateral sulcus.
5. Central lobe (Insula): At the bottom of lateral
sulcus (Fig. 2.20B).
Poles of cerebral hemisphere are 3 in number
1. Frontal pole (anterior).
2. Occipital pole (posterior).
3. Temporal pole (anterior and inferior).
Structural components
Fundamentally cerebral hemisphere is made up of
A. Outer gray matter: This is known as cerebral
cortex. Gray matter presents foldings called gyri
(gyrus singular) which increase the surface area
of cortex, so number of neurons within limited
capacity of cranial cavity (cavity of skull). Almost
all the gyri are named and separated from each
other by furrows named sulci. Different gyri or
cortical areas have different functions. Grossly
the different lobes of cerebral hemisphere posses
different functions as follows:
1. Frontal lobe:
i. Voluntary movements of skeletal muscles of
opposite half of body.
 Nervous System in Brief

Central sulcus
Parietal lobe

Frontal lobe
Parietooccipital sulcus
Frontal pole
Occipital lobe

Occipital pole
Temporal pole
Lateral sulcus
Temporal lobe
A

Insula

Inferomedial border Inferolateral border

B

Figs 2.20A and B Lobes, poles, surfaces and borders of cerebral hemisphere A. Lobes and poles of cerebral hemisphere, B. Surfaces and
borders of cerebral hemisphere

ii. Emotional activities substance. It is white in appearance as it is made

iii. Awareness of individual
iv. Motivation for any activity
v. Aggression or anger.
2. Parietal lobe: Reception, recognition (perception)
and evaluation of all superficial and deep (from
muscles, tendons, joints) sensations except vision,
hearing and smell.
3. Occipital lobe: Reception, perception and inter-
action of visual sensation.
4. Temporal lobe:
i. Reception, perception and evaluation of sense
of hearing.
ii. Reception, perception and evaluation of sense
of smell.
iii. Memory and intellect of an individual.
5. Limbic lobe: It is not a separate anatomical lobe.
But it is a ring-shaped component of cerebral
cortex situated in the border line (limbus means
border) between central cortex and diencephalons.
Limbic lobe is concerned with following functions.
i. Control on the activity for acquisition of food,
water and reproductive activity.
ii. Storage of short-term memory.
B. Inner white matter: It forms central core of
cerebral hemisphere. It is also known as medullary
up of nerve fibers (processes of nerve cells) which
are myelinated. The white matter or medullary
substance of cerebral hemisphere contain follow-
ing
i. Bundle of nerve fibers.
ii. Basal ganglia: Deep-seated masses of gray
matter within the core of white matter.
iii. Lateral ventricle: Cavity of telencephalon.
Nerve fibers in the white matter are compact
bundles of fibers of following types
1. Association fibers (Fig. 2.21A): These fibers may
be shorter to interconnect areas of adjacent gyrus.
Again they may be long enough to interconnect
areas of two different lobes. Association fibers lie
in the same hemisphere.
2. Commissural fibers (Fig. 2.21B): These fibers
connect identical areas of two hemispheres, so
cross the midline.
Both association fibers and commissure fibers do
not project to any center beyond cerebral hemisphere.
3. Projection fibers (Fig. 2.21C): These types
of fibers projects beyond cerebral cortex to the
subcortical centers of same side or opposite side.
31
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

A Association fibers

B Commissural fibers

C Projection fibers

Figs 2.21A to C Fibers of white matter of cerebrum A. Association fibers, B. Commissural fibers, C. Projection fibers

l Basal Ganglia (Fig. 2.22): These are collections
of gray matter deeply-seated inside white core of
cerebrum. These masses of gray matter are traversed
by fine myelinated nerve fibers which give a striated
appearance. That is why they are known as Corpus
Striatum.
Basal ganglia are composed of followings:
i. Amygdaloid nucleus
ii. Claustrum Medial part: Globus pallidus
iii. Lentiform nucleus
iv. Caudate nucleus Lateral part: Putamen
Phylogenetically, corpus striatum (basal ganglia)
are divided into
i. Archistriatum: Amygdaloid nucleus and clau-
strum
ii. Paleostriatum: Globus pallidus

Cortical gray matter

Corpus callosum Corona radiata in central white matter

Lateral ventricle
Caudate nucleus
Stria terminalis Caudate nucleus
Thalamostriate vein Claustrum
Third ventricle
Insula (central lobe)
Thalamus
Lentiform nucleus
Hypothalamus

Amygdaloid body

Fig. 2.22 Coronal section of cerebral hemisphere showing Telencephalon composed of cortical gray matter central white matter,
basal ganglia and ventricles, with diencephalon
32
 Nervous System in Brief

Corpus callosum

Lateral ventricle Lateral ventricle

Fornix
Caudate nucleus
Stria terminalis
Thalamostriate vein

Thalamus
Third ventricle

Hypothalamus

Fig. 2.23 Cavities of cerebral hemisphere

iii. Neostriatum: Putamen and caudate nucleus. 1. Forebrain: 2. Telencephalon 1st and 2nd
Different components of basal ganglia form a spe- (cavity dilated) ventricles
cific functioning system in brain called extrapyramidal (Both called
system which has following functions: lateral ventricle)
1. It has regulatory effect on tone of voluntary mu- Diencephalon 3rd ventricle
scles. (cavity: Narrow
2. During a desired voluntary movements, extrapy- midline cleft)
ramidal system inhibits unwanted movements of 2. Midbrain: Cavity is a narrow Aqueduct of
voluntary muscles and improves quality of motor linear slit Sylvius
functions.
Cavity of cerebral hemisphere (Figs 2.23 and 2.24): 3. Hindbrain: Cavity dilated 4th ventricle
Cavity of cerebral hemisphere (telencephalon) are 4. Spinal cord: Narrow slit
wide and usually bilaterally symmetrical. They are throughout whole
named lateral ventricle of brain. Right and left lateral length of
ventricles being the most proximal are considered as
spinal cord Central Canal
1st and 2nd ventricles. Both these ventricles comm-
unicate through aperture (interventricular foramen) Diencephalon
with the midline cavity of diencephalon called third
ventricle of brain. Diencephalon is the central or midline component of
It is the time now to notice that cavity of central forebrain. On both sides, from superolateral aspect,
nervous system is of different nature and different diencephalon is overlapped and hidden by cerebral
name in different levels as follows (Fig. 2.24): hemispheres (telencephalon).

}
Anterior horn
Central part
Interventricular foramen Posterior horn of Lateral ventricle
Third ventricle
Aqueduct of midbrain Inferior horn

Fourth ventricle

Central canal of spinal cord

Fig. 2.24 Cavities of central nervous system

33
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Thalamus

Metathalamus

Epithalamus
} Dorsal
diencephalon

Hypothalamic
sulcus
Midbrain

Subthalamus

Hypothalamus } Ventral
diencephalon

Fig. 2.25 Components of diencephalon

On either side of midline diencephalon presents Functions of thalamus

right and left identical halves separated by a narrow
midline cleft, cavity of third ventricle of brain
(Fig. 2.23). Two halves of diencephalon merge with
each other below 3rd ventricle of brain. This part of
diencephalon (hypothalamus) is only visible when
seen from inferior surface (base) of the brain.
Subdivisions of Diencephalon (Fig. 2.25):
l Dorsal Diencephalon:
1. The thalamus.
2. Metathalamus (meta: beyond) composed of
i. Lateral geniculate body
ii. Medial geniculate body.
3. Epithalamus: composed of
i. Pineal gland
ii. Habenular nucleus.
l Ventral Diencephalon:
4. Hypothalamus.
5. Subthalamus.
Thalamus
Thalami (pl) are two in number, right and left. These
are ovoid mass of gray matter which is made up of
different cell groups called thalamic nuclei. These
nuclei of thalamus are the relay stations below
cerebral cortex where all kinds of sensory pathway
(except that for smell) relay before their final relay in
respective sensory areas of cerebral cortex.
3rd ventricle of brain is the cavity of diencephalon
between medial surfaces of both thalami. It comm-
unicates on either side with respective (right and left)
lateral ventricles which are cavities of telencephalon
(cerebral hemisphere) (Fig. 2.23).
34
1. Thalamus is an important sensory relay station
where all sensory inputs converge (except sense of
smell) before they finally end in respective sensory
areas of cerebral cortex.
2. Thalamus is the center where sense of pain and
temperature can be perceived, even before they
reach cerebral cortex.
3. Thalamus is the center, where inputs are received
from cerebellum and basal ganglia. These inputs are
then integrated to send message to cerebral cortex
through efferent pathway for motor functions.
4. Efferent pathway from thalamus to limbic system
of forebrain regulates mood, behavior and inte-
llect of an individual.
Metathalamus (Fig. 2.25)
Metathalamus is made up of two small ovoid bulge
which protrude from posteroinferior aspect of thal-
amus. These are called lateral and medial geniculate
bodies.
Lateral geniculate body is the diencephalic relay
station of visual pathway.
Medial geniculate body is the diencephalic relay
station of pathway for hearing (auditory pathway).
Epithalamus (Fig. 2.25)
Epithalamus is a small sessile projection from poste-
rosuperior aspect of thalamus.
It is composed of
i. Pineal gland (pineal body).
ii. Habenular nuclei.

Functions of epithalamus
i. Pineal gland of epithalamus secretes a hormo-
ne, called melatonin. Melatonin regulates onset
of puberty. Early onset of puberty is found to
be related to reduced synthesis of melatonin.
In general, pineal gland has inhibitory effect
on gonads.
ii. Habenular nucleus of epithalamus, through
its connections with limbic system regulates
emotional and visceral activities on perception
of specific odors.
Hypothalamus (Fig. 2.25)
It is the anterior part of ventral diencephalon lying
below thalamus and infront of subthalamus. Hypotha-
lamus is the part of diencephalon which forms the
lower part of lateral wall as well as the floor of 3rd
ventricle of brain. Its lowermost part is the only part
of diencephalon which is visible from inferior surface
or base of the brain.
Hypothalamus is a very small area of brain which
contain various nuclei.
Functions
1. Autonomic: Anterior part of hypothalamus pro-
duces influence on parasympathetic part and
posterior part influences on sympathetic part of
autonomic nervous system. Through this influence,
hypothalamus controls visceral activities.
2. Hormonal: Pituitary gland (hypophysis cerebri),
being the bandmaster of endocrine symphony (fun-
ctions), is influenced by hypothalamus through hy-
pothalamo hypophyseal tract. Through influence
on pituitary, hypothalamus controls activities of
various other endocrine glands.
Subthalamus (Fig. 2.25)
It is the posterior part of ventral diencephalon lying
ventral to thalamus, posterior to hypothalamus and
above midbrain. It contains small compact mass of
gray matter called subthalamic nucleus.
Subthalamic nucleus is one of the centers of extra-
pyramidal system. It controls unwanted voluntary
movements and thus makes movements of voluntary
muscles smooth.
Coverings (Meninges) of Central Nervous
System and Cerebrospinal Fluid (CSF)
Both brain and spinal cord posses coverings which
are called meninges. The meninges are of following 3
layers from outside inwards
Nervous System in Brief
1. Dura mater: It is outermost and thickest. It is
made up of tough fibrous tissue containing plenty
of collagen fibers. This thick fibrous layer is opa-
que. Its main function is protective.
2. Arachnoid mater: It is thin, delicate and trans-
parent layer. It is related more close to the surface
of brain and spinal cord but does not dip into the
wall or bottom of sulci of brain.
3. Pia mater: It is thinnest and most delicate layer
made up of thin layer of fibroareolar tissue in
which lies fine network of blood vessels. This layer
is closely adherent to surface of brain and spinal
cord. It dips into the walls and bottom of sulci and
fissures.
Dura mater is known as Pachymeninges which
develops from mesoderm surrounding the developing
neural tube. Arachnoid mater and pia mater are
known as Leptomeninges which are ectodermal in
origin.
Space beneath arachnoid mater, i.e. between
arachnoid and pia mater of brain and spinal cord is
prominent. This space is called subarachnoid space.
Subarachnoid space contains thin watery fluid which
is called Cerebrospinal fluid (CSF). This fluid is also
present inside the cavity of whole central nervous
system. Cerebrospinal fluid is liberated from tufts of
capillaries related to wall of ventricles of brain, called
Tela Choroidea. CSF of ventricular system (cavity of
CNS) and subarachnoid space freely communicate
with each other through apertures on the roof of
4th ventricle. In normal individual a balance is
maintained between secretion and absorption of CSF.
In case of imbalance, that means either oversecretion
or less absorption, accumulations of excess CSF leads
to a clinical condition called hydrocephalus.
PERIPHERAL NERVOUS SYSTEM
Peripheral nervous system is the outflow from central
nervous system (brain and spinal cord). It is mainly
composed of peripheral nerves. It means that apart
from peripheral nerves, there are other constituents
of peripheral nervous system.
Composition of Peripheral Nervous System
1. Peripheral nerves: Outflow from brain and spinal
cord in the form of
a) 12 pairs of cranial nerves from brain.
b) 31 pairs of spinal nerves from spinal cord.
2. Collections of neurons outside the central nervous
system: These are named Ganglia (singular gan-
glion).
35
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Cortical sensory
neuron
Sensory cortex

Lemniscus

Thalamic nucleus

Thalamus

Skin
Ascending (afferent)
tract

Spinal cord

Sensory (tract) neuron

Spinal (lower) motor

neuron

Pseudounipolar primary
sensory neuron
A (mixed) spinal nerve

Efferent (motor) component

of spinal nerve

Effector organ (muscle)

Fig. 2.26A Destination of motor and sensory components of spinal nerve

Functional Components of Peripheral Nerves Functional Types of Peripheral Nerve

(Figs 2.26A and B)
Peripheral nerves are made up of axons of groups of
neurons situated inside the central nervous system
and/or dendrites of 1st order of neurons in the sensory
pathway. Axons carry impulse (direction) from the
central nervous system to the target organ (e.g.
muscles) and form motor or efferent component of
a peripheral nerve. Dendrites carry impulse (infor-
mations) from peripheral end organs (receptors) tow-
ards the central nervous system and form sensory or
afferent component of a peripheral nerve.
36
A peripheral nerve (cranial or spinal) may be either of
the following three functional types:
i. Motor nerve: When it contains only motor
component.
ii. Sensory nerve: When it contains only sensory
component.
iii. Mixed nerve: When it contains both motor and
sensory components.
Fundamental comparison between cranial and spinal
nerve
12 pairs of cranial nerves come out through the
surface of brain.
 Nervous System in Brief
Cell body of sensory root
of cranial nerve is not
Receptor pseudounipolar, unlike posterior
root ganglia of spinal nerve

Sensory nucleus of
cranial nerve

Motor nucleus of
cranial nerve

BRAIN

A cranial nerve may be

1. A motor nerve

Effector 2. A sensory nerve

or

3. A mixed nerve

Fig. 2.26B A cranial nerve may be motor, sensory or mixed unlike spinal nerve which is always mixed in composition

A pair of spinal nerve comes out through surface
of each of 31 segments of spinal cord. So number of
spinal nerves are 31 pairs.
All spinal nerves are mixed nerve but not all the
cranial nerves:
All the spinal nerves are mixed nerves as they are
made up of both motor as well as sensory roots. Motor
and sensory roots of spinal nerve are attached to different
sites of surface of spinal cord called anterolateral sulcus
and posterolateral sulcus respectively.
Out of 12 pair of cranial nerves some are sensory,
some are motor whereas some of these are mixed
nerves as follows:
Cranial Nerves I, II, VIII Sensory
Cranial Nerves III, IV, VI, XI, XII Motor
Cranial nerves V, VII, IX, X Mixed
Again, Ist (olfactory) and IInd (optic) cranial nerves,
carrying special sense of smell and vision respectively,
are attached to the forebrain, but other 10 pairs of cranial
nerves come out from the surface of brainstem. Unlike
the spinal nerves, separate motor and sensory roots of
some of mixed cranial nerves (V, VII) are attached close
to each other at the surface of brainstem.
Peripheral Nerve Forming Plexus (Networks)
(Fig. 2.27)
Adjacent spinal nerves in different regions, except
3rd thoracic to 11th thoracic intercommunicate with
each other in different regions (upper cervical, lower

Cords Divisions Trunks Nv. roots

C5
Anterior division U
Lateral cord
C6

M
Posterior cord C7

Posterior
divisions C8
L
Medial cord
Anterior division T1

Fig. 2.27 Peripheral spinal nerves forming plexus. C5 C8 and T1 spinal nerves, through formation of brachial plexus, supply upper limb
(through various nerves derived from lateral, posterior and medial cords)
37
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Umbilicus
Overlapping of T11
dermatome in the area
of T10 dermatome
Fig. 2.28 Belt of skin (Dermatome) supplied by sensory component of peripheral nerve
cervical, lumbar, sacrococcygeal) and finally give
named branches which are distributed peripherally.
Reasons for formation of nerve plexuses
1. A muscle developed by union of multiple meso-
dermal units (segments), will get supply of multiple
segmental motor nerve fibers by union of adjacent
spinal nerve roots through plexus formation.
2. A belt of skin of body is innervated (supplied)
by sensory fibers of one peripheral nerve. This
is called dermatome. There may be overlapping
of nerve supply by adjacent peripheral nerve to
adjacent dermatome (Fig. 2.28).
Different nerve plexuses
Each of the spinal nerves divides into ventral and
dorsal rami. Nerve plexuses at different regions of
body are formed by ventral rami. Ventral rami of 3rd
thoracic (T3) to 11th thoracic (T11) spinal nerves are
distributed to the body wall. Ventral rami of other
spinal nerves are distributed to following regions
of body through formation of different nerve plexus
named below.
Ventral rami of Name of the Distribution area
spinal nerve plexus formed sheath of a peripheral nerve. Structurally, it is
1 C1 to C4 nerves Cervical plexus Motor fibers to
Muscles of neck and
to diaphragm. lies very fine network of blood vessels.
Sensory fibers to
Skin of neck
2. C5 to T1(T2) nerves Brachial plexus Motor fibers to
Muscles of upper
limb
Sensory fibers to
Skin of upper limb
Contd...
38
T10 Dermatome
T11 Dermatome
Contd...
Ventral rami of Name of the Distribution area
spinal nerve plexus formed
3. T12 to L4 nerves Lumbar plexus Motor fibers to
Muscles of front of
Lower limb.
Sensory fibers to
Skin of front of
lower limb.
4. L4 to S5 nerves Sacral plexus Motor fibers to
Muscles of back of
Lower limb.
Sensory fibers to
Skin of back of lower
limb.
Spinal nerves which do not form plexuses
(T2 T11) but supply the body wall or trunk (thorax
and abdomen) are distributed as follows:
T2 T11 nerves Distributed in thorax.
T7 T11 nerves Distributed in abdomen. T12
nerve also supplies wall of abdomen.
Constituents of a Peripheral Nerve (Fig. 2.29)
A peripheral nerve is covered by connective tissue
sheath in different planes which are as follows:
1. Epineurium: It is the outermost connective tissue
made up of dense connective tissue which posseses
protective function. On the surface of epineurium
2. Perineurium: A peripheral nerve is composed of
bundles of nerve fibers. Many group of nerve fibers
which are called fasciculi (singular fasciculus)
are present in a nerve. Each fasciculus is enclosed
by a sheath of connective tissue which is smooth in
nature but made up of finer collagen fibers. This is
called perineurium.

Epineurium
Perineurium
Endoneurium (interstitial
connective tissue between
nerve fibers)
Fig. 2.29 Connective tissue elements of a peripheral nerve
3. Endoneurium: It is not present in the form of she-
ath. A nerve fasciculus enclosed by perineurium
is composed of number of nerve fibers. Interstitial
tissue inbetween nerve fibers inside a fasciculus is
called endoneurium. It is made up of very delicate
loose connective tissue.
Apart from the connective tissue related to a peri-
pheral nerve classified as above individual nerve fibers
which are myelinated are covered by myelin sheath.
Types of Nerve Fibers in a Peripheral Nerve
I. According to thickness so also velocity of conduction:
Thickness Velocity of iii. Arrectores pili muscles (involuntary) of skin.
Type Example
(diameter) conduction
1. Type A 1.5 22 4 120 i. Motor neurons
(thickest, microns meters/sec supplying skeletal
fastest and (voluntary)
myelinated) muscles and parasympathetic components.
ii. Most of the
sensory neurons.
2. Type B 1.5 3 3 15 Preganglionic
(medium in microns meters/sec autonomic nerve
thickness fibers
and as well
as conduction
speed and
myelinated)
3. Type C 0.1 2 0.5 4 i. Postganglionic
(thinnest with microns meters/sec automonic nerve
minimum fibers
conduction ii. Autonomic
speed and afferent (sensory)
non- fibers from viscera
myelinated) iii. Somatic
afferent (sensory)
fibers from
skin and muscles
Type AFibers are further classified as follows:
Type AMotor fiber Alpha, Beta and Gamma
Type ASensory fibers Types I, II, III.
II. According to area distribution (Figs 2.30A and B)
1. Somatic afferent (sensory): These fibers carry
impulse (sensory inputs or informations) from
skin, muscles, tendons and joints.
Nervous System in Brief
Fasciculi
2. Somatic efferent (motor): These fibers carry
impulse (command) from central nervous system
(brain and spinal cord) to the skeletal muscles
(effector organs).
3. Visceral afferent (sensory): These fibers carry
impulse (sensory inputs or information) from viscera,
like sense of pain, pressure, distension, stretch.
4. Visceral efferent (motor): These fibers carry
impulse (command) from central nervous system
(brain and spinal cord) to
i. Smooth (involuntary) muscles of viscera.
ii. Smooth (involuntary) muscles of cardiovascular
channels.
iv. Exocrine glands.
Out of the above mentioned fibers visceral afferent
and visceral efferent fibers are fibers of autonomic
nervous system which are made up of sympathetic
Somatic afferent and visceral afferent fibers enter
through the same route of sensory nerve (cranial as
well as spinal), but relay in different groups of neurons
in central nervous system (brain and spinal cord).
Again somatic efferent and visceral efferent fibers
come out through the same route of motor nerve
(cranial and spinal). But somatic efferent fibers end
directly to the target organs (effector organs) which
are voluntary muscles, and visceral efferent fibers
reach the target organs (involuntary muscles or
exocrine glands) after a relay in postganglionic neu-
rons thus forming autonomic ganglion (singular
ganglia) (Fig. 2.30B).
Additional functional components of fibers in
cranial nerves: During intrauterine life, six pairs of
mesodermal bars develop winding primitive phar-
ynx from its dorsolateral aspect. These are called
pharyngeal (branchial) arches. 5th branchial arch gets
degenerated finally. Some muscles in the region of head
and neck are developed from mesoderm of 5 (1st4th
and 6th) branchial arches. These muscles are voluntary
muscles but not somatic muscles. Some of cranial
nerves contain fibers which supply these branchial
arch muscle called branchial efferent component. These
39
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Posterior root
Somatic receptor ganglion
Somatic
afferent fiber

Somatic
efferent fiber

Somatic effector

Posterior root
Autonomic receptor ganglion
Visceral
afferent fiber

Autonomic
ganglion

Visceral
efferent fiber

Autonomic effector
B

Figs 2.30A and B Types of nerve fibers in peripheral nerve. A. Somatic fibers, B. Autonomic fibers

fibers of cranial nerves are also called special visceral
efferent component. In this connection, it is to be noted
here that, some special senses like taste (gustatory
sensation) is carried from viscera like tongue, part of
pharyngeal wall and soft palate. Sensory fibers of some
cranial nerves carrying this (taste) sensation are called
special visceral afferent component.
So, in addition to the previously mentioned four
components of a peripheral spinal nerve, some of
cranial nerves may contain following types of fibers.
40
5. Special visceral afferent: Fibers carrying taste
sensation.
6. Special visceral efferent (branchial efferent):
Fibers supplying (voluntary) muscles developed
from branchial arch mesoderm of 1st to 4th and
6th arches.
For more clear concept about functional components
of peripheral nerve, reader is suggested to go through
the chapters of spinal cord and brainstem.

Peripheral Nerve Injury (Figs 2.31A and B)
When a peripheral nerve is injured and cut, nerve
fiber (neuronal process) may be divided into two
segments. The two segments are as follows:
1. Proximal: This is connected to cell body of neuron,
known as proximal stump.
2. Distal: This is known as distal stump.
Following nerve injury, both the proximal as well
as distal stump of nerve fibers undergo degeneration.
The cell body also gets degenerated along with
proximal stump.
Nervous System in Brief
of nerve fiber towards the cell body which also
shows degenerative changes. This is known as
Retrograde or Wallerian degeneration. This so
called after the name of Waller who first noticed
the degenerative changes of nerve fiber.
This degeneration process starts within 48 hours
of nerve injury.
Degenerative changes of fibers of proximal stump
Disintegrated myelin sheath is converted into lipid
droplets.

Degenerative changes of nerve fibers Degenerative changes in cell body

1. Degeneration of proximal stump From the site i. Cell body is swollen and rounded.
of lesion (injury) degenerative process start in ii. Nucleus becomes eccentric (peripheral) in
retrograde direction through the proximal stump position.
Influx of macrophages

Nucleus Chromatolysis with Cell body is Endoneurium Schwann cells disintegrate

becomes disappearance of rounded is torn into lipid droplets
eccentric Nissl granules
A

Axonal process
regrows
All axonal sprouts Schwann cells
B except one disappear proliferate

Figs 2.31A and B Degeneration and regeneration of neuron. A. Process of degeneration, B. Process of regeneration
41
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
iii. Fragmentation of Nissl bodies This is called
chromatolysis.
iv. Neurofilaments are broken down.
Degenerative changes of distal stump
This is called anterograde degeneration. This occurs
immediately after injury. The degenerative process is
same as that of proximal stump fibers.
Regeneration of nerve fiber
During degeneration process of a nerve fiber, follo-
wing peripheral nerve injury, myelin sheath gets
disintegrated. But the endoneurium and neurolem-
mal sheath of proximal stump remain intact. That
is why chance of regeneration of proximal stump
of nerve fiber with cell body remains alive. But in
no case distal stump gets regenerated, unless and
until it is surgically connected with the proximal
stump. In central nervous system, nerve fibers do not
regenerate, because they are devoid of endoneurium.
Steps of regeneration
1. Many Schwann cells undergo proliferation at the
site of injury.
2. Some of the Schwann cells undergo changes to
macrophages which take out the tissue debris as
well as lipid droplets formed by disintegration of
myelin sheath.
3. Neuronal body return to its original nature and
shape. Its nucleus again come back to the central
position.
4. Terminal end of proximal stump presents knob-
like appearance from where number of sprouts
come out.
5. One of the sprouts is elongated and others dis-
appear.
6. The elongated sprouts it ensheathed by many of
the proliferating Schwann cells which thus form
new myelin sheath.
Regeneration of nerve fiber occur at a speed of
1mm per day. Complete regeneration may need a
period of 36 months.
Regeneration of a nerve fiber is arrested due to
following reasons:
1. If endoneurium is not intact.
2. If the distance between the two cut segments of
nerve fibers is more than 3 cm.
3. If nerve growth factor does not act.
4. If the site of injury is infected. It is important to
note here that leprosy bacillus travels beneath the
endoneurium in retrogate direction and damage
the Schwann cells, thus disintegrating myelin
sheath causes infective nerve injury.
42
Cellular Components of Peripheral Nervous
System (Figs 2.30A and B)
In the pathway of peripheral nervous system, apart
from the peripheral nerves, there are groups or
clusters of neurons, which are called ganglia (singular
ganglion).
There are two different types of ganglia. Though
both are commonly termed Ganglia structurally they
are different.
Sensory Root Ganglia
In peripheral nervous system, outside the central
nervous system, these are collections of cell bodies of
first order of sensory neurons in the afferent (sensory)
pathway which form sensory component of peripheral
nerves (cranial and spinal nerves).
Sensory root ganglia of sensory components of
some cranial nerves
These are cell bodies of 1st order of neurons present
in sensory components of cranial nerves (Fig. 2.26B)
which may be either purely sensory nerves or sensory
component of a mixed nerves.
The ganglia are as follows:
No. and name of Type of nerve Name of the ganglia
cranial nerves (mixed or sensory)
Vth Trigeminal Mixed Semilunar ganglia
VIIth Facial Mixed Geniculate ganglia
VIIIth Vestibu- Sensory Spiral ganglia and
locochlear vestibular ganglia
IXth Glosso- Mixed Superior and inferior
pharyngeal ganglia
Xth Vagus Mixed Superior and inferior
ganglia
Cells of these ganglia are mostly bipolar. Peripheral
process carries impulse from peripherally situated
sensory end organs towards the cell body. The central
process carries impulse from the cell body towards
the central nervous system (brainstem).
Posterior root ganglia of spinal nerves (Figs 2.26A
and 2.30)
These are cell bodies of 1st order of neurons carrying
sensory impulse towards the spinal cord. The ganglia
are attached to the dorsal (posterior) root of spinal
nerve close to spinal cord. The neurons are pseudo-
unipolar in nature whose single process bifurcates
in Tshaped manner into peripheral and central
process. The peripheral limb acting as dendrite carr-
ies impulse from peripherally situated sensory end
organs (receptors). The central limb of Tshaped proc-
ess carries impulse towards central nervous system.

It is important to note that these sensory neurons
of both cranial as well as spinal nerves are of two
types. Some carry somatic sensations from skin,
muscles, tendons, joints. Some of them carry visceral
sensation forming sensory component of autonomic
nervous system.
The sensory ganglia are covered by connective tis-
sue capsule. Inside the ganglia, cell body of each of
the neurons is enclosed by capsular or satellite cells
all around. These cells protect the neurons and also
provide nutrition to them lying between neurons and
blood capillaries.
Autonomic Ganglia (Fig. 2.30B)
In case of somatic neurons (cranial as well as spinal),
motor fibers coming out of central nervous system end
directly to the target organs (voluntary muscles). In
case of both sympathetic as well as parasympathetic
components of autonomic nervous system, motor
(efferent) fibers, after coming out of central nervous
Nervous System in Brief
system end in a relay stations, from where another
neuron (postganglionic) starts to reach the target
organs (involuntary muscles or exocrine glands).
These synaptic junctions with postganglionic cell
bodies are called autonomic ganglia. These ganglia
may be large and enclosed by connective tissue
capsule. Again it may be small and situated in the
network of autonomic nerves.
These autonomic ganglia lying in the peripheral
nervous system are, therefore, relay stations as well
as collections of cell bodies of second order (post-
ganglionic) of autonomic neurons.
Between central nervous system and target organs,
relative position of sympathetic and parasympathetic
autonomic ganglia vary. Sympathetic ganglia are more
close to the central nervous system. Parasympathetic
ganglia are away from central nervous system, so
more close to the target organs (involuntary muscles
or exocrine glands).
43
 Peripheral End Organs
By this time it is well-understood that a peripheral
nerve is composed of nerve fibers. These nerve fibers
may be motor or sensory in nature. Sensory fibers,
forming a sensory nerve, carry informations (input)
through its peripheral or terminal endings from
the periphery of body. The peripheral ends of these
sensory nerve fibers present specialized structure
to receive sensory inputs due to change in the
environment. Again a motor nerve is made up of nerve
fibers which carry impulse (directions or command)
from central nervous system to the peripheral target
organs (muscles or exocrine glands) for an effect. So,
peripheral or terminal ends of motor nerve fibers
come in close contact with target organs (muscles
or exocrine glands). These sites of contact present
specialized structures.
These specialized terminal endings of both sensory
as well as motor nerve fibers are called end organs
(Fig. 3.1).
Receptor Sensory nerve Central nervous system
Effector Motor nerve Central nervous system
Fig. 3.1 Peripheral end organs (receptor and effector)
3
End organs at the terminal ends of sensory nerve
fibers which receive sensory informations or inputs
are called receptors.
End organs at terminal ends of motor nerve fibers
which are to produce effect in the form of contraction
of muscles or secretion of exocrine glands, are called
effectors.
RECEPTORS
Receptors are specialized structures at the terminal
ends of sensory nerve fibers which are distributed
peripherally to receive sensory informations (inputs)
due to change in the environment (stimulus).
Anatomical Classification of Receptors
Fundamentally, receptors are classified as
l Exteroceptors.
l Proprioceptors.
l Interoceptors.
Exteroceptors
These receptors are distributed superficially in the
layers of skin and subcutaneous tissue. Exteroceptors
are stimulated by external stimulus liketouch, pres-
sure, pain by mechanical or chemical trauma and
alteration of temperature. These receptors are more
accurately called general exteroceptors.
Exteroceptors for perception of sense of smell
(olfactory), vision (visual), hearing (acoustic) and
taste (gustatory) are called special exteroceptors.

Proprioceptors
When a joint moves due to contraction of a muscle or a
group of muscles, we can feel it. This is called sense of
movements. Again, due to contraction of muscle, when
a part of body is stretched or adjusted, we can also
feel it. This is called sense of position. These feelings
or perceptions are because of impulse that are carried
through chain of sensory neurons from concerned part
of periphery of body to central nervous system. The
informations are carried from peripheral end organs
located in muscles, tendons and joints. These sensory
end organs are called general proprioceptors.
Specialized receptors are located in specialized
site of internal (innermost) ear, whose function is
related to perception and maintenance of balance
or equilibrium of body. These are called special
proprioceptors. Impulse is carried through vestibular
component of vestibulocochlear nerve (eighth cranial
nerve).
Interoceptors
Both exteroceptors as well as proprioceptors, defined
above, are related to endings of somatic sensory nerves,
thus carry sensations called somatic sensations.
There are various sensations carried from viscera.
These are sense of pain (due to ischemia), stretch,
Peripheral End Organs
distension, compression, etc. These sensations are
carried through autonomic sensory nerves. The
sensory end organs in the wall of viscera from where
these sensations are carried, are called interoceptors.
So, receptors are classified through following
table:
In this chapter, general receptors (general exter-
oceptors and general proprioceptors) are described.
For special receptors, the reader is to consult the
chapters of respective sensory pathways.
General exteroceptors
These receptors located in skin and subcutaneous
tissue are subdivided into two groups
1. Nonencapsulated.
2. Encapsulated.
Nonencapsulated receptors (Fig. 3.2)
These receptors do not present any specialized struc-
tures made up of modified cells of the tissue. These
are free endings of sensory nerve fibers in different
forms which directly come in contact with tissue-cell
or intercellular spaces.
Types of nonencapsulated receptors:
1. Free nerve endings: These nerve fibers may be
myelinated or nonmyelinated. But finally ends
of the fibers loose myelin sheath. Apart from the

Type of sensory nerve

Name of receptor
Location Type of sensations carried
through which carried
1. General exteroceptor Skin and subcutaneous Touch, pressure, pain, Somatic sensory
tissue temperature
2. Special exteroceptor Nose, eye, ear, tongue Smell, vision, hearing, taste Somatic sensory. Special
Visceral sensoryfor taste
3. General proprioceptor Muscles, tendons, joints Sense of movement and Somatic sensory
position of body
4. Special proprioceptor Ear Sense of body balance or equilibrium Somatic sensory
5. Interoceptor Viscera Sense of pain, stretch, distension, Autonomic sensory (both symp-
compression athetic and parasympathetic)

Epidermis
{
Dermis

{ Free nerve endings

Hair follicle receptor Merkel disk

Fig. 3.2 Nonencapsulated sensory end organ

45
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Meissners corpuscle Pacinian corpuscle
Fig. 3.3 Encapsulated sensory end organ
skin, these receptors are also located in cornea,
periosteum of bone and root of teeth. In skin, these
free nerve endings come in contact with basal cells
of epidermis or with collagen fibers of dermis.
Mostly, they carry pain sensation. But they may be
stimulated by touch, pressure as well as temperature.
2. Hair follicle receptors: These are also free
nerve endings, but in different forms. Terminal
unmyelinated ends of nerve fibers form a spiral
arrangement around the root of hair follicles below
the position of sebaceous gland.
These receptors are stimulated initially when
the hair is bent. But so long hair remains bent, the
receptors remain silent. When hair is released, a
second burst of stimulation occurs.
3. Merkel disks: These are also called Tactile Dis-
ks of Merkel. In this cases free nerve endings
present small disk-shaped endings which come in
contact with specialized dark cells in the basal or
deeper part of epidermis of skin. These cells are
called Merkel cells.
These receptors are located in nonhairy skin.
Stimulation of these receptors makes a person aw-
are of degree of pressure exerted while touching an
object.
Encapsulated receptors (Fig. 3.3)
These receptors present outer connective tissue cap-
sule surrounding a central core inside which lies the
free nerve ending. They are found in different size
and shape.
1. Meissners corpuscles: These are the receptors
for touch and that is why called Tactile Corpuscles
of Meissner. They are present in dermal papillae
of skin and are mostly found in the skin of those
parts of body which are very sensitive to touch,
46
End bulb of
krause
End bulb of
Ruffini
for example palm of hand, sole of foot, external
genitalia, nipple and eyelids.
Meissners corpuscles are oval in shape and pre-
sent a capsule surrounding a central core made up of
modified Schwann cells. At the center of the corpuscle
schwann cells are intermingled with free nerve
endings.
These receptors gives a special tactile power to the
skin. Because of their function, a person is able to feel
two points of skin touched close to each other. This is
called power of two point discrimination.
2. Pacinian corpuscles: Pacinian corpuscles are
largest in size, widely distributed in the body, oval
in shape being about 2mm in measurement.
They lie in dermis of skin and subcutaneous tissue,
being most abundant in palm, sole, breast. Apart from
the skin, these are also found in the structures related
to joints, e.g. capsules, ligaments, synovial membrane.
Firm pressure stimulates these receptors.
The oval corpuscles are 2mm in length and 0.5mm
in diameter. Structurally it is made up of:
i. Outermost capsule.
ii. Inside the capsule, the central core is formed
by concentric layers of flattened cells.
iii. A large myelinated sensory nerve fiber pierces
one pole of the corpuscle, looses its myelin
sheath. The naked nerve fiber traverses the
center of central core of flattened cells and end
in a small swollen terminal.
Though pacinian corpuscle is known as pressure
receptor, it is also sensitive to vibration.
3. End bulbs: These are so called because they are
bulbous and, spherical or fusiform in appearance
at the end of nerve terminal. They are of following
types:
a) End Bulb of Ruffini: They are fusiform in outline
and present in the dermis of skin. Capsule of

Fig. 3.4 Proprioceptive sensory end organs in skeletal muscle and its tendon
these receptors is cellular in nature and central
core is made up of fine collagen fibers. Each
corpuscle presents multiple large unmyelinated
nerve fibers ending within the center of colla-
gen fibers. They are stretch receptors and stim-
ulated when skin is stretched.
b) End Bulb of Krause: These are spherical in
outline. The capsule is made up of cells as well
as fibers. The nerve fiber, after piercing the
capsule, presents a club-shaped appearance at
the central core of the bulb.
Though these end organs are enlisted here, these
are not universally accepted as receptors. These are
considered by many as degenerating or regenerating
nerve terminal rather than a receptor.
General proprioceptors
These are deep-seated receptors present in the mus-
cles, tendons and joints. These receptors are
1. Muscle Spindle or Neuromuscular Spindle: These
sensory end organs are present in muscles.
2. Golgi Tendon Organ or Neurotendinous Spindle:
The receptors are present in tendons.
3. Proprioception sensation is also carried from
joint structures like: Capsule, ligaments and
synovial membrane. These receptors are Pacinian
corpuscles which have been already discussed.
Neuromuscular spindle (Fig. 3.4)
Neuromuscular spindles are also known as muscle
spindles. These are sensory end organs present in
voluntary muscles. They are more abundant in number
in the muscle close to its junction with tendons. These
receptors, on stimulation, send information to the
central nervous system regarding state of contraction
Peripheral End Organs
Sensory nerve
Neuromuscular spindle
(Intrafusal fiber)
Neurotendinous spindle
(Golgi tendon organ)
and position of voluntary muscles. Central nervous
system uses this information for control of activity of
voluntary muscles.
Neuromuscular spindle is a fusiform or spindle-
shaped organ whose long-axis is parallel to the length
of a muscle. Length of this end organ varies from
14 mm. It is enclosed by a connective tissue capsule.
Inside the capsule of this fusiform organ, units of this
sensory receptors are situated. These are specialized
muscle fibers called intrafusal fibers. In contrast to
these intrafusal fibers (inside the spindle), usual
muscle fibers (myocytes) of voluntary muscle, outside
the spindle, are called extrafusal fibers which are
effector in nature (Fig. 3.5).
The intrafusal fibers of neuromuscular spindle are
of following two types
1. Nuclear bag fibers.
2. Nuclear chain fibers.
Both these types of fibers are specialized muscle
fibers. Their long-axis are parallel to the length of the
spindle. Their number in a spindle varies from 614.
Each of them presents a central part (equatorial
part) and two terminal ends. Fundamentally term-
inal ends of both these fibers present transverse
striations of voluntary muscles and are contractile
in nature. Central or equatorial part lacks striation
property and present accumulation of many nuclei
(Figs 3.6 and 3.7).
n Nuclear bag fibers: Equatorial part of these
fibers presents spherical sac which is filled up with
nuclei. Length of nuclear bag fiber is more. Their ends
project beyond the capsule and are fixed through their
attachment to connective tissue of extrafusal fibers.
n Nuclear chain fibers: Structurally these differ
from nuclear bag fibers. These are shorter in length
47
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Nuclear bag fiber

Intrafusal fibers
{ Nuclear chain fiber

Central equatorial
parts containing
nuclei
Extrafusal fibers
Terminal striated
contractile parts
Capsule of neuromascular
spindle

Fig. 3.5 Neuromuscular spindle composed of intrafusal fibers, and its relation with extrafusal fibers

and uniform in breath althrough. But the equatorial
part presents collection of nuclei in the form of rows
or chains.
Both intrafusal fibers are receptor as well as
effector organs It is important to notice at this
stage that, though the neuromuscular spindle are
proprioceptive sensory end organs, intrafusal fibers
inside the spindle act as both receptor as well as
effector. Equatorial or central noncontractile part acts
as receptors and terminal cross striated, contractile
parts act as effectors, which receive sensory and
motor nerve fibers respectively.
Higher centers
Basal ganglia
Reticular formation
Cerebellum

1. Descending fiber tracts relay to

gamma motor neuron

2.
Axon of gamma neuron innervates
terminal contractile parts of intrafusal
fibers

3. Stretching of both ends of nuclear bag
type of intrafusal fiber stimulates central
noncontractile part

4. Annulospiral endings of afferent nerve fiber carry impulse to

spinal cord to stimulate alpha motor neuron through synapse

5. Axon terminal of alpha neuron innervates

extrafusal fiber

Fig. 3.6 Illustration to explain mode of function of neuromuscular spindle (nuclear bag fiber)
48

n Mode of function of neuromuscular spindle
(Figs 3.6 and 3.7): It is understood that central
(equatorial) nonstriated as well as noncontractile part
of both nuclear bag and nuclear chain type intrafusal
fibers are receptor of voluntary muscle. From receptors
proprioceptive sensations are carried by sensory root
of spinal nerves to the spinal cord. The terminal
contractile parts of both type of intrafusal fibers receive
efferent (motor) nerves which are axons of small-sized
(less than 25 microns) gamma motor neurons of gray
mattter of spinal cord. Again extrafusal fibers, lying
outside neuromuscular spindle, are supplied by axons
of large sized (more than 25 microns) alpha motor
neurons of spinal cord gray matter.
It is very important as well as interesting to note
at this stage that functions of the neuromuscular
spindle proprioceptors is interrelated to the function
of contractile terminal parts of intrafusal fibers supp-
lied by gamma motor neurons as well as function of
extrafusal fibers supplied by alpha motor neurons.
Fig. 3.7 Illustration to explain mode of function of neuromuscular spindle (nuclear chain fiber)
Peripheral End Organs
Even when a muscle is in a resting stage, in
unnoticed (subconscious) state of an individual, motor
impulse is carried from higher centers (Figs 3.6 and
3.7) of brain, e.g. basal ganglion, cerebellum, reticular
formations to the gamma motor neurons of spinal cord
through descending motor fiber tracts (Figs 3.6 and
3.7). Impulse pass via axons of gamma neurons to both
the contractile ends of intrafusal fibers. When both the
ends are contracted, central noncontractile receptor
part (proprioceptor) gets stretched and so stimulated.
Sensory impulse is carried from here through afferent
(sensory) roots of spinal nerve to the gray matter of
spinal cord where it forms synapse with alpha motor
neurons. Stimulation of alpha neurons helps to keep
the extrafusal fibers so the whole voluntary muscle
in a partially contracted stage (in resting condition)
which maintains thus the tone of the muscle.
n Neuromuscular spindle acting for stretch
reflex: In reference to the above stages of functions,
even if the influence of higher centers of brain, e.g.
Higher centers
Basal ganglia
Reticular formation
Cerebellum
1. Descending fiber tracts relay to
gamma motor neuron
2. Axon of gamma neuron innervates terminal
contractile parts of intrafusal fibers
3. Stretching of both ends of nuclear chain
type of intrafusal fiber stimulates central
noncontractile part
4. Flower-spray endings of afferent nerve
fiber carry impulse to spinal cord to
stimulate alpha motor neuron through
synapse
5. Axon terminal of alpha neuron innervates
extrafusal fiber
49
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
basal ganglia, cerebellum or reticular formation is not
there to stimulate gamma neuron so the intrafusal
fibers, stretching of the voluntary muscle, causing
elongation of intrafusal fibers at their ends will
stimulate the central receptor part. Sensory impulse
will be carried to the spinal cord via afferent nerve
which will synapse with motor neurons supplying
extrafusal fibers at the spinal cord segement level.
This is called stretch reflex.
Neurotendinous spindles (Golgi tendon organ) Fig. 3.4
These are fusiform or spindle-shaped proprioceptive
receptors present in the tendons of voluntary muscle.
They are situated in the muscle-tendon close to its
junction with fleshy belly. These receptors send
information to the central nervous system to make an
individual aware of the state of tension of a muscle-
tendon.
Like neuromuscular spindle, neurotendinous spin-
dles are also fusiform in outline and covered by a
connective tissue capsule. But it is filled with parallel
bundles of collagen fibers along long axis of the spindle.
Fibroblasts are larger and more in number in between
the bundles of collagen fibers. The myelinated nerve
pierces the capsule, looses its myelin sheath and
divides into finer branches which end in knob-like
endings in between the collagen fibers. When these
fibers are stretched due to tension of a tendon, these
knob-like endings are squeezed and thus carry the
impulse.
n Mode of Function of Neurotendinous Spindle
(Fig. 3.8): A tendon is continuation of a muscle. A
Afferent fibers carried from
Golgi tendon organ
Golgi tendon organ
Fig. 3.8 Illustration explaining mode of action of neurotendinous spindle (Golgi tendon organ)
50
muscle presents neuromuscular spindle (intrafusal
fibers) and also extrafusal fibers. A tendon contains
Golgi tendon organs or neurotendinous spindles.
These are receptors present in tendon. Increase in
tension of a muscle also causes increase in tension of
tendon which stimulates the neurotendinous spindles.
Afferent (sensory) impulse is carried through sensory
nerve root of spinal nerve to reach the spinal cord.
Afferent nerve form synaptic reflex arc with alpha
neuron through an intermediate (internuncial) neur-
on. Alpha neuron ends in extrafusal fibers which
remain in a contracted state through stimulation
of alpha neurons. But when impulse is carried
through internuncial neurons to alpha neuron, these
internuncial neuron produces inhibitory effect to
alpha neuron, being inhibitory in nature. Result is
the release of tension of the muscle.
General proprioceptors in relation to joints
These sensory end organs are situated in the substance
of capsule, ligaments and synovial membranes of
joints. Sense of position of joints and sense of their
movements are detected when these receptors are
stimulated. Moreover sense of stretch, pressure and
pain are also carried due to stimulation of these
receptors.
n Types: These are of following four types
l Type I: These are nothing but Ruffini endings
structurally. They carry sense of position and
movement of the joint.
Internuncial neuron
Axon of alpha motor neuron supplies
extrafusal muscle fibers

l Type II: Structurally these are Pacinian corpu-
scles. They carry the sense of pressure.
l Type III: These are neurotendinous organ or
Golgi tendon organ. As found in tendons, these
are present in ligaments. Due to stretching of
ligament these carry inhibitory impulse through
internuncial neurons of spinal cord, these prevents
excessive movements of voluntary muscle.
l Type IV: These are free nerve endings which carry
pain sensations from synovial membrane.
RECEPTORS OTHER WAYS OF CLASSIFICATION
According to Nature of Stimulation
1. Mechanoreceptors: These are stimulated by mec-
hanical deformation, i.e. Receptors which carry
sense of
i. Touch, pressure and stretch
ii. Sense of hearing Through sound waves
iii. Sense of body balance (equilibrium).
2. Thermoreceptors: These are stimulated by cha-
nge of temperature in the environment surround-
ing them.
i. Rise of temperature Heat
ii. Fall of temperature Cold.
3. Chemoreceptors: These are stimulated by chem-
ical change in their environment.
i. Receptors for taste
ii. Receptors for smell.
4. Nociceptors: These receptors are stimulated due
to injury or damage in the tissue. Due to stimulation
of these receptor, unpleasant sensations are felt
like-pain, irritation or discomfort.
5. Photoreceptors: They are stimulated only by
light causing perception of vision. Example
Receptors in retina of eyeball called rods and cones
cells.
1. Epithelial receptor 2. Neuroepithelial receptor (Bipolar
(Pacinian corpuscles) cells of nasal mucosa)
Fig. 3.9 Structural classification of receptors
Peripheral End Organs
6. Osmoreceptors: They are stimulated by change
of osmotic pressure in the tissue.
Structural Classification (Fig. 3.9)
In general we know that receptors are specialized
cells present in the peripheral tissue from where start
the sensory neurons to carry the impulse.
These afferent (sensory) neurons carry impulse to
the central nervous system. Variation in this usual
structural pattern divides receptors in three different
types. In first variety the specialized cells are
epithelial cell. So the receptors are called epithelial
receptors (1). Majority of the receptors are examples of
this type. Sometimes, these specialized cells forming
receptors are modified neurons which are present in
the epithelial lining, as are the bipolar neurons in the
epithelial linings of nose, carrying sensation of smell
(olfactory sensation). These are called neuroepithelial
receptors (2). In third variety, no specialized cells are
present to be defined as receptors. In this case, free
nerve endings of peripheral dendritic processes of first
order of sensory neurons themselves act as receptors.
Examples are nonencapsulated exteroceptors (cutan-
eous receptors). These are named as neuronal rece-
ptors (3).
MOTOR END ORGANS (EFFECTORS)
Effectors are the specialized junctional areas where
terminal ends of motor nerve fibers come in contact
with effector organs. These effector organs are of
following three types
1. Somatic effectors: These are skeletal muscle
fibers (myocytes) which receive terminal ends of
somatic motor nerve fibers. These specialized sites
are known as somatic neuromuscular or myon-
eural junctions.
2. Visceral effectors: These are smooth muscle
fibers (myocytes) which receive terminal ends of
3. Neuronal receptor (Free nerve
endings)
51
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
autonomic motor nerve fibers (sympathetic or pa-
rasympathetic). These specialized junctional sites
are known as visceral neuromuscular or myo-
neural junctions.
3. Secretomotor effectors: These are specialized
junctional areas between secretomotor autonomic
nerve endings and specialized contractile cells
in the walls of alveoli (acini) of exocrine glands.
These contractile cells are known as myoepithelial
cells.
Somatic Neuromuscular Junction (Myoneural
Junction)
Each of the somatic (skeletal) muscle fibers gets
direct contact with endings of motor nerve fibers
for innervation. This site of contact is called neuro-
muscular junction or myoneural junction.
These muscle fibers are of two types
i. Extrafusal fibers: Which receive endings of
alpha neuron
ii. Intrafusal fibers: Which receive endings of
gamma neuron. It has already been studied
Axon terminal
Skeletal muscle fiber
(myocyte)
Fig. 3.10 Motor end plate
52
that both terminal contractile ends of intrafusal
fibers receive gamma motor nerve endings.
Myoneural junctions, in relation to above two
types of muscle fibers, may show following variations.
n A. Motor end plates or en plaque endings
(Fig. 3.10): Most of the myoneural junctions are of
this variety. In these types, the axon terminal of a
motor nerve comes to an oval specialized area of a
muscle fiber at its center. This specialized oval area
at the surface of muscle fiber is called sole plate. The
junctional area between sole plate and axon terminal
is known as motor end plates.
n B. En Grappe endings (Fig. 3.11A): In this
variety, axon terminal runs along the length of muscle
fiber. While running along, it divides, into series of
short branches which end into knob-like endings on
the surface of muscle fiber.
n C. Trail endings (Fig. 3.11B): In this type, axon
terminal run along the length of muscle fibers and
end in multiple finer endings.
En Grappe and trail endings are found in
intrafusal fibers of muscle spindles.
Motor nerve fiber
Motor end plate (en-
plaque ending)
 Peripheral End Organs
Axon terminal Axon of a motor neuron

Noncontractile Striated contractile part of

En-grappe equatorial part muscle fiber
ending containing nuclei

Axon of a motor
Axon terminal neuron
Noncontractile equatorial
part containing nuclei
Striated
contractile part

Figs 3.11A and B Neuromuscular junction of intrafusal fibers. A. En-grappe endings, B. Trail endings

MOTOR UNIT (FIGS 3.12A AND B)
A motor unit is defined as a single alpha motor neuron
and number of skeletal muscle fibers (extrafusal
fibers) innervated by it. So composition of a motor
unit is as follows:
i. A motor neuron cell body in central nervous
system (alpha neuron).
ii. Its axonal process coming out as motor nerve
fiber.
iii. Number of muscle fibers (myocytes) innervated
by a single axon.
Depending upon the number of muscle fibers supp-
lied by a single motor neuron, a motor unit may be of
two types
1. Large: When one axonal process supplies more
number of muscle fibers, as many as(!) 500, as
found in coarse muscle for gross movements, like
Gluteus maximus (muscle of buttock).
2. Small: When one axonal process supplies less
number of muscle fibers (10 in number), as found
in small muscles of hand for finer movements.
Neuromuscular Junction or Myoneural
Junction
It is called motor end plate which is defined as
specialized junction between terminal end of one of the
divisions of axon of a motor neuron (neural element)
and a skeletal muscle fiber (muscular element).
A motor nerve enters inside a skeletal muscle
along with its blood vessels for innervation through a
point called neurovascular hilum. Inside the muscle,
the nerve divides further into number of axons. One
axonal process divides into number of branches. Each
of these branches of axon presents a terminal knob-
like endings (telodendria). This terminal swelling
comes in contact with a gutter or depression on mi-
ddle of surface of a single muscle fiber (myocyte).
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Axon of a motor neuron

Axon terminal
Skeletal Motor end plate
muscle fiber

Skeletal Motor end plate Axon of a

muscle fiber Axon terminal motor neuron

Figs 3.12A and B Motor unit. A. Large motor unit, B. Small motor unit

This junctional area is called motor end plate
(neuromuscular junction or myoneural junction).
Structure of motor end plate (Fig. 3.13)
Motor end plate presents structural characteristics
similar to that of a typical synaptic junction between
two neurons. Structure of motor end plate shows follo-
wing 3 components.
1. Neural element: It is the terminal, nonmyel-
inated, swollen end of the division of axon of
motor neuron (Telodendria). It is called synaptic
knob.
2. Muscular element: It is the central, raised sur-
face of a muscle fiber with a gutter which comes
in contact with synaptic knob. This is called sole
plate.
3. Synaptic cleft: It is the gap between neural and
muscular element measuring 3040 mili micron or
nanometer.
54
Synaptic knob at the terminal end of division of axonal
process is swollen because axoplasm is crowded here
with
i. Many mitochondria.
ii. Large number of electron-dense, membrane
bound vesicles called presynaptic vesicles.
These vesicles are filled with Acetylcholine
which acts as neurotransmitters.
At the site of motor end plate, sole plate is
characterized by a surface elevation which is at the
middle of the muscle fiber. This elevation is due to
condensation of sarcoplasm (cytoplasm of muscle
fiber) which shows granular appearance beneath the
sarcolemma (cell membrane of muscle fiber). This area
also presents accumulation of more number of nuclei,
mitochondria, Golgi apparatus and endoplasmic
reticulum.
The raised surface of sole plate presents a
depression called primary cleft which is related to
axon terminal. But, as already mentioned, axolemma

Presynaptic vesicle
Synaptic cleft
Sarcoplasm
Mitochondria
Nucleus
Fig. 3.13 Structure of motor end plate
(cell membrane of axon) at the site of axon terminal
is separated by synaptic cleft from primary cleft of
sole plate covered by sarcolemma. Surface of primary
cleft is thrown into number of foldings to increase the
surface area. These are called secondary cleft. Bottom
(floor) of the secondary cleft presents specialized
features called receptors.
Mechanism of neuromuscular transmission
When the nerve impulse reaches axon terminal at
the site of neuromuscular junction, Acetylcholine
is released from presynaptic vesicles into the syn-
aptic cleft through a process called exocytosis. Rele-
ased Acetylcholine diffuses at a high speed through
synaptic cleft and binds with the receptors at the
secondary cleft of postsynaptic membrane of sole
plate. The receptors get activated. Activation of
receptors causes depolarization of postsynaptic mem-
brane which results in muscular contraction due to
generation of action potential.
Contraction of a muscle fiber (so also the whole
muscle) is to be followed by relaxation. This becomes
possible because, as soon as depolarization occurs
to cause contraction of muscle fiber, Acetylcholine
is broken down (hydrolyzed) by the enzyme cholin-
esterase into choline and acetic acid. This enzyme is
bound to both pre as well as postsynaptic membrane.
Choline is reutilized back into the axoplasm for re-
synthesis of acetylcholine.
Neuromuscular Blocking Agent
Tubocurarine is a drug which blocks neuromuscular
transmission. In clinical conditions causing violent
Peripheral End Organs
Axolemma
Myelin sheath
Synaptic knob
Sole plate
Sarcolemma
Receptor
Myofilaments
muscle spasm, function of this drug can be utilized.
It becomes possible because the drug binds with
the receptors at postsynaptic membrane, thus not
allowing acetylcholine to come in contact with the
receptors to result depolarization for generation of
action potential.
Myasthenia Gravis an Autoimmune Disease
Myasthenia gravis is an autoimmune disease which is
characterized by generalized muscular weakness and
muscular fatigue. Muscles of eye, face, respiration
and swallowing are mostly affected. This disorder
is due to formation of an antibody. This antibody
binds with many (not all) of the receptors which are
thereby destroyed. So acetylcholine finds less number
of receptors at postsynaptic membrane to bind for
generation of action potential. This disorder can be
compensated by administration of a drug named neo-
stigmine which posseses anticholinesterase activity
which prevents breakdown of acetylcholine at the
synaptic cleft.
Myoneural junction of smooth muscle
This does not show classical structure of neuro-
muscular junction or motor end plate. Axon terminal
does not come in contact with surface of muscle fiber.
Rather, there is considerable gap between the two.
Terminal segment of axon is nonmyelinated and may
be covered by cytoplasm of Schwann cells. At the
terminal end axoplasm presents vesicles containing
neurotransmitter. In case of parasympathetic nerve
ending neurotransmitter is acetylcholine, but in
55
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Secretomotor
nerve axon
Fig. 3.14 Secretomotor nerve endings supplying myoepithelial cells related to acini of exocrine gland
case of sympathetic it is catecholamine (usually
noradrenaline). In sympathetic system, monoamine
oxidase is the enzyme which destroys catecholamine.
In relation to muscle fibers of gastrointestinal and
urinary tract, some autonomic nerve endings release
another variety of neurotransmitter called adenosine
triphosphate which is inhibitory in nature.
NERVE ENDING RELATED TO EXOCRINE GLAND
ACINI (FIG. 3.14)
Same as myoneural junction of smooth muscle,
in case of nerve endings of secretomotor fibers to
56
Epithelium
lining acini of
exocrine gland
Myoepithelial
cell
Axon terminal
glandular acini or alveoli, there is no specialized
junctional area. Glandular alveoli are lined by single
layer of cells resting on basement membrane. Close
to the basement membrane in the substance of loose
fibroconnective tissue there are some specialized cells
which are contractile in nature. These are called
myoepithelial cells. Autonomic secretomotor axon
terminals come in relation to these myoepithelial
cells close to the basal surface of acinar cells.
Following release of neurotransmitter (acetylcholine),
myoepithelial cells contract and squeeze the acinar
wall leading to discharge of glandular content through
the duct.
 Spinal Cord
DEFINITION AND SITUATION
Spinal cord is the distal, narrow, cylindrical and
elongated part of central nervous system which is
situated in upper two-thirds of vertebral canal as a
continuation of medulla oblongata of hindbrain (Fig.
4.1).
ROLE OF SPINAL CORD AS A PART OF CENTRAL
NERVOUS SYSTEM
1. It provides innervation (nerve impulse) to the
trunk and limbs through its peripheral outflow
known as spinal nerves.
2. It receives sensory information from the receptors
distributed peripherally in the trunk and limbs
and transmits to the brain.
3. It contains cell groups at some levels (not thro-
ughout whole length of spinal cord) which form
spinal autonomic centers (sympathetic and para-
sympathetic) to send impulses to the autonomic
effector organs (smooth muscles and exocrine
glands) and to receive sensory information from
the visceral wall.
4. It forms local circuit (at its segmental level) kno-
wn as reflex arc which regulates some bodily
functions at unconscious level.
EXTENT
n Beginning: Spinal cord begins as continuation of
medulla oblongata beyond foramen magnum at the
level of upper border of 1st cervical vertebra (atlas).
4
n Termination: Spinal cord terminates as a coni-
cal end known as conus medullaris at the level of
intervertebral disk between first and second lumbar
vertebrae. A connective tissue filaments known as Fil-
um terminale extends from conus medullaris down-
wards to be attached to the back of first piece of coccyx.
IMPORTANT NOTES IN CONNECTION WITH
TERMINATION
Upto third month of intrauterine life, rate of growth of
body wall so also the vertebral column is coextensive
with that of spinal cord. Subsequently vertebral
column with the trunk grows at a rapid rate than
spinal cord, when appears the disparity in length of
the two. At birth spinal cord is found to extend upto
lower border of body of third lumbar vertebra.
In 40% cases of adult, spinal cord extends upto the
level of lower border of second lumbar vertebra or the
disk between second and third lumbar vertebra. On
rare occasions, spinal cord terminates at the level of
lower border of twelfth thoracic vertebra.
The knowledge of termination of spinal cord is
important for the clinicians to avoid injury to the spinal
cord during lumbar puncture to take out cerebro-
spinal fluid.
PARAMETERS OF SPINAL CORD
l Length: 45 cm
l Weight: 30 gm
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Medulla oblongata

Spinomedullary junction

Cervical part

Spinal nerve of left side seen from lateral view

Thoracic part
Spinal cord

Lumbar part

Cauda equina
Sacral part

1 Coccygeal
segment
Conus medullaris

Filum terminale

Fig. 4.1 Spinal cord (lateral view)the distal, narrow, elongated and tubular part of central nervous system

l Segments: Spinal cord is made up of 31 numbers

of units known as segments of spinal cord. Adjacent
segments cannot be demarcated on the surface. Each
of the segments gives rise to one pair of spinal nerves
(right and left). Each of the spinal nerves shows
surface attachment of one ventral (motor or efferent)
and one dorsal (sensory or afferent) nerve root. The
two roots unite within the vertebral canal to form a
mixed spinal nerve which finally comes out through
intervertebral foramen.
Therefore, an universal truth is learnt that ventral
root of a spinal nerve is made up motor fibers and its
dorsal root is composed of sensory fibers only. This is
known as Bell-Magendies law.
It is important to note at this stage that all the
spinal nerve (31 pairs) are mixed in nature, composed
of motor as well as sensory components. But a cranial
nerve (out of total 12 pairs) may be mixed, purely
motor or purely sensory.
58
REGIONAL CLASSIFICATION OF SPINAL CORD
SEGMENTS (FIG. 4.1)
31 segments of spinal cord are regionally classified as
follows:
Cervical 8
Thoracic 12
Lumbar 5
Sacral 5
Coccygeal 1
It is to be noted here that number of cervical
vertebrae are 7 and coccygeal pieces are 4. But the
numbers of thoracic (12), lumbar (5) and sacral (5)
cord segments correspond with the same number of
respective regional vertebrae.
Each of the spinal cord segments gives rise to a pair
of spinal nerve of corresponding name and number.
Each spinal nerve, as already mentioned is formed
by a ventral motor (efferent) and a dorsal sensory

Anterolateral sulcus
Ventral root of spinal nerve coming
out through anterolateral sulcus
Fig. 4.2 Segments of spinal cord (left lateral view) showing ventral and dorsal roots of spinal nerves coming out through corresponding
sulcus
(afferent) root. Attachment of ventral roots forms a
fine and shallow anterolateral sulcus and similarly
posterolateral sulcus is defined along the line of atta-
chment of dorsal nerve roots. Dorsal nerve roots,
close to the site of surface attachment present a small
enlargement known as posterior root ganglion which
contains the cell bodies of first order of sensory neurons
located outside the central nervous systems (Fig. 4.2).
EXIT OF SPINAL NERVES FROM VERTEBRAL FORAMEN
All the spinal nerves come out of vertebral canal
through the corresponding intervertebral foramina
except fifth sacral nerve and coccygeal nerve which
Fig. 4.3 Lower spinal nerves form cauda equina before they come out through corresponding intervertebral foramina at a lower level
Spinal Cord
Posterior root ganglion
Posterolateral sulcus
Dorsal nerve root coming out
through posterolateral sulcus
A spinal nerve
come out through sacral hiatus. To adjust the disparity
of numbers of cervical spinal cord segments (8) and
cervical vertebra (7), cervical spinal nerves (1st to 7th)
come out above the pedicles of corresponding vertebra
and 8th cervical nerve comes out below the pedicle of 7th
cervical vertebra, through the intervertebral foramen
between 7th cervical and 1st thoracic vertebra.
As the spinal cord is shorter in length than the
vertebral column, lower spinal nerves (lumbar, sacral
and coccygeal) are to descend through the vertebral
canal in the form of a bunch to reach corresponding
intervertebral foramen. These bunch of nerves are
known as cauda equina as they look like a horses
tail (Fig. 4.3).
Lower end of spinal cord
Conus medullaris
Filum terminale
Bunch of lower spinal nerves forming
cauda equina before their exit through
respective intervertebral foramina
Exit of vth sacral and coccygeal nerves
through sacral hiatus
59
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
3
Cervical enlargement
(C3T2 Segments)
Lumbosacral enlargement
(L1S3 Segments)
1 3
Fig. 4.4 Enlargements of spinal cord
CORRELATION OF SPINAL CORD SEGMENTS WITH
VERTEBRAL LEVEL
More lower is the segment of spinal cord, its distance
from corresponding intervertebral foramen so also
the corresponding vertebra is more. Interrelations of
their levels are as follows:
Spinal cord segments Vertebral level
Upper cervical C 3 same level = C3
Lower carnival C 7 - 1 = C6
Upper thoracic T5 - 2 = T3
Lower thoracic T8 - 3 = T5
Lumbar (upper) L3 - 4/5 = T11
Lumbar (lower) L5 - 4/5 = T12
Sacral /coccygeal S 1 - 6/10 = T12
S 5 - 6/10 = L1
Clinical Importance of Correlation of Levels
In case of spinal injury, fracture dislocation of
vertebra may cause lesion of spinal cord segment of
the same level. A clinician will be able to judge of
level of spinal segment affected in spinal injury from
the above mentioned guidelines. Level of fracture
dislocation of vertebra is counted through identi-
fication of vertebral landmark.
60
Key to remember level of
2 enlargement
Key to remember level of
enlargement
ENLARGEMENT (FIG. 4.4)
The spinal cord is almost cylindrical althrough its length.
However, it presents two expansions as enlargements.
These are at the cervicothoracic (C3 T2 segments) and
lumbosacral (L1S3 segments) levels (Fig. 4.4). These
enlargements appear in fetal life with the formation
of upper and lower limb buds, because of more amount
of motor neurons in these segments to supply limb
musculature and stretching of nerve fibers arising from
the plexuses for upper and lower limbs.
SURFACE FEATURES (FIG. 4.5)
Linear depression along the anterior and posterior
median line of spinal cord are known as anterior
median fissure and posterior median sulcus respe-
ctively. Anterior (ventral) median fissure is 3mm
deep, but posterior (dorsal) median sulcus is comp-
aratively shallower. Besides, linear depressions
along the lines of attachment of ventral (motor) and
dorsal (sensory) nerve roots are respectively known
as anterolateral and posterolateral sulcus. Spinal
arteries and venous tributaries run along the sulci
and fissure. Single unpaired anterior spinal artery
 Spinal Cord
Midline posterior Posterior median sulcus
spinal vein in posterior
median sulcus
Posterior root ganglion
Posterolateral sulcus with entry
of posterior root of spinal nerve
and presence of posterior spinal
artery and vein

Spinal nerve

Lateral anterior
spinal vein
Anterolateral sulcus with exit of
anterior root of spinal nerve and
presence of anterior spinal vein
Anterior spinal artery
with corresponding
vein in anterior median
fissure

Fig. 4.5 Surface features of spinal cord

runs down along anterior median fissure, whereas 2. Arachnoid mater

paired bilateral posterior spinal arteries descend 3. Pia mater.
along posterolateral sulci. Each of the fissure and These superimposed coverings are either in close
sulci are occupied by one of six (3 anterior and 3 post- contact to each other (dura and arachnoid) or separated
erior) spinal veins. by a space (arachnoid and pia).

COVERINGS (MENINGES) AND SPACES AROUND Dura Mater

THE SPINAL CORD (FIG. 4.6) This is tough and dense fibrous membrane made up of
Coverings (meninges) of spinal cord are the following connective tissue which contains abundant collagen
from outside inwards. fibers. It encloses spinal cord as well as cauda equina.
1. Dura mater Proximally dura mater of spinal cord extends upto

Subarachnoid space Subarachnoid septum

containing CSF
Wall of vertebral canal

Subarachnoid sheath

Spinal nerve
Dura

Meninges
of spinal
cord
{ mater

Arachnoid
mater
Pia mater
Intervertebral foramen

Epidural space Ligamentum

denticulatum
Epidural (internal
vertebral) venous plexus Linea splendens
in epidural space

Fig. 4.6 Coverings (meninges) and spaces around spinal cord

61
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
foramen magnum of cranium above which it is
continuous with inner (meningeal) layer of dura mater
of brain. Below, dura mater extends upto lower border
of body of second sacral vertebra beyond lower end of
spinal cord to enclose cauda equina and upper larger
part of filum terminale. Beyond that level, dura mater
is continued downward enwrapping external part of
filum terminale to blend with periosteum of first piece
of coccyx. At the level of each segment of spinal cord
dura mater is prolonged outwards around the spinal
nerve to be attached to the margin of intervertebral
foramen. Inner surface of spinal dura is in close
contact with arachnoid mater. But outer surface of
dura is separated from vertebral canal by a space
known as epidural space. This space contains loose
areolar tissue containing fat in semiliquid state. The
epidural space also contains plexus of veins known as
epidural venous plexus or internal vertebral venous
plexus.
Clinical Importance of Epidural (Internal-
vertebral) Venous Plexus
This venous plexus extends throughout whole length
of vertebral canal and it is proximally connected to
the veins of skull. In the vertebral canal it receives
basivertebral veins and also veins from the viscera
(e.g. prostate). These communications may be hazar-
dous to cause spread of cancer cells (metastasis) from
viscera like prostate to vertebral bodies and even
cranial bones.
L1
L2
L3
Lumbar vertebrae
L4
L5
S1
S2
Sacrum
S3
S4
S5
Coccyx
Fig. 4.7 Distal part of vertebral canal in sagittal section and prominent spinal subarachnoid space with illustration for site of lumbar puncture
62
Arachnoid Mater
Arachnoid mater is a thin transparent membrane
covering the spinal cord. It extends upwards beyond
foramen magnum to be continuous with arachnoid of
brain and below extends like dura mater up to second
sacral vertebra. Unlike dura mater, arachnoid is
prolonged for a short distance around spinal nerves
beyond intervertebral foramen. Arachnoid is sepa-
rated from pia mater with spinal cord by a space
known as subarachnoid space, which is continuous
above with the same space around brain. The subara-
chnoid space (of spinal cord as well as brain) contains
a thin watery fluid known as cerebrospinal fluid.
Subarachnoid space containing cerebrospinal fluid
is more prominent below lower end of spinal cord
(L2S2).
Spinal Subarachnoid Space and Clinical
Anatomy of Lumbar Puncture (Fig. 4.7)
Spinal subarachnoid space is the space beneath
the arachnoid mater covering the spinal cord. It
is continuous with the subarachnoid space over
the brain and contains cerebrospinal fluid. The
subarachnoid space around the spinal cord becomes
more spacious below the termination of spinal
cord (L2) upto its lower limit (S2), which contains
cerebrospinal fluid of considerable amount and is
known as lumbar cistern.
Conus medullaris of
spinal cord
Subarachnoid space
Lumbar puncture needle inserted
between L3 and L4 spine
Interspinous and
supraspinous ligaments
Dura and arachnoid ending at the
level of lower border of S2 vertebra
Filum terminale attached to back of
1st piece of coccyx

Lumbar Puncture (Spinal Tap)
Various diseases of spinal cord so also whole central
nervous system may cause abnormal increase in
normally freely flowing quantity of cerebrospinal
fluid or may cause change of physical, biochemical or
microscopical characteristics of cerebrospinal fluid. In
these cases for diagnosis and treatment of the disease,
cerebrospinal fluid (CSF) may be required to be drawn
out from lumbar cistern below the termination of
spinal cord. Again some drugs may be required to be
injected into the spinal subarachnoid space (lumbar
cistern) for treatment of some neurological disease or
for induction of (spinal) anesthesia. This procedure is
known as lumbar puncture (spinal tap).
Anatomical Guidelines for Lumbar Puncture
(Fig. 4.7)
l Site: Puncture (introduction of needle cannula to
draw fluid) is done through the interspinous space
of vertebral column.
l Level: Spinal cord normally extends upto the level
of intervertebral disk between 1st and 2nd lumbar
vertebrae. On rare occasion it may extend lower
down upto 2nd lumbar vertebra. Ideal level for
puncture is the space between 3rd and 4th lumbar
spines.
l How to locate the levels of lumbar spines: Trans-
cristal line is the line passing through the level of
highest point of both iliac crests. It passes through
the level of 4th lumbar spine which will help to
locate the interspinous space between 3rd and 4th
lumbar spines.
l Position of body: Trunk of the body so also the
vertebral column must be ventrally flexed either
in lateral lying down position in bed or in sitting
position to achieve two advantages.
i. Interspinous space becomes wider.
ii. Lower end of spinal cord is raised slightly
upwards.
Knowledge of Planes of Puncture
During introduction of the needle-cannula, gentle
and uniform (sustained) pressure is to be applied.
After supraspinous and interspinous ligaments, and
tough layer of dura mater are penetrated, suddenly a
loss of resistance is felt. It confirms that needle has
reached the subarachnoid space. At this stage patient
may feel tingling root pain as nerve of cauda equina is
touched by the tip of needle. But it is just for a while
as it floats away in the cerebrospinal fluid.
Pia Mater
Pia mater is a thin delicate membrane which closely
invests the surface of spinal cord. It is made up of fine
Spinal Cord
layer of fibroreticular tissue into which is embedded
network of fine blood vessels. Spinal pia mater
presents following special features.
n Filum terminale: It is a thin, white, delicate and
shining thread-like structure which extends vertically
downwards from conus medullaris of spinal cord. Its
lower end is attached to the dorsal aspect of first piece
of coccyx.
Length 20cm
Structural composition: It is mainly composed
of nonnervous pial connective tissue. But its upper
end also contains nervous element. It is supposed to
be rudiments of 2nd, 3rd and 4th coccygeal nerve.
Central canal of spinal cord extends beyond conus
medullaris for about 5mm in the upper end of filum
terminale, which is called terminal ventricle.
Parts: Spinal dura and arachnoid end at the level
of 2nd sacral vertebra. But filum terminale extends
from L1/L2 vertebra to 1st piece of coccyx. That is why
it is divided into following two parts.
1. Filum terminale internum: It is proximal 15cm
lying inside subarachnoid space.
2. Filum terminale externum: It is distal 5mm which
is beyond S2 vertebra.
n Linea splendens: It is condensation of pia mater
along the anterior median line of spinal cord, where it
dips into anterior median fissure.
n Subarachnoid septum: It is a thin fenestrated
pial septum along the posterior median line of spinal
cord extending from posterior median sulcus to deep
surface of arachnoid mater.
n Ligamentum denticulatum: This is a bilateral
pial septum extending throughout whole length of
spinal cord in between lines of attachment of ventral
and dorsal nerve roots. Lateral margin of ligamentum
denticulatum is ragged and presents 21 tooth like
pointed projections. First pair is situated above the
margin of foramen magnum of skull. Last pair is
longer and oblique. It is attached at the level of conus
medullaris and descends obliquerly downwards and
laterally between twelfth thoracic and first lumbar
nerves.
INTERNAL STRUCTURE OF SPINAL CORD
n Embryological background: Knowledge of internal
structure of spinal cord is based on fundamental
concept of its embryological background. Spinal cord
is developed from caudal elongated narrow tubular
portion of neural tube which is ectodermal in origin.
At 4th week of intrauterine life surface ectoderm
along the midline gets condensed anteroposteriorly
known as neural plate (Fig. 4.8). Neural plate lies
dorsal to notocord which is related on either side to
63
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Neural plate
Ectoderm
Notochord
Mesoderm

Endoderm
A

Neural groove
Neural crest

Ependyma
Surface
ectoderm Neural tube
Neural crest cells

Proliferating cells

E F

Figs 4.8A to F Illustrating development of spinal cord. A. Embryonic disk (Sectional view), B. Formation of neural plate, C. Formation of
neural groove, D. Formation of neural crest, E. Neural tube lined by single layer neuroectodermal cells, F. Proliferation of neural tube cells

secondary mesoderm. The neural plate gradually

becomes grooved or folded cephalocaudally along its
long axis to form neural groove. This causes elevation
of two parallel ridges known as neural crests. It is
followed by two changes. Some cells of neural crest
get detached and migrate ventrally on either side of
midline beneath surface ectoderm. These are named
neural crest cells. Secondly, the neural groove grad-
ually deepens more and more with prominence of both
sided neural crests which finally fuse to form neural
tube. Fusion starts from the middle and proceed
toward both cephalic and caudal ends. Just before 6th
week of intrauterine life, when closed neural tube is
formed, cephalic and caudal ends present openings
known as anterior and posterior neuropores. Cephalic
end of neural tube shows three dilatations known as
forebrain, midbrain and hindbrain vesicles which will
from brain. Caudal narrow, elongated tubular part of
neural tube forms spinal cord.
64
FORMATION OF DIFFERENT ZONES OF SPINAL CORD
(FIG. 4.9A)
The whole neural tube is initially lined by single layer
of ectodermal cells known as neuroectoderm. Part of
the tube giving rise to spinal cord, shows proliferation
of cells same as proximal part. The canal of neural tube
becomes a narrow cleft and shows thickening of lateral
wall. Its thin dorsal and ventral walls are known as
roof plate and floor plate. The original inner lining is
known as ependymal layer or matrix cell layer. This
layer of cells ultimately forms columnar epithelium
lining the central canal of spinal cord known as
ependymal cells. Free surface of these cells shows
presence of ultramicroscopic finger-like, nonmotile
processes known as stereocillia. Proliferated daughter
cells, pushed to the periphery, form mantle layer. Cells
of this layer shows differentiation into two types which
are called neuroblasts and spongioblasts. Neuroblasts

Alar lamina
Mantle
layer
(zone)
{ Basal lamina
Fig. 4.9A Differentiation of mantle and marginal zones
Sensory neurons
developed in alar
lamina
Motor neurons
developed in
basal lamina
Fig. 4.9B Formation of different fundamental cells of spinal cord
will form neurons of spinal cord whose processes will
be elongated to be pushed to the periphery to form
more peripheral marginal zone. Spongioblasts will
form supporting cells (neuroglia) of larger size known
as macroglia (astrocytes and oligodendrocytes). The
most of the glial cells are pushed to the peripheral
marginal zone. Cells bodies of neurons present in
the mantle zone showing grayish appearance will
form central gray matter of spinal cord. Processes of
neurons (nerve fibers) located in peripheral marginal
zone will be myelinated by oligodendrocyte group of
cells of macroglia. This myelination will give whitish
appearance of marginal zone of spinal cord for which
it is called white matter.
cell columns as
FORMATION OF DIFFERENT FUNCTIONAL CELL
GROUPS (FIG. 4.9B)
1. Cells of ependymal (matrix) layer: As already
stated, these are original cell layer lining central
canal of spinal cord called ependymal cells.
The cells lined by stereocilia posses absorptive
function.
2. Cells of mantle zone: On either side of midline
the neurons developed from neuroblasts are
Spinal Cord
Neural crest cells
Ependyma
Mantle zone
Marginal zone
Posterior root
ganglion cells
Spinal nerve
divided into dorsal and ventral groups by two
parallel cephalocaudal linear grooves on lateral
wall of ependymal lining called sulcus limitans.
Ventral and dorsal groups of neurons are known
as Basal and Alar lamina respectively. Neurons
of basal lamina will be motor neurons and
those of alar lamina will form sensory neurons.
Alar laminae of both sides are apposed towards
each other so obliterating dorsal part of central
canal of spinal cord. Two basal laminae diverge
ventrolaterally forming future ventral median
fissure of spinal cord.
The neurons of basal lamina from two different
i. Somatic efferent (motor): Medial and close to
floor plate. The processes of these neurons
will supply voluntary (skeletal) muscles after
leaving the spinal cord through ventral root of
spinal nerve.
ii. Visceral efferent (motor): Lateral to and away
from floor plate. Their processes leave spinal
cord also through ventral root of spinal nerve
as preganglionic fibers for involuntary (smo-
oth) muscles and exocrine glands.
65
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
The neurons of alar lamina form the following
cell columns.
i. Somatic afferent (Sensory): This cell column is
medial and close to roof plate. Neurons of this
column receive connections from the sensory
cells outside central nervous system (posterior
root ganglia cells) carrying somatic sensation
from peripheral receptors.
ii. Visceral afferent (Sensory): These neurons
form cell column which is lateral to somatic
afferent column and away from roof plate.
They receive sensory impulse from the wall of
viscera via posterior root ganglia cells.
Somatic efferent and somatic afferent cell columns
of gray matter of spinal cord extend throughout
whole length of spinal cord to be present in all 31
segments of spinal cord. Visceral efferent and visceral
afferent cell columns being close to each other in the
intermediate and lateral area of gray matter form
spinal center of autonomic nervous system.
But these cell groups, unlike somatic centers do not
extend throughout all the segments of spinal cord.
Neuronal groups of these columns extending from 1st
thoracic (T1) to 2nd lumbar (L2) segments of spinal
cord form sympathetic center and those of second,
third and fourth sacral (S2, S3 and S4) segments
form parasympathetic center of spinal autonomic
nervous system.
Beside the above four groups of neurons developed
in the mantle zone (gray matter) of spinal cord, some
cells are known as interneurons or internuncial
neurons which are functionally connecting neurons.
3. Cell of marginal zone(Marcoglia): They are
supporting cells called marcoglia group of neuroglia
which are astrocytes and oligodendrocytes. Some
glial cells are also present in mantle zone. Astro-
cytes form connecting link between neurons and
capillaries for selective transport of nutritive
substances from capillaries to neurons and prev-
enting entry of toxic materials (blood neuron
barrier).
4. Migrated cells from bloodstream (Microglia):
Microglia are characterized by letter M. It is
mesodermal in origin, derived from, monocytes
and migratory in nature to act as macrophages.
PERIPHERAL OUTFLOW OF SPINAL CORD
Spinal Nerves
Spinal cord is made up of 31 segments. These segments
are numbered regionally as Cervical-8, Thoracic-12,
Lumbar-5, Sacral-5 and Coccygeal-1. A pair of nerve
(right and left) is attached to the surface of each of
66
the segments of spinal cord by two roots known as
anterior (ventral) and posterior (dorsal) roots. Along
the length of spinal cord anterior and posterior roots
are attached along the lines of anterolateral sulcus
and posterolateral sulcus respectively. Anterior or
ventral roots of spinal nerve are outgoing (efferent)
fibers of spinal nerve which go to the peripheral target
organs, e.g. muscles or glands. They are called motor
or efferent fibers. Posterior or dorsal roots of spinal
nerve are the incoming (afferent) fibers of spinal nerve
which carry informations from peripheral sensory end
organs known as receptors. They are called sensory
or afferent fibers.
All spinal nerves are mixed nerve: It is very clear
from the above that each of the spinal nerves, either
right or left, is composed of outgoing or efferent
(motor) and incoming or afferent (sensory) fibers. So
all of them are considered as mixed nerve.
It is to be remembered at this stage that, out of
12 pair of cranial nerve, some are mixed like spinal
nerve, whereas others are either motor or sensory.
INTERNAL STRUCTURE OF SPINAL CORD
Internal structure of spinal cord can be understood
through the study of its cross section (Fig. 4.10).
Cross section of spinal cord shows fundamentally
following two components.
1. Central gray matter: This is so called due to
grayish color of cell bodies of neurons. Central
zones of gray matter looks like butterfly on cross
section. Roughly it resembles the capital letter
H. Intermediate bar of H represents the body,
whereas wings of butterfly are represented by two
limbs of the letter.
Basic components of spinal gray matter: Inter-
mediate part of spinal gray matter is traversed
centrally be central canal of spinal cord throughout
its whole length.
Central canal of spinal cord is lined by ependymal
cells. The gray matter anterior and posterior to
central canal are known as anterior and posterior
gray commissures respectively.
Each side of spinal cord gray matter is composed
of following components:
a) Anterior known as anterior horn
b) Intermediate area
c) Posterior known as posterior horn.
When considered the whole length of spinal cord,
anterior gray horn forms the anterior gray column and
posterior gray horn forms the posterior gray column.
In addition to the above mentioned three comp-
onents, first thoracic to second lumbar segments
(T1 L2) of spinal cord gray matter show a lateral

Posterior funiculus
Lateral funiculus
Anterior white
commissure
Anterior
funiculus
Fig. 4.10 Fundamental components of internal structure of spinal cord
projection of intermediate area, which is known as
intermediolateral cell column. Neurons of this area
constitute sympathetic center of autonomic nervous
system. It is important to note at this stage that spinal
center of parasympathetic nervous system is formed
by neurons of intermediate area of second, third and
fourth (S2, S3 and S4) sacral segments of spinal cord.
The different components so also the entire gray
matter of spinal cord show variations in appearance
in different regions of spinal cord, because it depends
upon the relative amount of nerve cells. Basically gray
matter is proportionately broader in lower cervical
and lumbosacral regions of spinal cord.
2. Peripheral white matter: This is mainly made
up of compact bundles of nerve fibers running
vertically either in ascending or in descending
direction.
These fibers in the bundles are myelinated. The
lipid-protein substance of myelin sheath of nerve
fibers is white in color for which this peripheral zone
of spinal cord is called white matter.
The bundles of ascending fibers carry sensory
informations to the centers of brain above the level
of spinal cord. The descending bundles carry impulse
from higher motor centers of brain (above spinal cord)
to the motor neurons situated in anterior horn of
spinal cord.
On either side of midline, the white matter is
composed of following three components called
Funiculi (Singular Funiculus).
a) Anterior funiculus: It is the part of white
matter between anterior median fissure and
anterolateral sulcus presenting outgoing fibe-
rs of ventral nerve root. Anterior funiculi of
two sides are bridged by a thin midline strip
Spinal Cord
Posterior median
septum
Posterior gray
commissure
Posterior gray horn
Intermediolateral
gray horn
Anterior gray horn
Anterior gray
commissure
Anterior median
fissure
of white matter known as anterior white
commissure.
b) Lateral funiculus: It is the part of white mat-
ter demarcated between outgoing fibers of
ventral root and incoming fibers of dorsal root
of spinal nerve.
c) Posterior funiculus: It is the part of white matter
between posterior median sulcus and incoming
fibers of dorsal root of spinal nerve attached to
the posterolateral sulcus. Posterior funiculi of
both sides are separated incompletely or even
completely by posterior median septum.
The bundles of fibers either ascending (sensory or
afferent) or descending (motor or efferent) are called
tracts or fasciculi (Singular-Fasciculus).
It is interesting to note at this stage that posterior
funiculus is composed of only ascending tracts wher-
eas anterior and lateral funiculi are composed of both
ascending as well as descending tracts.
n Fundamental cell groups of spinal gray matter:
All neurons of spinal cord are multipolar.
Fundamentally the three different zones of spinal
gray matter are made up of following four different
neuronal groups.
1. Posterior horn: Sensory (afferent ) or tract neurons
2. Anterior horn: Motor (efferent) neurons.
3. Intermediate area:
i. Interconnecting neurons (interneurons), and
ii. Parasympathetic neurons at S2, S3 and S4
segments only.
4. Intermediolateral area: Sympathetic neurons
(only T1 L2 segmetns).
Both the sympathetic as well as parasympathetic
areas are composed of motor and sensory neurons.
67
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Somatic afferent neuron
Internuncial neuron
Tract neurons
Visceral afferent neuron
Sensory neuron Primary sensory
neurons

Carrying
somatic
Skin sensation
Carrying
visceral
sensation

Supplying
smooth muscles,
exocrine glands

Supplying
voluntary
muscles

Visceral efferent neuron

Voluntary muscle

Motor neuron Somatic efferent neuron

Fig. 4.11 Fundamental types of neurons of spinal gray matter

Functional classification of neurons of spinal terminate in extrafusal fibers of voluntary

gray matter (Fig. 4.11):
A. Tract neurons: These are sensory or afferent
neurons present in posterior horn.
They are so called because their axons form
compact bundles of ascending (sensory) tracts to relay
in higher centers in brain.
They receive synaptic connections from central
process of pseudounipolar neurons of posterior root
ganglion which collect sensory informations from
peripheral sensory end organs (receptors).
It is important to note at this stage that axons of
tract cells may ascend in the same side or may cross
the midline and then ascend along opposite side of
spinal cord to form uncrossed (ipsilateral) or crossed
(contralateral) tracts respectively.
B. Motor neurons (efferent neurons): The neu-
rons of anterior horn are motor neurons. Their axons,
leaving spinal cord through ventral root, end in
voluntary muscles via spinal nerve.
These motor neurons of spinal cord are called lower
motor neurons on which relay the axons of nerve cells
situated at higher centers (brain) which are called
upper motor neurons.
Motor neurons of anterior horn of spinal cord
sending axons to voluntary muscles are of two types:
i. Alpha motor neurons: Their cell bodies are
more than 25 microns in size and their axon
68
muscles, stimulation of which results in musc-
ular contraction.
ii. Gamma motor neurons: Cell bodies of these
neurons are less than 25 microns in size and
their axons terminate in intrafusal fibers of
voluntary muscles, stimulation of which is
concerned with increase in muscle tone.
C. Interneurons (internuncial neurons): These
are example of short axoned Golgi type II neurons.
Their axon as well as dendrite are shorter being
confined in the gray matter of spinal cord.
Functionally they are interconnecting in nature
forming synaptic link between sensory and motor
neuron which together form a local reflex arc (Fig.
4.11).
Internuncial neuron also leads to an advantage
by connecting one first order of neuron, through its
multiple axon collateral, to the multiple third order of
neurons.
Further classification of motor and sensory neurons
(Fig. 4.11):
It is already understood from the knowledge of
embryological background that, mantle zone of
developing spinal cord forming gray matter forms
four column of cells which are as follows from ventral
to dorsal aspect.
1. Somatic motor (efferent)
2. Visceral motor (efferent)

3. Visceral sensory (afferent)
4. Somatic sensory (afferent).
Among above four cell groups somatic efferent
and somatic afferent cell groups extend over all the
31 segments of spinal cord in anterior and posterior
gray columns (horns) respectively. Somatic efferent
neurons of anterior horn send axons to voluntary or
skeletal (somatic) muscles. Somatic afferent neurons
of posterior horn from tract neurons whose axons
form ascending tracts.
Visceral efferent and visceral afferent neurons do
not extend throughout whole length of spinal cord,
but are present in two levels as follows:
a) T1 L2 segments of spinal cord: Here both the
motor and sensory cell groups form additional
horns called intermediolateral horn, where
visceral efferent and visceral afferent cell
groups form motor and sensory centers of symp-
athetic part of autonomic nervous system res-
pectively.
b) S2, S3 and S4 segments of spinal cord: Here the
cell groups are present in intermediate area of
gray matter without forming any additional
lateral horn. Visceral efferent and visceral
afferent neurons in these cell groups form
motor and sensory centers of parasympathetic
part of autonomic nervous system respectively.
INTERNAL STRUCTURE OF SPINAL GRAY MATTER
Gray matter of spinal cord, as mentioned earlier, is
so called because of grayish coloration of cell bodies
of neurons. But apart from the neuronal cell bodies,
spinal gray matter is composed of neuronal processes,
neuronal junctions (synapses), neuroglia and blood
vessels.
Nucleus marginalis
Substantia gelatinosa
of Rolando
Nucleus proprius
Visceral afferent column
Intermediolateral cell
column
(Spinal symp center)
Retrodorsolateral group
Dorsolateral group
Ventrolateral group
Fig. 4.12A Cell groups spinal cord gray matter
Spinal Cord
VARIOUS CELL GROUPS OF SPINAL GRAY
MATTER (FIG. 4.12A)
Throughout the length of spinal cord, different neu-
ronal groups are present in the form of linear columns.
Following two fundamental points are to be noted
before individual cell groups are studied.
1. Some of the cell columns extend throughout whole
length of spinal cord, but some cover part of its
length.
2. Cell groups are primarily subdivided into following
areas.
l Posterior gray column: Tract (sensory) neurons.
l Intermediate area: Autonomic neurons and inte-
rneurons.
l Anterior gray column: Motor neurons.
CELL GROUPS IN POSTERIOR GRAY COLUMN
(FIG. 4.12A)
From apex towards the base they are as follows:
1. Nucleus marginalis: It is ill-defined, thin strip
of gray matter extending throughout whole length
of spinal cord. It contains neurons of varying size
with intermingling reticulum of fibers.
2. Substantia gelatinosa of Rolando: It is a
narrow area extending throughout the whole
length of spinal cord. Afferent fibers, entering
through posterior nerve root which carry pain and
temperature sensations from synaptic connection
with these neurons. Axons of these neurons
cross midline and ascend through contralateral
lateral white column of spinal cord to form lateral
spinothalamic tract.
3. Nucleus proprius: It is the main bulk of neurons
in posterior horn and extend throughout whole
Clarkes column (nucl. dorsalis)
Intermediomedial cell column
(spinal parasympathetic center)
Substantia gelatinosa centralis
Central group
Dorsomedial group
Ventromedial group
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
length of spinal cord. Nucleus proprius consists of
following neurons.
i. Some of these cells receive incoming posterior
nerve root fibers which carry sensations of
crude touch and pressure. However it is told
these days that crude touch and pressure
fibers end in many cell group of posterior horn.
ii. Axons of some of cells of nucleus proprius link
adjacent segments of spinal cord for intraspinal
coordination.
4. Nucleus dorsalis (Clarkes column): It is also
called nucleus thoracis. It extends from eighth
cervical to third or fourth lumbar segments of
spinal cord. Nucleus dorsalis or Clarkes column of
cells are situated on medial side of base of dorsal
gray horn and show a projection on posterior white
column of spinal cord. Neurons of this column
of varying size and shape are of following two
varieties.
i. Neurons which receive incoming afferent fibe-
rs via nerve root carrying unconscious propr-
ioceptive sensation from muscle spindle and
Golgi tendon organs. These neurons send axo-
ns which ascend through marginal strip of
lateral white column forming dorsal as well as
anterior spinocerebellar tract.
ii. Interneurons of Golgi type II characterized by
short dendrites as well as short axons.
5. Visceral afferent cell column: These cell
groups are situated lateral to Clarkes column of
cells at the base of dorsal gray horn. But it exists
in following two levels of spinal cord.
i. T1 to L1/L2 segments of spinal cord: The cell
groups receive sympathetic afferent fibers
which enter the spinal cord through posterior
root of spinal nerve. It receives sensations
from wall of viscera.
ii. S2, S3 and S4 segments of spinal cord: These
cell groups receive parasympathetic afferent
fibers which also enter the spinal cord through
posterior root of spinal nerve. It receives
parasympathetic sensation from the wall
of the viscera wherefrom carried via pelvic
splanchnic nerve.
CELL GROUPS IN INTERMEDIATE AREA OF SPI-
NAL GRAY MATTER (FIG. 4.12A)
Cells are fundamentally classified in two groups.
n Interneurons: These interneurons link between
sensory neuron of dorsal horn and motor neuron
of ventral horn, so form a local circuit of reflex arc.
n Autonomic motor neurons: Having following
two components, which are not coexistant in a
spinal segment.
70
i. Intermediolateral: These cell groups extend
from C8/T1 to L2/L3 segments of spinal cord and
form an outward projection called intermedio-
lateral cell column. These cells form motor
center for sympathetic part of autonomic
nervous system and send out axons which leave
the spinal cord through ventral nerve root.
ii. Intermediomedial: These functional cell groups
are present only in S2, S3 and S4 segments
of spinal cord. But their existance does not
show any outward projection in intermediate
gray column of spinal cord. These cells form
spinal center for parasympathetic component
of autonomic nervous system. Their axons
also pass out through ventral nerve root of
corresponding sacral nerve.
CELL GROUPS IN ANTERIOR GRAY COLUMN (FIG.
4.12A)
Cells of these groups are variable in size and are
either motor neurons or interneurons.
Neurons, whose cell body size is more than 25
microns, are known as alpha motor neurons. Their
axons leave spinal cord via ventral nerve root
and supply extrafusal fibers of voluntary muscle,
stimulation of which is responsible for initiation of
movements of voluntary muscle.
Neurons, whose cell body size in between 15 to
25 microns are either interneurons or gamma motor
neurons. Gamma motor neurons, through their out-
going axons passing through the ventral root of spinal
nerve, supply intrafusal fibers of muscle spindle
stimulation of which is responsible for maintenance
of muscle tone.
Motor neurons of anterior gray column of spinal
cord are divided into three groups Medial, lateral
and central. These groups extend for varying level in
spinal cord.
Medial group extends throughout whole length of
spinal cord. It may be deficient in fifth lumbar and
first sacral segment. In thoracic and upper lumbar
level medial group of anterior horn cells is divided
into ventromedial and dorsomedial parts. Neurons
of medial column are concerned with innervation of
axial musculature, i.e. muscles of trunk.
Lateral group exists only in the segments of lower
cervical and lumbosacral enlargements of spinal cord,
as cells of this group innervate musculature of upper
and lower limb respectively.
Cell group of lateral column is divided into vent-
rolateral, dorsolateral and retrodorsolateral compon-
ents.
Nucleus of Onuf: These are cells of ventrolateral
group at first and second sacral segments which
supply perineal striated muscles.

Central group of neurons form independent colu-
mn in cervical and lumbosacral segments only.
In cervical segments central group forms following
two nuclei.
l Phrenic nerve nucleus: It extends from C3C5
segments of spinal cord. Their axons, forming
independent phrenic nerve, supply musculature
of diaphragm which is very important respiratory
muscles. Recent study shows phrenic nerve nuc-
leus extends up to C7 segments.
l Nucleus of spinal accessory nerve: It is formed by
central group of anterior horn cells from C1C5
segment of spinal cord. Axons of these cells form
spinal root of accessory nerve which supplies
sternomastoid and trapezius muscles.
Though existance of lumbosacral segments of
central group is established, their function is not
yet clear.
CELL GROUPS AROUND CENTRAL CANAL (FIG.
4.12A)
This is the area which forms anterior and posterior
gray commissures. It extends throughout whole
length of spinal cord. This area is populated by neur-
oglia and nonspecific neurons. This area is called
substantia gelatinosa centralis.
REXEDS LAMINATION OF SPINAL GRAY MATTER
(FIG. 4.12B)
On cross-section of spinal cord, cells of various
columns of spinal gray matter represent a strip-like
appearance which is called Rexed lamination. These
Lamina I
Lamina II
Lamina III
Lamina IV
Lamina V
Lamina VI
Lamina VII
Lamina VIII
Lamina IX
(lateral)
Fig. 4.12B Rexed lamination of spinal cord gray matter
Spinal Cord
laminae are ten in number, which are sequentially
numbered from the dorsal horn side towards ventral
horn, as per Roman numerals.
The cells of these laminae are classified according
to shape, size, density and cytological characteristics.
These laminae corresponds more or less to the
different cell-groups stated earlier.
n Lamina I: It is also called lamina marginalis. It is
a very thin layer on the tip of dorsal horn. This lamina
is composed of cells of different size and shape with
intermingling fibers giving a reticular appearance.
n Lamina II: It is made up of densely packed and
darkly stained cells with nonmyelinated fibers. It is a
part of substantia gelatinosa.
n Lamina III: It is made up of loosely packed and
large sized cells with myelinated fibers. This lamina
is made up of cells of nucleus proprius and some cells
of substantia gelatinosa.
n Lamina IV: It is thick and homogeneous lamina
forming nucleus proprius.
n Lamina V and VI: These two laminae constitute
base of posterior horn. Cells of this laminae receive,
i. Afferent fibers carrying proprioceptive sens-
ations and sensation from viscera.
ii. Projections from corticospinal tracts which
suggests that they are concerned with regu-
lation of movement.
n Lamina VII: It contains following cell group
i. Intermediolateral cell group: Cells of sympat-
hetic center of autonomic nervous system.
ii. Intermediomedial cell group: Cell forming
spinal parasympathetic center of autonomic
nervous system.
iii. Clarkes column of cells.
Lamina X
Lamina IX (medial)
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Lamina VIII: It is made up of interneurons which
receive terminals from
i. Cells of adjacent laminae of same side
ii. Cells of lamina VIII of opposite side through
gray commissures.
n Lamina IX: This lamina presents lateral and
medial strips which are made up of
i. Alpha and gamma motor neurons
ii. Interneurons.
n Lamina X: These are the nonspecific cells of
anterior and posterior gray commissures encircling
central canal.
INTERNAL STRUCTURE OF SPINAL WHITE MATTER
Each of the funiculi (Singularfuniculus) of white
matter of spinal cord is mostly made up of vertically
running fibers, parallel to the length of spinal cord.
These fibers posses following characteristics.
1. The fibers vary in caliber having the range from
110 mm.
2. They are either myelinated or nonmyelinated.
3. The fibers are grouped in bundles. Those of
one particular bundle have common origin and
common destination. These bundles are tracts
which are mostly of following two types.
n Ascending Tracts: They carry sensory infor-
mation from the level of spinal cord to the higher
sensory areas of central nervous system ultimately to
reach sensory area of cerebral cortex.
n Descending Tracts: These are axons of upper
motor neurons (UMN) located in supraspinal centers
Third order neuron
(thalamic nuclei)
Second order neuron
above spinal cord
Long primary
sensory neuron
Short primary
sensory neuron
Fig. 4.13 Principle of formation of ascending tract as a part of sensory pathway made up of three orders of neuron
72
which are motor area of cerebral cortex or other sub-
cortical centers. Fibers of the descending tracts relay
in lower motor neurons (LMN) located in anterior
horn of spinal gray matter to give command for motor
activities.
Some fibers of spinal white matter ascend or
descend for a few segments and localized entirely in
spinal cord for intersegmental coordination. These
are called propriospinal tract.
Ascending Tracts
Ascending tract is a part of sensory pathway. Sensory
pathway transmits sensory inputs (impulse) from
peripheral receptors to concerned sensory areas of
brain through chain of neurons. Mostly the chain
is made up of three neurons called neurons of first,
second and third orders (Fig. 4.13).
First order neuron is called primary sensory
neuron. Its cell body is situated in posterior root
ganglion of spinal nerve. Peripheral process of this
neuron carries sensory impulse from receptors or
sensory end organs. Its central process or axon, ent-
ering the spinal cord, will have either of the follo-wing
two fates:
i. It terminates in different laminae of posterior
gray horn of spinal cord to relay in the tract
neuron. These are short primary sensory neu-
rons.
ii. Axons of some primary sensory neuron (called
long primary sensory neurons) run vertically
upwards through white matter of spinal cord
to relay in some cell groups or nuclei above the
Ascending tract
Second order neuron in spinal
cord (Tract cell)

level of spinal cord, e.g. nucleus gracilis and
nucleus cuneatus of medulla oblongata.
Axons of tract neurons of spinal cord and axons
of long primary sensory neuron, as compact bundles,
carrying one specific type of sensation (exteroceptive
or proprioceptive), ascend through different funiculi
of spinal cord to form ascending tracts.
Second order neurons are therefore tract neurons
of spinal cord, or some nuclei above spinal cord, where
long primary sensory neurons relay.
Third order neuron is present in the thalamus
in the form of different nuclei receiving inputs for
different sensations. Axons of third order of neurons
finally send projection fibers to sensory areas of
cerebral cortex.
At this stage, it is important to repeat that ascending
tract and sensory pathways are not synonymous
term. It is already understood that ascending tract is
a part of sensory pathway. It is further important to
note that, some of sensory pathway is made up of less
than three neuronal chain, e.g. pathway for spino-
cerebellar tract. Again, some are composed of more
than three orders of neurons, e.g. visual pathway.
l Classification of ascending tracts on functional
basis:
A tract, as classified below, may carry either
exteroceptive or proprioceptive sensation. Again one
may transmit sensations of both these kinds.
Type of sensation Name of tract
Discriminative touch, i.e. ability Tracts of posterior funiculus,
to localize two points touched very called dorsal column (fasc-
close to each other on skin, fine iculus gracilis and fascic-
touch or light touch, sense of vibr- ulus cuneatus).
ation, sense of position and move-
-ments carried from muscles and
joints.
Pain and thermal sensation Lateral spinothalamic tract.
(heat or cold).
Crude touch and pressure. Anterior spinothalamic tract.
Unconscious information (unconsc- Dorsal (posterior) and ven-
ious proprioceptive) from muscles, tral (anterior) spinocere-
tendons, joints and even from sub- bellar tract.
cutaneous tissue for automatic,
stereotyped postural adjustment
of body. muscles and joints relay in tract cell in Clerkes
Pain, thermal and tactile informa- Spinotectal tract to superior
tion to the midbrain level for reflex colliculus of tectum of
visual response through pathway midbrain.
for spinovisual reflex. column tract along with axons of long primary
Impulse from skin, muscles and Spinoreticular tract
joints to reticular nuclei of brain-
stem for awakefulness. So, it is clear from above description that, dorsal
An alternative and indirect Spinoolivary tract (part of
pathway of spinocerebellar tract. spinoolivocerebellar tract).
Spinal Cord
Before further study of ascending tracts, it is impor-
tant to note following points.
1. Only major ascending tracts from above table are
described below.
2. All ascending tracts (so also descending tract) are
bilateral, and symmetrical in position in both side.
3. Fibers of adjacent tracts may present overlapping.
4. Some of the tracts are uncrossed (ipsilateral) and
some are crossed (contralateral). Decussation (cro-
ssing) occurs mostly at the level of spinal cord.
Some cross in supraspinal level. For example,
ventral (anterior) spinocerebellar tract crosses at
the level of midbrain.
5. Ascending tracts are described below only upto the
level of their primary destination beyond spinal
cord. Their further course has been mentioned
while studied cross section (internal structure) of
different levels of brainstem and forebrain.
Dorsal column (Fig. 4.14)
Note: Reader must consult the figure while reading.
This is the ascending tract passing through dorsal
white column of spinal cord for which it is so called.
Dorsal white column or posterior funiculus is made up
of this ascending tract which is ipsilateral in nature.
Dorsal column transmits following sensory infor-
mations.
1. Exteroceptive: Discrimination touch with the
help of ability to localize two points touched very
closely on the body surface.
2. Proprioceptive: Sense of position and movements
from muscles and joints, and vibration sense.
Discriminative touch (and pressure also) sensation
is carried from peripheral receptors to the spinal cord
through its posterior nerve root. Primary sensory
neurons carrying this exteroceptive sensation are
called long primary sensory neurons because their
axons, i.e. central process of the posterior root ganglia
cells, do not form synaptic connection with spinal
sensory neurons. They pass vertically upwards
through the posterior funiculus to form the dorsal
column tract.
Short primary sensory neurons carrying vibration
sense and sense of position and movements from
column and other cell group of laminae IV to VI.
Axons of these second order neuron ascend through
posterior column to take part in formation of dorsal
sensory neurons carrying discriminative touch (and
also pressure to some extent).
column tract is formed by axons of two different kinds
as follows.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nucleus gracilis

Nucleus cuneatus
Central canal
Fasciculus cuneatus Fasciculus gracilis

Cross section of lower half of

medulla oblongata

Fasciculus cuneatus

Fasciculus gracilis
} = Dorsal column

Posterointermediate
septum demarcating
fasciculus gracilis from
Short primary afferent neuron carrying fasciculus cuneatus
sense of position, movement and
vibration from upper half of body

Long primary afferent neuron carrying

cutaneous sensation of discriminative
touch from upper half of body

Fasciculus gracilis

Midthoracic level Midthoracic level

Tract neuron in lamina

IV to VI

Short primary afferent neuron carrying

sense of position, movement and
vibration from lower half of body

Long primary afferent neuron carrying

cutaneous sensation of discriminative
touch from lower half of body

Fig. 4.14 Dorsal column (fasciculus gracilis and fasciculus cuneatus)

1. Axons of long primary sensory neurons carrying
sensory impulse for discriminative touch and
pressure.
2. Axons of tract neurons from Clarkes column and
other sensory neurons of lamina IV to VI carrying
impulse for sense of position and movements and
also vibration sense.
Fiber tracts of dorsal column carrying sensory
impulse from lower half of body (below midthoracic
level), entering through lower group of spinal nerves,
are placed in the medial part of posterior funiculus.
It is called fasciculus gracilis. It is superadded by
similar kind of fiber bundle which enter the spinal
cord carrying similar sensation from upper half of
body (above midthoracic level). These fiber bundles of
dorsal column ascend through lateral part of posterior
funiculus lateral to medially placed fasciculus gracilis.
It is called fasciculus cuneatus. It is demarcated
from fasciculus gracilis by intermediolateral septum.
74
Both kinds of fibers of fasciculus gracilis and fasciculus
cuneatus, i.e. axons of long primary sensory neurons as
well as those of tract neurons of lamina IV to VI, relay
in nucleus gracilis and nucleus cuneatus in posterior
part of lower half of medulla oblongata. Posterior
surface of lower half of medulla oblongata presents
two round bulge known as gracile tubercle and cuneate
tubercle beneath which lies corresponding nucleus.
Spinocerebellar tracts
n General consideration: These tracts are two in
number, called ventral (anterior) and dorsal (post-
erior) spinocerebellar tracts.
Instead of going upto sensory area of cerebral
cortex via thalamus, they terminate in cerebellar
cortex.
Functions of spinocerebellar tracts are concerned
wih coordination of movements.

Impulse is carried from neuromuscular spindle
(muscle spindle), neurotendinous spindle (Golgi ten-
don organ) and joint receptors.
End organs are stimulated due to stretching of
muscles and tendons, and movements of the joints.
Both the spinocerebellar tracts are situated in
the form of narrow strip covering the peripheral
part of lateral funiculus, being anteroposteriorly
related.
Both the tracts are ipsilateral. But it is important
to note that fibers for ventral spinocerebellar tract
cross at the level of corresponding spinal cord
segments. But for the second time the tract crosses as
a whole at the level of midbrain.
Both the tracts are made of myelinated fibers of
large diameter. Ventral spinocerebellar tract also
contains some thin calibered fibers.
Individual characteristics of either of the tracts
will be clear from their description below.
Dorsal spinocerebellar tract (Fig. 4.15)
It is formed by axons of Clerkes column of cells.
Therefore this tract start formation and so also starts
ascending from second or third lumbar segment of
spinal cord. It is also not difficult to understand that
dorsal spinocerebellar tract gets formed from L2 / L3
Dorsal spinocerebellar tract-formed
by axons of Clarkes column of cells
1
2
Impulse from muscle, tendon
and joint receptors carried
3 of cells axons of which form
through posterior spinal nerve
roots (T1L2 segments) relay in
Clarkes column of cells
Proprioceptive sensation from
neuromuscular and neurotendinous
spindles and joint receptor from
lower limb enter spinal cord to form
fasciculus gracilis
Fig. 4.15 Formation of dorsal spinocerebellar tract
Spinal Cord
segment to T1 segment. It receives therefore input
from the trunk through T1L2 / L3 segmental spinal
nerve. It is interesting to note that it also receives
inputs from lower limb. Proprioceptive impulse from
neuromuscular spindle, neurotendinous spindle and
joints of lower limbs are carried by dorsal column
(fasciculus gracilis). Reaching upto L2 / L3 segments,
collaterals are given from dorsal column to relay in
Clarkes column of cells of L2/L3 segments.
These collateral are given by the fibers of dorsal
column carrying impulse from the lower limb
through spinal segment, as they reach the level of
L2/L3 segments. Again above T1 segment, propri-
oceptive sensations from neuromuscular spindle,
neurotendinous spindle and joint receptors ascends
through fasciculus cuneatus to relay also in accessory
cuneate nucleus which is a smaller oval bulge
superolateral to nucleus cuneates. Fibers from this
nucleus reach the cerebellum via cuneocerebellar
tract.
Ventral spinocerebellar tract (Fig. 4.16)
Ventral (anterior) spinocerebellar tract is formed by
axons of tract neurons of lamina V to VII of spinal
cord in addition to Clarkes column of cells.
Fasciculus gracilis
Collaterals from fasciculus gracilis
conveys inputs from lower limb
proprioceptors to Clarkes column
dorsal spinocerebellar tract
Fasciculus gracilis
1. Fasciculus gracilis
2. Fasciculus cuneatus
3. Dorsal spinocerebellar tract
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Ventral spinocerebellar tract
Dorsal spinocerebellar tract
(ipsilateral)
Ventral spinocerebellar tract
(contralateral)
Fig. 4.16 Formation of ventral spinocerebellar tract
These second order neurons, receives information
from muscle, tendon and joint receptors via the
first order neurons, which are primary sensory
neurons of posterior root ganglia. In addition, ventral
spinocerebellar tract carries sensory information from
skin and subcutaneous tissue also.
These sensation are carried via ventral spino-
cerebellar tract from trunk as well as upper and lower
limb.
Before the tract is being formed by the axons of
lamina V to VII and also Clarkes column of cells,
majority of fibers cross the midline along ventral
white commissure of spinal cord, while the minority
of fibers remain in same side. Fibers take the position
over a narrow strip of anterior peripheral part of
lateral funiculus to ascend upwards in front of dorsal
spinocerebellar tract. Fibers of ventral spinocerebellar
tract run upwards carrying contralateral fibers,
through the brainstem beyond spinal cord. Reaching
the level of midbrain, fibers cross the midline for second
time to reach cerebellar hemisphere of the same side
through superior cerebellar peduncle.
Spinothalamic tracts
These are two in number, known as lateral and
anterior (ventral) spinothalamic tracts passing thr-
ough lateral and anterior white columns of spinal cord
respectively. Lateral spinothalamic tract conducts
pain and temperature sensations, whereas through
anterior spinothalamic tract pass sensations of coarse
(nondiscriminative) touch and pressure. In cases of
76
Fasciculus cuneatus (ipsilateral)
Fasciculus gracilis (ipsilateral)
Primary sensory neuron
carrying proprioceptive
sensation as well as
cutaneous sensation
from skin and
subcutaneous tissue
Tract cells of lamina V to VII
send axons which cross midline
to form ventral spinocerebellar
tract which carries
proprioceptive sensations from
muscles, tendons and joints and
also exteroceptive sensation
from skin and sup. fascia
both the spinothalamic tracts, concerned sensory
impulse pass from respective receptors through prim-
ary sensory neurons or first order neurons, which are
posterior root ganglia cells. Their central process enter
spinal cord to relay in second order neurons.
Lateral spinothalamic tract (Fig. 4.17)
This tract is positioned in lateral funiculus, medial
to anterior spinocerebellar tract and lateral to ante-
rior gray horn and emerging fibers of anterior nerve
root.
It is formed by axons of tract neurons which are
second order neuron situated in substantia gelatinosa
of posterior gray horn. The fibers cross the midline and
ascend upwards through lateral funiculus, carrying
therefore sensation from opposite side of body. This
tract carries pain and temperature sensations.
Anterior (ventral) spinothalamic tract (Fig. 4.18)
It is so called because it ascends through anterior
white column of spinal cord. It is placed medial to
emerging fibers of ventral root of spinal nerve.
This tract is formed by axons of tract neurons of all
the sensory laminae of posterior gray horn. Before the
tract is formed, the fibers cross the midline, thereby
carrying sensation from opposite side of body.
This tract carries coarse (nondiscriminative) touch
and pressure sensations.
Positions of the important ascending tracts,
discussed above are shows in both sides of spinal cord
are shown in Figure 4.19.
 Spinal Cord

Lateral spinothalamic tract

Axons of tract neurons of
substantia gelatinosa cross the
midline to form lateral spino-
thalamic tract at lateral funiculus

Primary sensory neuron carries

pain and temperature sensation to
relay in tract neurons of substantia
gelatinosa of posterior horn
Lateral spinothalamic tract formed
at lateral funiculus of opposite side
lateral to emerging ventral nerve
root

Fig. 4.17 Formation of lateral spinothalamic tract

Anterior spinothalamic tract Tract neuron of all laminae of

posterior gray horn crosses
midline to form anterior
spinothalamic tract

Primary sensory neuron carries

coarse touch and pressure
sensations to relay in tract
neurons of all laminae of
Anterior spinothalamic tract posterior gray horn
formed at anterior funiculus
medial to emerging fibers of
ventral nerve root

Fig. 4.18 Formation of anterior spinothalamic tract

1. Fasciculus gracilis
Ipsilateral
(uncrossed)
tract { 2. Fasciculus
cuneatus
3. Dorsal
spinocerebellar tract

4. Ventral

Contralateral
(crossed)
tract
{ spinocerebellar tract
5. Lateral
spinothalamic
tract
6. Ventral (anterior)
spinothalamic tract

Fig. 4.19 Positions of important ascending tracts of spinal cord

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
What is Dorsolateral Spinothalamic Tract?
Existence of this tract is established in animals. It
is formed by axons of lamina I. The tract carries
noxious, mechanical and thermal sensations from
skin. It is a crossed tract and passes through
dorsolateral funiculus which is the small area of
white matter between dorsal and lateral white
columns. It is proved that in case of man, this tract
is concerned with transmission of clinicopathological
pain from which a patient gets relief after dorso-
lateral cordotomy.
Descending Tracts
l Descending tracts of spinal cord pass down through
lateral and anterior white columns of spinal cord.
l Descending tracts are axons of neurons of various
supraspinal centers which include motor centers in
cerebral cortex and brainstem.
l The neurons of supraspinal centers are known as
upper motor neurons which finally project on motor
neurons of anterior horn cells of spinal cord called
lower motor neurons.
l Descending tract is a part of motor pathway which
is usually made up of three order of neurons. The first
order neurons are neurons of supraspinal centers.
Second order neurons are internuncial neurons situ-
ated in anterior gray column of spinal cord. Third
order neurons are alpha and gamma motor neurons
of spinal cord. Axons of these neurons reach the
effector organs (voluntary muscles) via the anterior
root of spinal nerve which is known as final common
pathway of Sherrington.
l Descending tract discharges constantly impulse
on lower motor neuron to exert following functions.
1. It controls movements, muscle tone and posture.
2. It modulates spinal reflex mechanism.
3. It also modulates transmission of afferent infor-
mation to higher centers.
4. It exerts influence on visceral activities through
its control on spinal autonomic motor neurons.
l Broad classification: Descending tracts are broadly
classified into following groups
1. From motor areas of cerebral cortex
l Corticospinal tracts
l Corticobulbar (corticonuclear) tracts: Projecting to
motor nuclei of cranial nerves situated in brain-
stem, which do not extend low down upto spinal
cord.
2. From different subcortical centers to the spinal
cord:
l Noncorticospinal tracts.
78
Corticospinal and corticobulbar tracts
l Two tracts having common origin and different
destination: Corticospinal as well as corticobulbar
(corticonuclear) tracts arise from cerebral cortex. The
fibers of both the tracts arise from:
1. Primary motor cortex (area 4) = 30%
2. Premotor cortex (area 6) = 30%
3. Postcentral gyrus (area 3, 1, 2) and adjacent pari-
etal cortex (area 5) = 40%.
Initially corticospinal and corticobulbar (cortico-
nuclear) tract fibers run down in association with each
other through subcortical white matter to the level of
brainstem where corticobulbar (corticonuclear) fibers
terminate in contralateral motor nuclei of different
cranial nerves. Corticospinal tract fibers descend
alone further through the spinal cord.
l Corticospinal tract is also called Pyramidal tract:
While passing through the medulla oblongata to
approach spinal cord, fibers of corticospinal tract
arising from pyramidal cells of cerebral cortex passes
beneath the paramedian ventral bulge looking like a
pyramid with its narrower end directed downwards.
That is why corticospinal tract is called pyramidal
tract (Fig. 4.20).
Fibers of Pyramidal tract (Corticospinal tract)
l Number of fibers: Pyramidal tract of each side
contains 1 million fibers.
l Fibers mostly myelinated: 70% fibers are myel-
inated.
l Fibers are of varying caliber
90% = 1 4 mm in diameter
9% = 5 10 mm
1% = 11 22 mm, which are the axons of giant
pyramidal cells of Betz situated in primary motor
cortex (area 4).
Two corticospinal tracts lateral (crossed) and ante-
rior (uncrossed) (Fig. 4.20)
Just proximal to spinomedullary junction, i.e. at
the lower end of pyramid of medulla oblongata,
75% to 90% fibers of corticospinal tract cross the
midline from either side forming a decussation
beneath the anterior median fissure of medulla. The
majority crossed fibers descend vertically through
the lateral white column (lateral funiculus) of spinal
cord to form lateral corticospinal tract. This tract
is positioned medial to dorsal spinocerebellar tract
and ventrolateral to posterior gray column. The
remaining uncrossed fibers (10%25%) descend
through anterior white column (anterior funiculus)
of same side to form anterior corticospinal tract
which is an uncrossed tract.
 Spinal Cord

Motor area of cerebral cortex

Corticospinal tract is called

pyramidal tract as it passes
through pyramid of medulla
oblongata

Medulla oblongata

Pyramid of medulla oblongata

7590% of fibers cross

midline at the level of lower 1025% of fibers descend
part of medulla to form lateral uncrossed to form anterior
corticospinal tract corticospinal tract

Fig. 4.20 Corticospinal tract Originating from different areas of motor cortex

Termination of corticospinal tract (Figs 4.21A and B)
While descending through respective funiculus, in
every segment of spinal cord successively, fibers of
both the tracts (axons of upper motor neuron) relay in
both alpha and gamma motor neurons (lower motor
neurons) of anterior gray column. As the lateral
corticospinal tract is a crossed tract, it is very clear
to understand that, it possesses influence on anterior
horn cell of contralateral side (Fig. 4.21A and B).
But it is very important to notice at this stage that,
though anterior corticospinal tract is an uncrossed
(ipsilateral) one, in every segment of spinal cord fibers
for the respective segment cross the midline through
anterior white commissure and relay in opposite
sided motor neurons of spinal cord (Fig. 4.21A and
B). So it is not difficult to understand that, ipsilateral
anterior corticospinal tract also possesses influence
on contralateral lower motor neurons.

Medulla oblongata
Olive
Pyramid

Anterior corticospinal tract (uncrossed)

Lateral corticospinal tract (crossed)

Lateral corticospinal tract in

lateral funiculus

Anterior corticospinal tract

in anterior funiculus

Fig. 4.21A Both lateral (crossed) and anterior (uncrossed) corticospinal tracts beyond medulla oblongata, and their position in lateral
and anterior white columns of spinal cord respectively
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Anterior corticospinal tract

Lateral corticospinal tract

In each segment of spinal

cord, fibers from uncrossed
anterior corticospinal tract
cross midline through
anterior white commissure to
In each segment of spinal relay in opposite sided lower
cord, lateral corticospinal motor neurons
tract which is already
crossed at medullary level,
gives fibers to relay in lower
motor neurons of same side Ventral root of spinal nerve

Fig. 4.21B Corticospinal tracts. Lateral corticospinal tract A crossed (contralateral) tract which descends through lateral funiculus.
Anterior corticospinal tract An uncrossed (ipsilateral) tract which descends through anterior funiculus

Corticospinal tracts terminates indirectly through
interneurons
Most of the fibers of corticospinal tracts terminate
contralaterally on interneurons of laminae V to VII,
which finally relay in alpha as well as gamma motor
neurons of lamina IX. Direct termination on motor
neurons are mostly found in segments of cervicothoracic
and lumbosacral enlargements of spinal cord.
Variations of corticospinal tract
1. Corticospinal fibers may be totally crossed.
2. All the fibers may remain uncrossed in very rare
occasion.
Principle of functions of corticospinal tract
1. Fibers arising from primary motor cortex and
premotor cortex (area 4 and 6 respectively), thro-
ugh their influence on both alpha and gamma
motor neurons of spinal cord, facilitate activities
of extensor group of muscles. They are concerned
with prcised and skillful movements, particularly,
of distal part of limbs. It is proved by lesions of the
tract, which very commonly occurs due to cerebro-
vascular accident. It affects mostly the movements
of distal part of limbs with fingers and toes.
80
2. Fibers arising from parietal cortex, i.e. postcentral
gyrus (area 3, 1, 2) and adjacent parietal area (area
5), projecting on neurons of posterior gray horn,
modulate spinal reflex activities and transmission
of afferent informations to higher sensory centers.
Noncorticospinal tract
These are the descending tracts which originate
from various centers of brainstem, below the level of
cerebral cortex, which are considered as subcortical
centers.
Like corticospinal tracts, cell of these centers are
upper motor neurons which project on lower motor
neurons, i.e. alpha and gamma motor neurons of
spinal cord.
These tracts are described below in reference to
the following points:
l Origin
l Nature, i.e. extent and, crossed or uncrossed
l Localization in spinal cord
l Termination
l Function.
RUBROSPINAL TRACT
n Origin: Central core (tegmentum) of upper
half of midbrain (at the level of superior colliculus)
 Spinal Cord
Rostral Aqueduct of midbrain
parvocellular part

Caudal magno-
] Red
nucleus
Red nucleus
cellular part

Ventral tegmental
decussation

Rubrospinal tract
Rubrospinal tract

Fig. 4.22A Rubrospinal tract originates from caudal Fig. 4.22B Fibers of rubrospinal tract originating from red nucleus
magnocellular part of red nucleus cross midline at midbrain to form ventral tegmental decussation

presents a reddish gray colored ovoid mass of nerve
cells, called red nucleus which is divided into rostral
parvocellular part made up of smaller neurons and
caudal magnocellular part made up of larger neurons.
Rubrospinal tract originates from caudal magno-
cellular part of red nucleus which contains 150200
neurons (Fig. 4.22A).
n Morphology: In man, rubrospinal tract is rudim-
entary and poorly defined. In animals, it extends upto
lumbosacral segments of spinal cord.
l Nature: Rubrospinal tract is a crossed tract.
Fibers of this tract cross horizontally, just after their
origin from red nucleus. It is called ventral tegmental
decussation. After decussation fibers descend through
central core (tegmentum) of brainstem to reach spinal
cord (Fig. 4.22B).
n Localization: Fibers of rubrospinal tract are
localized in the lateral white column of spinal cord,
just in front of lateral corticospinal tract with which
its fibers are intermingled (Fig. 4.23).
n Termination: Rubrospinal tract extends upto
only upper three cervical segments of spinal cord.
Before terminating into alpha and gamma motor
neurons of spinal cord, fibers from polysynaptic
connection via interneurons of laminae V to VII.
n Functions: Functions of rubrospinal tract are
similar to those of corticospinal tract.
TECTOSPINAL TRACT
n Origin: Dorsal part of midbrain, which is behind
aqueduct (central canal) of midbrain, is called Tectum.
When viewed from behind, tectum is seen to be made
up of one upper and one lower pair of bulges called
superior and inferior colliculi (Singular-colliculus).
These colliculi are made up of clusters of nerve
cells which are arranged in the form of superficial,
intermediate and deep layers.
Tectospinal tract originates from intermediate
and deep layers of cells of superior colliculus of both
sides at the upper half of midbrain.
n Nature: Tectospinal tract is crossed tract like
rubrospinal tract. Fibers of this tract also cross

Fasciculus gracilis

Fasciculus cuneatus

Dorsal spinocerebellar tract Lateral corticospinal tract

Rubrospinal tract
Ventral spinocerebellar tract Lateral reticulospinal tract
Medial reticulospinal tract
Lateral spinothalamic tract
Anterior corticospinal tract

Anterior spinothalamic tract Olivospinal tract

Vestibulospinal tract
Ascending tract Tectospinal tract
Descending tract
Crossed Uncrossed Crossed Uncrossed

Fig. 4.23 Cross-section of spinal cord showing ascending (afferent) and descending (effercent) tracts
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
horizontally in front of aqueduct of midbrain, in a
more posterior plane, just after their origin from
tectum. It is called dorsal tegmental decussation.
After decussation, fibers of this tract descend through
central core (tegmentum) of brainstem to reach the
level of spinal cord.
n Localization: Tectospinal tract is localized in
anterior white column of spinal cord, in front of
anterior corticospinal tract, just by the side of ventral
part of anterior median fissure (Fig. 4.23).
n Termination: Tectospinal tract extends only upto
upper cervical segments of spinal cord.
Before terminating into alpha and gamma motor
neurons of spinal cord, fibers form polysynaptic
connection via interneurons of laminae VI to VIII.
n Functions: Before the function of tectospinal
tract is understood, it is to be noted that, this tract
forms efferent component of a reflex pathway known
as spinovisual reflex. Activity of this pathway is
manifested by turning neck with head away when a
powerful light falls on retina of eyeball.
5 components of this reflex pathway are following:
1. Receptor: Rod and cone cells of retina (photor-
eceptors) which are stimulated by light falling
on retina.
2. Afferent path: Visual pathway from retina - optic
nerve optic chiasma optic tract lateral
geniculate body superior brachium.
3. Center: Superior colliculus of midbrain which
receives collaterals from lateral geniculate body
through superior brachium.
4. Efferent path: Tectospinal tract.
5. Effector: Voluntary muscles of neck.
VESTIBULOSPINAL TRACTS
l They are two in number known as lateral and
medial vestibulospinal tracts.
l Though called lateral and medial, both are present
in anterior white column of spinal cord, but latero-
medially positioned.
l These tracts arise from vestibular nuclear com-
plex situated at the lateral angle of floor of
fourth ventricle at pontomedullary junction (Fig.
4.24A).
n Origin (Fig. 4.24B):
Lateral vestibulospinal tract from lateral vestib-
ular nucleus.
Medial vestibulospinal tract from
i. Medial and inferior vestibular nuclei
ii. Some fibers From lateral nucleus.
n Nature:
Lateral uncrossed (ipsilateral)
Medial crossed (contralateral) as well as uncros-
sed (ipsilateral).
Fibers of medial vestibulospinal tract extend upto
midthoracic level.
n Localization: Both the tracts are located in
ventral marginal part of anterior white column
(Fig. 4.23).
n Termination: Both vestibulospinal tracts term-
inate in alpha as well as gamma motor neurons of
spinal cord via interneurons of laminae VII and VIII.
n Function: Lateral vestibulospinal tract is excitatory
to the spinal motor neurons which supply extensor

Superior colliculus
Inferior colliculus

Superior cerebellar peduncle

Vestibular triangle

Floor of 4th ventricle

Inferior cerebellar peduncle

Cuneate tubercle
Gracile tubercle

Fig. 4.24A Vestibulospinal tract arises from vestibular nuclear complex lying beneath vestibular triangle of floor of 4th ventricle at
pontomedullary junction
82

Lateral vestibular nucleus
Inferior vestibular nucleus
Lateral vestibulospinal tract originates
from lateral vestibular nucleus
Fig. 4.24B Origin of lateral and medial vestibulospinal tracts
muscles of neck, back and limbs. It is inhibitory to
neurons which supply flexor muscles of limbs.
Medial vestibulospinal tract inhibit spinal motor
neurons which supply muscles of neck and upper part
of back.
RETICULOSPINAL TRACT
Reticulospinal tracts are two Medial and lateral.
These tracts project from reticular nuclei of brainstem
(upper motor neurons) to alpha and gamma motor
neurons (lower motor neurons) of spinal cord either
directly or through interneurons of laminae VII and
VIII. Upper motor neurons for these tract are called
reticular nuclei because the cells are intermingled
with network (reticulum) of fibers.
n Origin:
Medial: From reticular nuclei of pons and medulla
oblongata.
Lateral: From reticular nuclei of medulla oblongata.
n Nature:
Medial: Crossed as well as uncrossed.
Lateral: Uncrossed.
n Localization (Fig. 4.23):
Medial: Located in anterior white column, medial
to base of anterior horn.
Lateral: Located in lateral white column, lateral
to base of anterior horn, close to lateral corticospinal
tract and rubrospinal tract.
n Termination: Both the tracts terminate in alpha
as well as gamma neurons of anterior horn cells
(Lamina IX) of spinal cord either directly or through
interneurons of laminae VII and VIII.
n Function:
Medial reticulospinal tract: It is concerned with
i. Postural adjustment
Spinal Cord
Superior vestibular nucleus
Medial vestibular nucleus
Medial vestibulospinal tract originates
from medial and inferior vestibular nuclei
ii. Steering of head and trunk movement in
response to external stimulus.
iii. Stereotyped movement of muscles of limbs.
Lateral reticulospinal tract: It is involved in regu-
lation of:
i. Motor function
ii. Perception of pain sensation.
OLIVOSPINAL TRACT
There is doubt in existence of this tract in man now-
adays. It was thought that this tract originates from
inferior olivary nucleus and project on motor neurons
of spinal cord. It was thought to be localized in lateral
white column of spinal cord.
HYPOTHALAMOSPINAL TRACT
It is better to be called hypothalamospinal fibers
rather than tract as the fibers do not form compact
bundle.
n Origin: From paraventricular (and some other)
nuclei of anterior and posterior half of hypothalamus.
n Nature: Uncrossed (ipsilateral)
n Localization: Lateral funiculus of spinal cord.
n Termination:
i. Sympathetic neurons of intermediolateral cell
column of T1 to L2 segments of spinal cord.
ii. Parasympathetic neurons of intermediate area
of S2, S3 and S4 segments of spinal cord.
n Function: Supraspinal control of sympathetic
and parasympathetic visceral function.
SOLITARIOSPINAL TRACT
n Origin: Nucleus tractus solitarius of medulla
oblongata. It is a composite special visceral sensory
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
nucleus having parts for VIIth, IXth and Xth cranial
nerves. It receives sensory fibers of these cranial
nerves carrying taste sensation from tongue and soft
palate.
n Nature: Mostly crossed
n Localization:
i. Anterior funiculus and
ii. Anterior part of lateral funiculus.
n Termination:
i. Anterior horn cells of C3, C4 and C5 segment of
spinal cord supplying diaphragm.
ii. Anterior horn cells of thoracic segments of
spinal cord supplying intercostal muscles.
n Function: Reflex movements of intercostal mus-
cles and diaphragm on stimulation of nucleus tractus
solitarius.
CLINICAL ANATOMY OF SPINAL CORD
Protection of Spinal Cord
Spinal cord, which is part of central nervous system
and, made up of delicate and sensitive nervous tissue,
is well-protected by:
1. Vertebral column Inside which, in vertebral
canal, it is lodged.
2. Spinal meninges Dura, arachnoid and pia
maters, mainly dura mater which is toughest,
outermost fibrous membrane.
3. Cushion of cerebrospinal fluid Inside subarac-
hnoid space.
Factors Holding Spinal Cord in Position
1. Spinal nerves (31 pairs), formed by union of ventral
and dorsal roots, come out through intervertebral
foramen. Dural sheath of spinal nerves is attached
at the margin of intervertebral foramen.
2. Ligamentum denticulatum One on either side,
with 21 pairs of tooth-like pial projections bind
lateral surface of spinal cord to the inner surface
of arachnoid mater.
3. Filum terminale It is the nonnervous filamentous
band which ties conus medullaris of spinal cord
below to the back of 1st piece of coccyx.
Ligamentum Denticulatum A Guide for
Selective Cordotomy
l Anterolateral cordotomy is done to relieve excrut-
iating pain. Surgeon passes his knife through
anterolateral part of cord to cut ascending (sensory)
tracts which are anterior to the plane of ligamentum
denticulatum.
l Posterolateral cordotomy is done to relieve ab-
normal muscular spasm. Surgeon passes his kni-
84
fe through the posterolateral part of cord to cut
descending (motor) tracts which are posterior to the
plane of ligamentum denticulatum.
Knowledge of Termination of Spinal Cord in
Clinical Practice
Upto 3rd month of fetal life, rate of growth of vertebral
column and that of spinal cord are co-extensive. After
3rd month vertebral column grows more rapidly
than spinal cord. That is why, at birth spinal cord is
found to end at the level of lower border of body of 3rd
lumbar vertebra. This status remains in infancy. But
finally, spinal cord is found to end at the level of lower
border of body of 1st lumbar vertebra. Sometimes,
it may extend upto 2nd lumbar vertebra in case of
adults.
But arachnoid and dura maters extend upto lower
border of body of 2nd sacral vertebra. So subarachnoid
space below the level of termination of spinal cord (L1/
L2), and above S2 level, is prominent which is filled
with cerebrospinal fluid where float the fibers of cauda
equina. This area of prominent spinal subarachniod
space is approached from outside through a procedure
called spinal tap or lumbar puncture which helps in
diagnosis and management of some central nervous
system diseases.
Lumbar Puncture (Spinal Tap) (Fig. 4.7)
It is the clinical procedure to approach spinal
subarachnoid space below the level of termination of
spinal cord for following two purposes.
1. Diagnostic: For the purpose of diagnosis of some
diseases of nervous system which is related to
alteration of character of cerebrospinal fluid, this
procedure is adopted to take out the sample of fluid
for its physical, chemical/biochemical, microscopic
and bacteriological examination.
2. Therapeutic: Instead of withdrawal of cerebro-
spinal fluid, some drugs are injected for the
following two purposes:
i. Some drugs in the form of anesthetics are
injected for induction of spinal anesthesia
before performing surgical operations. There
are some indications where surgeons prefer
spinal anesthesia to general anesthesia.
ii. Some drugs are injected through this route for
treatment of some diseases of central nervous
system.
Where to Perform Lumbar Puncture?
Lumbar puncture needle, specially designed, is
introduced through interspinous space in the back
between 3rd and 4th lumbar spine.

How to Locate L3/L4 Interspinous Space?
It is the space just above L4 spine. To find out the
space, L4 spine is located. L4 spine is at the level of a
horizontal plane which passes through highest point
of two iliac crests (transcristal plane).
How to Perform Lumbar Puncture?
After taking proper aseptic measures, patient is
placed in lateral position in bed or upright sitting
position and vertebral column is flexed. Two
advantages are enjoyed in flexed position of spine.
Interspinous space becomes wider and lower end of
spinal cord is further elevated above lower border of
body of L1 vertebra.
Lumbar puncture needle is introduced through
midline interspinous space between L3 and L4
spines. The tip of the stellate followed by needle is
directed horizontally with slight upward inclination.
A sustained resistance is felt till the needle crosses
supraspinous and interspinous ligament and finally
it passes through dura mater with arachnoid mater.
n Queckenstedt sign: Normal CSF pressure is
60150 mm of water. Pressure applied over internal
jugular vein leads to cerebral venous congestion
causing rise of subarachnoid CSF pressure as a
result of less absorption of CSF through arachnoid
granulations. In case of expanding tumor of spinal
cord (glioma) or meninges (meningioma), due to
blockade of subarachnoid space, even rise of cerebral
Intervertebral disk
Fig. 4.25A Spinal nerve is predisposed for compression at intervertebral foramen which may cause root canal pressure
Fig. 4.25B Disruption of annulus fibrosus squeezes out nucleus pulposus of intervertebral disk to press over spinal nerve roots
Spinal Cord
venous pressure by application of pressure over
internal jugular vein does not cause rise of CSF
pressure. This is called positive Queckenstedt sign.
Lesion of Spinal Nerve Emerging Through
Intervertebral Foramen
Intervertebral foramen is bounded above and below
by the pedicles of two adjacent vertebrae. The
foramen is bounded anteriorly by intervertebral disk
and posteriorly by zygapophyseal joint or facet joint
of articular processes. This foramen transmits spinal
nerve root formed by union of ventral and dorsal
rami. At this site the spinal nerve may be lesioned
due to stretching, pressure or edema resulting from
i. Fracture dislocation of vertebra
ii. Osteoarthritis due to inflammation of facet
joint or
iii. Herniation of intervertebral disk.
Compression of spinal nerve root in the interv-
ertebral foramen due to above reasons leads to a
clinical condition known as root canal pressure (Fig.
4.25A). Herniation of intervertebral disk causing
root canal pressure is not midline but posterolateral.
Disruption or tear of annulus fibrosus squeezes out
the nucleus pulposus to press over spinal nerve root
(Fig. 4.25B). Common sites of herniation are cervico-
thoracic and lumbosacral junction of vertebral column
where mobile part of vertebral column changes into
immobile part.
Pedicle
Zygapophyseal (facet) joint
Spinal nerve emerging through
intervertebral foramen
Torn annulus fibrosus
Herniated nucleus pulposus
Compressed spinal nerve
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Effect of root canal pressure: Spinal nerve,
being mixed nerve, when compressed or irritated,
gives rise to motor as well as sensory manifestations.
Motor effect will be painful muscular spasm with
weakness of the muscles. Involvement of sensory
fibers ranging from irritation to compression leads to
variable effects like altered sensation (paresthesia) to
exaggerated sensation (hyperesthesia) with tingling
pain over the belt of skin (dermatome) supplied by the
corresponding segmental nerve.
n Pyramidal and extrapyramidal tracts two
reciprocal components of descending (motor)
pathway: Efferent (motor) descending pathway ori-
ginating from different areas of cerebral cortex, e.g.
primary motor area (area 4), premotor area (area 6)
and even primary sensory area (area 3, 1, 2) project to
motor neurons (alpha as well as gamma motor neurons)
of spinal cord. Thereby this tract is called corticospinal
tract. Before crossing the midline in lower medulla
to relay in lower motor neurons of spinal cord, this
tract passes through the bulge of pyramid of medulla
oblongata. That is why it is called pyramidal tract.
Other types of descending tracts originating from
subcortical centers, various nuclei of brainstem are
called noncorticospinal tracts. As these tracts are not
passing through pyramid of medulla oblongata, they
are called extrapyramidal tracts.
Two basic motor activities, namely voluntary
movements following contraction of skeletal mus-
cles and maintenance of muscle tone are the
result of balanced combined activity of pyramidal
(corticospinal) and extrapyramidal (noncorticospinal)
tracts.
Voluntary Movements
Execution of voluntary movements resulting from
contraction of group of muscles is the effect of
stimulation of alpha motor neurons of anterior gray
column of spinal cord by pyramidal (corticospinal) as
well as extrapyramidal (noncorticospinal) tracts.
Cortical as well as subcortical motor centers
receives the information from sensory system, eyes,
ears and even the stored information from memory.
Then these centers (UMN) give command to the alpha
motor neurons (LMN) of spinal cord through their
descending axons (descending tracts). Axons of alpha
motor neurons of spinal cord leave through spinal
nerve to stimulate extrafusal fibers of voluntary
muscles which causes muscular contraction resulting
voluntary movements.
But basic difference between corticospinal and
noncorticospinal tracts are as follows. Corticospinal
tract regulates prime mover muscles, particularly
86
those muscles which are concerned for skilful
voluntary movements of distal part of limbs. Non-
corticospinal tracts control gross, basic voluntary
movements resulting easy and rapid movements of
the joints for maintenance of posture.
Muscle Tone
Muscle tone is defined as a state of continuous partial
contraction of a muscle which is obviously the result
of continuous stimulation of extrafusal fibers. But
it is interesting to note that, this effect depends,
beforehand on impulse received by gamma motor
neurons at intrafusal fibers through corticospinal
(facilitatory) and noncorticospinal (inhibitory) tra-
cts. This impulse (facilitatory and inhibitory) from
intrafusal fibers is carried back to spinal cord by
proprioceptive reflex arc with alpha motor neurons
which supply extrafusal fibers.
It is interesting to note the following points at this
stage:
l Normal muscle tone is maintained by balanced
facilitatory effect of corticospinal tract and inhib-
itory effect of noncorticospinal tract on intrafusal
fibers of muscle spindle through gamma motor
neurons.
l In case of lesions of upper motor neurons or
descending tracts, patient presents manifestations
which are the effect of combined damage to
pyramidal and extrapyramidal tracts.
l Lesions of extrapyramidal (noncorticospinal) tract
leads to release (withdrawal) of inhibitory effect
on gamma motor neurons, which thereby causes
spasticity due to increase of muscle tone.
Upper Motor Neurons Lesions
It is the combined lesion of both pyramidal (cor-
ticospinal) and extrapyramidal (noncorticospinal)
tracts. Corticospinal tract originates from different
areas of cerebral cortex. Noncorticospinal tract origin-
ates from different motor centers of brainstem. But
these centers are also influenced by some descending
cortical fibers. It means therefore, even in case
of lesion of upper motor neuron anywhere above
brainstem, patient will present effect of combined
lesion of corticospinal as well as noncorticospinal
tracts.
Lesion of Corticospinal Tract (Pyramidal Tract)
1. It results in loss of fine, skilled voluntary
movements. It affects particularly distal part of
limbs. This manifestation is due to loss of command
of corticospinal tract over alpha motor neurons of

spinal gray matter whose axons innervate extra-
fusal fibers of skeletal muscle.
2. Loss of function of efferent component (corticospinal
tract) of some reflex pathway
It is well-known that a reflex pathway is composed
of 5 components i) receptor ii) afferent path
iii) center iv) efferent path and, v) effector organ.
Corticospinal tract forms efferent component of
some reflex pathway which are, not horizontally,
but vertically oriented. So when corticospinal tract
is lesioned, these reflexes are abolished or lost.
n Plantar reflex Its 5 components are
i. Receptor At skin of lateral border of sole of
foot.
ii. Afferent component Sensory nerves from
lateral border of sole of foot, ascending tract of
spinal cord which reaches upto cerebral cortex.
iii. Center Motor area of cerebral cortex.
iv. Efferent component Corticospinal (pyramidal)
tract, motor (efferent) nerve of lower limb
supplying plantar muscles.
v. Effector organ Plantar muscles.
Due to integrity of this reflex pathway, scratching
of lateral border of sole of foot causes plantar flexion
of foot normally. Therefore, in case of lesion of
corticospinal tract, there becomes interruption of the
circuit of reflex pathway, which results in
a) Abolition of plantar reflex
b) In addition, withdrawal phenomenon of limbs
occurs by dorsiflexion of the great toe with
fanning (abduction) of other toes. This is called
positive Babinski sign.
In case of infants, myelination of corticospinal tract
is completed at the age of 2 years. So upto age of 2 years,
nonmyelinated corticospinal tract is characterized
by loss of velocity of action potential, which makes
it nonfunctioning. So in an attempt to elicit plantar
reflex, it will show positive Babinski sign.
n Superficial abdominal reflex
Components
1. Receptors: Stretch receptors under the skin of
anterior abdominal wall.
2. Afferent component: Sensory fibers of lower inter-
costals nerve carrying sensation to the spinal cord
Ascending tracts of the spinal cord reaching
finally to cerebral cortex.
3. Center: Motor area of cerebral cortex.
4. Efferent component: Corticospinal tract anterior
horn cells of spinal cord motor fibers of lower
intercostal nerve.
5. Effector organ: Flat muscles of anterior abdominal
wall.
In normal individual, scratching of skin of anterior
abdominal wall causes brisk visible contraction of
Spinal Cord
muscles of anterior abdominal wall. In lesion of
corticospinal tract, which is part of efferent component
of reflex pathway, superficial abdominal reflex is
found to be absent.
n Cremesteric reflex
Components
1. Receptors: Stretch receptors beneath the skin of
medial side of front of thigh below groin.
2. Afferent component: Femoral branch of genito-
femoral nerve (L1 L2) Ascending tract from L1/
L2 level of spinal cord to end finally to cerebral
cortex.
3. Center: Motor area of cerebral cortex.
4. Efferent component Corticospinal tract Genital
branch of Genitofemoral nerve (L1, L2)
5. Effector: Cremester muscle in male so this reflex is
elicited only in male patients.
In normal individual, scratching of skin of front
of thigh below groin causes contraction of cremesteric
muscle leading to slight upward pull to testis which
is visible through skin of scrotum. In case of lesion of
corticospinal tract, which is efferent component of the
reflex pathway, cremesteric reflex is absent.
Lesion of Noncorticospinal Tracts
(Extrapyramidal tracts)
1. Widespread paralysis of voluntary muscles which
are concerned with gross movements.
2. Hypertonicity: Muscle tone is increased because,
inhibitory effect of extrapyramidal tract on gamma
motor neurons is cut off. As the muscles are
paralyzed, it gives rise to spasticity. So paralysis
is called spastic paralysis.
3. Exaggerated tendon reflexes: In normal individual,
tapping of tendon of quadriceps femoris (ligam-
entum patellae) causes brisk jerky extension mov-
ement of knee. This is due to integrity of local
reflex arc at the spinal cord level. In case of lesion
of extrapyramidal (noncorticospinal) tracts, its
inhibitory effect on gamma motor neuron is cut off,
which will cause exaggeration of tendon jerks.
Lower Motor Neurons Lesion
Motor neurons (both alpha as well as gamma) of
anterior gray column of spinal cord are known as
lower motor neurons (LMN) which are governed
by upper motor neurons (UMN) of all supraspinal
centers. The axons of all the lower motor neurons of
spinal cord leave central nervous system to end in the
target organs (voluntary muscles) via ventral (motor)
root of spinal nerve. That is why the ventral motor
root is called final common pathway of Sherrington.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Same as upper motor neuron, lower motor neuron
lesions may occur due to following causes.
1. Traumatic
2. Ischemic
3. Infective
4. Degenerative
5. Neoplastic.
Whatever the reason is, lower motor neuron lesion
results in damage to cell bodies of anterior gray horn
and/or their axonal process emerging as ventral nerve
root.
Effects or manifestations are as follows:
1. Flaccid paralysis: It is the paralysis of voluntary
muscles supplied by the affected spinal segments
with loss of muscle tone because of lesion of gamma
with alpha motor neurons.
2. Atrophy of muscles following atonic paralysis.
3. Loss of reflexes related to affected muscles. It
explains abolition of tendon jerks (e.g. knee jerks)
depending upon the corresponding segment.
4. Contracture of muscles: It is the shortening of
the muscles which occurs in antagonists, as they
are not opposed by the paralyzed muscles.
SPINAL CORD INJURIES
Incidence of spinal cord injuries (spinal injuries)
is very common in modern days. These injuries are
catastrophic as there is very little or no chance of
regeneration of damaged neural tissue. It leads to
permanent disabilities.
Principles of Management
1. Decompression of spinal cord by realignment of
vertebra fractured and/or dislocated.
2. Stabilization of injured area.
3. Rehabilitation.
4. Recently, use of certain drugs, e.g. GM1, Ganglioside
and methylprednisolone, soon after injury results
in improvement of neurological deficit.
Causes of Spinal Cord Lesion
1. Traumatic: i) Fracture dislocation of vertebra
ii) Penetrating injury e.g. stab injury, gunshot
injury.
2. Vascular: i) Arterial occlusion or compression
causes degeneration of nerve cells and fibers.
ii) Venous compression causes edema of neural
tissue.
3. Infective: Viral or bacterial.
4. Degenerative: Causing demyelination of nerve
fibers.
5. Neoplastic: By expanding tumor.
88
Depending upon the site, lesions may be subdivided
as follows:
1. Extradural
2. Intradural: i) Extramedullary lesion outside
spinal medulla (spinal cord) ii) Intramedullary
inside spinal medulla.
Spinal Cord Syndrome
Depending upon causes of spinal cord lesion, spinal
cord may be compressed to a variable extent, i.e.
completely or partially leading to different types of
clinical manifestations. These are as follows:
1. Complete cord transection syndrome
2. Anterior cord syndrome
3. Central cord syndrome
4. Cord hemisection syndrome or Brown-Squard
syndrome.
It is important to note at this stage that, patient
attacked with any of the above mentioned syndrome
passes initially and temporarily through an acute
phase of shock, which is called spinal shock syndrome.
Spinal Shock Syndrome
It is the initial phase of blackout faced by spinal cord
following injury of any type causing damage to spinal
cord.
n Duration: In most of the cases, this phase lasts
for 1 day (24 hours). In some cases, of course, it may
extend upto 1 week to 1 month (4 weeks).
n Clinical features: Fundamentally it is charac-
terized by depression or loss of all cord functions
(motor and sensory) below the level of lesion. These
are
1. Flaccid paralysis
2. Hypotonia or atonia, i.e. loss of muscle tone
3. Loss of tendon jerks and reflexes
4. Loss of all sensation below the level of lesion
5. If the lesion is higher level, hypotension (fall
of blood pressure) due to loss of sympathetic
vasomotor control
6. Loss of bladder and bowel function.
Regeneration of function of cord
After the phase of spinal shock is over, partial
regeneration of cord function occurs because
i. Neurons, which are not permanently damaged,
get back the power of irritability and cond-
uctivity.
ii. Edema of the affected neural tissue subsides.
After the period of spinal shock is over, neurological
impairment (clinically called neurodeficit) is categ-
orized as following syndromes.
1. Complete cord transection syndrome
2. Anterior cord syndrome

3. Central cord syndrome
4. Cord hemisection syndrome (Brown-Squard
syndrome).
These syndromes differ from one another depen-
ding upon the area of the segment of spinal cord
affected.
The clinical findings are combination of following
fundamentally
1. Lower motor neuron lesion at the level of segment
affected.
2. Upper motor neuron lesion below the level of lesion.
3. Sensory loss below the level of lesion.
Combination of clinical manifestations in any of
the above syndromes will vary according to the level
of spinal cord lesion.
Complete Cord Transection Syndrome (Fig.
4.26A)
Causes
1. Fracture dislocation of vertebral column (spinal
injury).
Spinal Cord
2. Panetrating injury Stab injury or gunshot injury.
3. Expanding tumor.
Effects
All motor and sensory impairments will be bilateral
as follows
1. Damage of anterior horn cells (LMN) and emerging
motor nerve roots of the segment affected will
cause bilateral lower motor neuron paralysis of
the muscles supplied by motor nerve roots arising
from the particular segment.
This paralysis will ultimately will be followed by
atrophy of the muscles affected.
2. Damage of both sided corticospinal as well as non-
corticospinal tracts will cause following bilateral
manifestations below the level of lesion.
i. Spastic paralysis
ii. Babinski sign positive
iii. Loss of abdominal and cremesteric reflexes.
3. Damage of all sensory tracts in anterior, lateral
and posterior funiculi of both sides will cause
bilateral loss of all sensations (exteroceptive as
well as proprioceptive) below the level of lesion.

A B

C D

Figs 4.26A to D Various types of spinal cord syndrome. A. Complete cord transection syndrome, B. Anterior cord syndrome, C. Central
cord syndrome, D. Cord hemisection syndrome (Brown-Squard syndrome)
89
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
4. Loss of voluntary control of bladder and bowel
function due to damage of descending autonomic
fibers.
Anterior Cord Syndrome (Fig. 4.26B)
Causes
1. Traumatic: i) Fracture dislocation of anterior
component of vertebral column ii) Herniation of
intervertebral disk.
2. Ischemic: Occlusion or compression of anterior
spinal artery which supplies anterior two-third of
spinal cord.
Effect
Effects are bilateral:
1. Damage of anterior horn cell and emerging ante-
rior nerve roots will cause lower motor neurons
paralysis of the muscle supplied by the segment
affected.
The paralysis of the muscle affected will be follo-
wed by muscular atrophy.
2. Bilateral spastic paralysis below the level of les-
ion due to damage of anterior corticospinal and
various noncorticospinal tracts.
3. Lesion of anterior and lateral spinothalamic tracts
will cause bilateral loss of pain, temperature
(lateral spinothalamic tract) and pressure and light
touch (anterior spinothalamic tract) sensation.
Touch is not affected as fine touch and discrim-
inative touch sensation is carried through dorsal
white column (fasciculus gracilis and fasciculus
cuneatus). Due to same reason, sense of position and
movements, and vibration sensation are also not lost.
Central Cord Syndrome (Fig. 4.26C)
Cause
Severe hyperextension of cervical part of vertebral
column (called hyperextension injury) which occurs
due to violent force applied to the back of neck in
automobile accident.
In this type of injury, central part of spinal cord
is compressed by vertebral bodies and ligamentum
flavum from front and back respectively.
Effect
All the manifestations as explained below are bilateral.
As this lesion occurs classically in cervical region,
both motor and sensory loss involve both upper and
lower parts of body.
1. Lesion of anterior horn cells causes lower motor
neuron lesion manifested by paralysis of the
muscles which are innervated by that particular
90
segment of spinal cord. Paralysis will be followed
by atrophy of muscles.
2. Bilateral spastic paralysis with all features of
upper motor neuron lesion. It is due to damage to
both corticospinal and noncorticospinal tracts. It
affects both upper and lower limbs as the lesion is
in the cervical part of cord.
3. Bilateral loss of pain, temperature and pressure
sensation as lateral and anterior spinothalamic
tracts are affected. The sensory loss is below the
level of lesion, which in this type of injury is at
cervical level. Though the lesion of central cord
syndrome is in cervical region, lower limb may
remain unaffected for somatomotor and somato-
sensory loss, because in both motor and sensory
tracts, peripherally placed sacral fibers are spared
(Fig. 4.26C).
Though crude touch is affected fine touch is
preserved as peripheral parts of fasciculus gracilis
(from lower half of body) and fasciculus cuneatus
(from upper half of body) remain undamaged. For
the same reason, sense of position, movement and
vibration is also not affected.
Brown-Squard Syndrome (Fig. 4.26D) (Cord
hemisection syndrome)
Cause
Penetrating injury like gunshot injury or stab injury.
Effect
Fundamental difference of this spinal cord injury from
above mentioned types is that it produces unilateral
effects which are as follows.
1. Ipsilateral lower motor neuron paralysis of the
muscles which are supplied by the lesioned spinal
cord segment. It is caused due to injury to the
anterior horn cells and emerging anterior nerve
root of the particular segment. The paralysis is
followed by muscular atrophy.
2. Ipsilateral loss of all cutaneous sensations (an-
esthesia) over the dermatome supplied by the
incoming sensory nerve root of the affected
segment. Initially this area of dermatome may
present hyperesthesia (exaggerated sensation)
due to irritation of posterior nerve root.
3. Ipsilateral spastic paralysis due to lesion of
same sided corticospinal and noncorticospinal
tracts passing through lateral and anterior white
column. Paralysis is below the level of lesion.
Depending upon the level of lesion, clinical
finding may include Babinski sign positive, loss of
abdominal and cremesteric reflexes, exaggerated
tendon jerks.
4. Ipsilateral loss of fine as well as discriminative
touch (exteroceptive sensation) and sense of

position, movement with vibration sensation
(proprioceptive sensation) are manifested due to
lesion of dorsal white column tracts (fasciculus
gracilis and fasciculus cuneatus). Sensory loss is
below the level of lesion.
5. Contralateral loss of pain and temperature (lateral
spinothalamic tract) and pressure sensation (ante-
rior spinothalamic tract) is observed below the
level of lesion.
Touch sensation is not affected as crude touch
of the same side and fine touch of opposite side are
preserved due to noninvolvement of opposite half of
spinal cord.
SELECTIVE LESIONS OF SPINAL CORD
The above mentioned spinal cord syndromes are the
results of spinal cord lesions which are of traumatic,
A Tabes dorsalis
C Syringomyelia
D Multiple sclerosis
Figs 4.27A to E Various types of selective lesions of spinal cord. A. Tabes dorsalis, B. Anterior poliomyelitis, C. Syringomyelia,
D. Multiple sclerosis, E. Amyotrophic lateral sclerosis
Spinal Cord
ischemic or neoplastic origin. Various infective or
degenerative causes may give rise to selective lesion
of different motor and/or sensory tracts, upper or
lower motor neurons which are as follows.
Tabes Dorsalis A Sensory Lesion (Fig. 4.27A)
It is a neurological disease caused by syphilis when
central nervous system is affected (neurosyphilis).
It damages selectively the posterior white column
(fasciculus gracilis and fasciculus cuneatus) and
also posterior nerve root fibers entering dorsal
column. Commonly thoracic and lumbosacral segm-
ents are affected.
Effect
Due to lesion of dorsal column tracts (fasciculus
gracilis and fasciculus cuneatus)
B Anterior poliomyelitis
E Amyotrophic lateral sclerosis
91
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
1. Loss of sense of position and movement, and loss
of vibration sensation.
2. As the patient is not aware of position of limbs
while walking, the limbs strike against the ground
causing stumping gait. Patient tries to compensate
this disability with the help of vision.
3. If visual help is withdrawn by closure of eyes, in
standing position, due to loss of sense of position,
patient will have a tendency to fall. It is known as
positive Romberg sign.
4. Loss of sensation of fullness of urinary bladder, as
this sensory pathway traverses dorsal column.
Due to lesion of posterior nerve root fibers
5. Loss of exteroceptive sensation over the dermatome
areas of skin opposite the segments of spinal cord
affected.
Due to irritation of dorsal nerve root ganglia
6. Paresthesia (altered sensation) or hyperesthesia
(exaggerated sensation) with stabbing pain sen-
sation of the dermatome areas corresponding to
affected spinal cord segments.
Poliomyelitis Acute Viral Infection of Spinal
Motor Neurons (LMN) (Fig. 4.27B)
It is the neuronal disease caused by poliovirus which
cause selective damage to the motor neurons of
anterior gray column of spinal cord and motor nuclei
of cranial nerves supplying muscles of face, tongue,
larynx and pharynx.
Worldwide immunization program by poliovac-
cine remarkably reduced the horror of incidence of
the disease among children.
The viral infection is characterized by edema
of neural tissue with selective damage of anterior
horn cells (LMN). It causes paralysis with wasting
of muscles. Lower limb is more affected than upper
limb. If motor nuclei of cranial nerves are affected, it
causes paralysis of muscles of face, tongue, pharynx
and larynx. In severe poliomyelitis, respiratory mus-
cles (diaphragm and intercostal muscles) may be
paralyzed.
Patient recovers from disease when edema sub-
sides and motor neurons regain power. Permanent
death of some neurons is characterized by residual
paralysis.
Syringomyelia A Lesion of Embryological
Cause (Fig. 4.27C)
Syringomyelia is a degenerative lesion of spinal cord
characterized by excavation (dilatation) of central
canal of some segments of spinal cord due to some
developmental reason. Usually cervicothoracic (lower
cervical and upper thoracic) segments of spinal cord
92
are affected. At the site of lesion cavitation followed
by gliosis gives rise to following clinical findings.
1. Before formation of lateral spinothalamic tract,
fibers carrying sensation from opposite side of
body, decussate in front of central canal in the
anterior gray and white commissures of the seg-
ments commonly affected (lower cervical and
upper thoracic). Cavitation of central canal causes
damage to these fibers causing loss of pain and
temperature sensation over skin of neck, upper
limb and upper part of trunk. Area of anesthesia
simulates area of body covered by a jacket. That is
why it is called Jacket type of anesthesia.
2. Dilatation of central canal (in lower cervical
and upper thoracic segments) starts from C8T1
segments of spinal cord and proceeds upwards as
well as downwards. So initially dilatation is maxi-
mum at C8T1 segments for which at these two
segments lesion extends peripherally to damage
anterior horn cell which causes paralysis of small
muscles of hand followed by muscular atrophy.
Subsequently other muscle of upper limb are also
paralyzed.
3. If excavation of central canal progresses further
laterally, it will damage corticospinal and noncort-
icospinal tracts leading to spastic paralysis with
exaggerated tendon jerks of both lower limbs, i.e.
below the level of lesion.
Multiple Sclerosis A Demyelinating Disease
(Fig. 4.27D)
It is a degenerative disease of spinal cord caused by
demyelination of both descending as well as ascen-
ding tracts. Following are the cause alone or in
combination
1. Heredity
2. Autoimmunity
3. Infection.
Young adult age groups are affected. Because of
above mentioned predisposing factors, functioning of
blood brain barrier looses it integrity. It will cause more
chance of infection which will lead to entry of leukocytes
in central nervous system tissue. Inflammation will
cause loss of myelin sheath (demyelination) of tract
fibers of spinal cord. Demyelination will cause initial
reduction and ultimate loss of velocity of action
potential of tract fibers.
During active phase of the disease following
demyelination, the patient present impaired sens-
ation, weakness of muscle at different levels depending
upon level of spinal cord affected. There may be signs
of ataxia as tracts of the cerebellum is affected.

The disease is characterized by Recovery and
Recurrence. Recovery is due to remodeling of plasma
membrane of demyelinated axons which become able
to regenerate velocity of action potential.
But in unfortunate cases of progressive type of the
disease, instead of recovery, loss of myelin sheath is
followed by permanent damage of the axons.
Amyotrophic Lateral Sclerosis A Progressive
Degenerative Disease (Fig. 4.27E)
It is a progressive degenerative disease of unknown
cause victimizing middle-aged people. It damages
selectively the corticospinal and noncorticospinal
descending tracts causing spastic paralysis below
Spinal Cord
the level of lesion. It is associated with damage to
anterior horn cells causing lower motor neuron lesion
of the muscles supplied by the affected segment.
The disease turns to a fatal state within 5 to 6
years.
Combined Degeneration of Spinal Cord In
Pernicious Anemia
Pernicious anemia, a type of megaloblastic anemia is
caused due to vitamin B12 deficiency. The disease is
associated with combined degeneration of descending
(motor) and ascending (sensory) tracts of spinal cord
due to lesion of posterior and lateral white column. It
is characterized by widespread motor and sensory less.
93
 Brainstem
Brainstem is the tubular stalk-like part of the brain
made up of midbrain, pons and medulla oblongata
from above downward (Fig. 5.1). It is so called beca-
use it is like stem of a tree. Main mass of the brain,
cerebrum with cerebellum rests on the brainstem and
through it, is connected to spinal cord below. Long
axis of brainstem is oblique, directed downward and
backward.
n Extent: Above, upper end of brainstem (midbrain)
is continuous with diencephalon of forebrain.
n Below: Lower end of brainstem (medulla oblon-
gata) passes out of cranial cavity through foramen
magnum to become continuous with spinal cord at the
level of upper border of first cervical vertebra.
Relations of Brainstem
n With cranial cavity: Brainstem lies in posterior
cranial fossa of skull and rests on the slope of clivus
Midbrain
Pons
Medulla oblongata
Fig. 5.1 Brainstem (lateral view)
5
which is formed by posterosuperior surface of basilar
parts of sphenoid and occipital bones.
n With tentorium cerebelli: Tentorium cerebelli
is a crescentic horizontal shelf of dura mater of brain
lying between posterior part of cerebrum (occipital
lobe) and cerebellum. It posseses peripheral convex
border. In front of concave anterior border (tentorial
notch), brainstem passes downwards. Midbrain is the
supratentorial part and, pons with medulla oblongata
is the infratentorial part of brainstem lying above and
below the tentorium cerebelli respectively (Fig. 5.2).
n With cerebrum and cerebellum: Cerebrum
with thalamus (diencephalon) is above and, cerebe-
llum is behind the brainstem. Ventral compact part
Supratentorial
part of
brainstem
Tentorium
cerebelli
Infratentorial
part of
brainstem
Fig. 5.2 Tentorium cerebelli divides brainstem into supratentorial
and infratentorial parts

Cerebral peduncle
Middle cerebellar peduncle
Fig. 5.3 Cerebellum and peduncles (cerebral as well as cerebellar) related to brainstem
of midbrain, composed of bundle of descending
fibers connects the brainstem (midbrain) above with
cerebrum. It is called cerebral peduncle having right
and left identical halves. Cerebellum is connected to
midbrain, pons and medulla oblongata of brainstem by
three pairs of compact bundle of white matter. These
are called superior, middle and inferior cerebellar
peduncles respectively (Fig. 5.3).
n With fourth ventricle of brain: Fourth ventricle
is the cavity of hindbrain. It is related anteriorly
to pons and medulla oblongata and posteriorly to
cerebellum (Fig. 5.4).
Cavity Related to Brainstem
Cavity related to brainstem is of different shapes and
natures at different level as follows:
l Midbrain A narrow linear slit known as aqueduct
of Sylvius.
Aqueduct of Sylvius
Fourth ventricle of brain
Central canal of lower end of
medulla oblongata
Fig. 5.4 Cavity related to brainstem
Brainstem
Superior cerebellar peduncle
Cerebellum
Inferior cerebellar peduncle
l Pons and upper part of medulla oblongata: A wide
tent shaped space forming cavity of hindbrain
called fourth ventricle of brain.
l Lower part of medulla oblongata: A narrow central
canal of medulla continuous below with central
canal of spinal cord.
Structural and Functional Characteristics
Intermingling of gray matter and white matter
Brainstem is the part of central nervous system where
gray matter and white matter are not demarcated
into two separate zones. Unlike spinal cord, it is not
divided into central gray matter and peripheral white
matter. Again, unlike cerebrum and cerebellum it
does not show superficial cortex and deeper medullary
substance. Brainstem presents intermingling of gray
matter and white matter.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
White Matter of Brainstem
Brainstem acts as a bridge, composed of compact
vertical bundles of fibers in the form of ascending and
descending tracts connecting spinal cord with higher
centers.
Horizontal fibers from the three components of
brainstem connect cerebellum through three pairs of
cerebellar peduncles.
Gray Matter of Brainstem
Gray matter inside the brainstem is present in the
form of clusters of nerve cells called nuclei which are
as follows
1. Cranial nerve nuclei: There are motor and
sensory nuclei of 3rd to 12th cranial nerves.
2. Other nuclear masses: In all the three compo-
nents of brainstem, there are other nuclear
masses, for example red nucleus in midbrain,
pontine nucleus in pons and olivary nucleus in
medulla oblongata.
3. Reticular nuclei: Throughout the whole length
of central core of brainstem, scattered collection
of nerve cells are present. There are intermingled
with network (reticulum) of nerve fibers. These
constitutes reticular formation of brainstem. Scatt-
ered nerve cells are known as reticular nuclei.
Special Functional Areas in Brainstem
1. Brainstem contains Vital Centers which regulate
the activities of cardiovascular and respiratory
systems.
2. Brainstem contains center which controls auton-
omic reflex activities.
3. Brainstem reticular formation, which is defined ab-
ove, regulates level of consciousness and alertness.
External Features of Brainstem
In this connection, two important points are to be
noted.
1. External features of three components of brainstem
are described here together.
2. External feature of brainstem are described in
following three points:
a) Surface features of brainstem
b) Surface attachments of roots of 3rd to 12th
cranial nerves.
c) Surface relations of brainstem with different
arteries.
Relative length
Midbrain 2 cm
Pons 2.5 cm
Medulla oblongata 3 cm.
Surface Features of Brainstem
Ventral surface (Fig. 5.5)
A. At the level of medulla oblongata
1. Along the midline of ventral surface of medulla
oblongata a longitudinal fissure extends. It is
called ventral median fissure. Lower end of
fissure is continuous below with ventral median
fissure of spinal cord. Upper end of fissure, at
pontomedullary junction, ends in a small shallow
depression called foramen cecum.
2. On either side of ventral median fissure, there is
a narrow linear elevation called pyramid with its
broader upper end and narrower lower end. Deep
to it, passes a descending (motor) tract called
pyramidal tract (corticospinal tract). Some of the

Aqueduct of Sylvius Upper cut surface of midbrain

Cerebral peduncle

Basilar sulcus

Basilar part of pons

Cut surface of middle cerebellar peduncle
Foramen cecum

Inferior cerebellar peduncle

Anterior median fissure
Olive
Posterolateral sulcus
Anterolateral sulcus
Pyramid

Fig. 5.5 External features of brainstem (ventral surface)

96

fibers of this tract decussate (cross) at the lower
end of pyramid. Decussation of these fibers is
visible at the lower end of ventral median fissure.
3. Pyramid is demarcated laterally by anterolateral
sulcus which is continuous below with same sulcus
of spinal cord.
4. An oval elevation, with its long axis being vertical,
is present lateral to upper end of anterolateral
sulcus. It is called olive. Deep to olive lies a mass
of gray matter called inferior olivary nucleus.
5. Posterolateral to olive, a sulcus extends vertically
which is parallel to anterolateral sulcus. This is
called posterolateral sulcus. It is continuous below
with same sulcus of spinal cord.
6. Further posterolateral, a compact vertical band of
medulla, passes upwards, backwards and laterally
to cerebellum. It is called inferior cerebellar ped-
uncle.
B. At the level of pons
1. Junction between pons and medulla oblongata
presents a deep transverse sulcus. Midline of po-
ntomedullary junction presents a small blind depr-
ession called foramen cecum.
2. Along the midline of ventral surface of pons, a
wide shallow sulcus extends vertically. It is known
as basilar sulcus. Basilar artery passes along this
sulcus from below upwards.
3. On either side of basilar sulcus, ventral surface of
pons presents a bulge, called basilar part of pons.
4. Lateral to basilar part, pons presents thick
compact band-like part which is horizontal in
direction and passes laterally and backwards to
cerebellum. This is middle cerebellar peduncle.
Superior colliculus
Inferior colliculus
Superior medullary velum
Floor of 4th ventricle
Facial colliculus
Hypoglossal triangle
Vagal triangle
Dorsal surface of lower closed
part of medulla oblongata
Fig. 5.6 External features of brainstem (dorsal surface)
Brainstem
C. At the level of midbrain
Ventral surface of midbrain presents bilateral,
compact, thick band-like structures separated by
a midline depression or broad sulcus. This is called
cerebral peduncle. Upper cut surface of midbrain
shows that cerebral peduncle is the part of midbrain
which is ventral to aqueduct of Sylvius. Anterior most
part of the cerebral peduncle is made up of compact
bundle of descending (motor) fibers. This part is called
crus cerebri.
Dorsal surface (Fig. 5.6)
For better understanding, surface feature of dorsal
surface of brainstem is described in following three
components.
A. At the level of lower half of medulla oblongata.
B. At the level of upper half of medulla oblongata and
pons.
C. At the level of midbrain.
A. At the level of lower half of medulla oblongata
1. Along the midline, a vertical sulcus runs. It
is called median intermediate sulcus which is
continuous below with posterior median sulcus of
spinal cord.
2. On either side of this sulcus, dorsal surface of
lower half of medulla oblongata present a linear
vertical elevation.
3. Upper end of this elevation, on either side, presents
a small elevation called gracile tubercle.
Cut upper surface of midbrain
Trochlear nerve
Superior cerebellar peduncle
Middle cerebellar peduncle
Inferior cerebellar peduncle
Cuneate tubercle
Gracile tubercle
Median intermediate sulcus
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
4. Superolateral to each gracile tubercle, another ele-
vation is present. This is called cuneate tubercle.
Beneath the above two tubercles, lie nucleus gra-
cilis and nucleus cuneatus respectively.
5. Superolateral to cuneate tubercle, compact band-
like structure, called inferior cerebellar peduncle
passes upwards and laterally to the cerebellum.
B. At the level of upper half of medulla oblongata
and pons
Dorsal surface of this part of brainstem presents
following characteristics.
i. This area form the floor of 4th ventricle of
brain.
ii. This area receives the opening of central canal
of medulla oblongata below and the opening of
aqueduct of midbrain above.
Details of features of this area is described in the
chapter of 4th ventricle of brain. Some important
features are as follows:
1. The total area is rhomboid in outline, so called
Rhomboid fossa.
2. It is divided into right and left symmetrical tria-
ngular halves by a vertical midline sulcus called
median sulcus.
3. On either side of median sulcus, there is a linear
elevation called medial eminence.
4. Medial eminence at the level of pons, presents a
round elevation called facial colliculus.
5. At the level of medulla oblongata, medial eminence
area is divided by a small sulcus into two triangular
areas. The superomedial triangular area is called
Hypoglossal triangle, and inferolateral one is
called vagal triangle.
6. The medial eminence is bounded laterally by a
sulcus, known as sulcus limitans.
7. Small depressions at upper and lower ends of
sulcus limitans area known as superior fovea and
inferior fovea respectively.
8. Area lateral to sulcus limitans is triangular which
is called vestibular triangle.
For further details, reader is suggested to go
through text of floor of 4th vertricle of brain.
C. At the level of midbrain
1. Uppermost part of dorsal surface of midbrain
presents two pairs round elevations. They are
known as superior and inferior colliculi or corpora
quadrigemina (Singularcolliculus). Superior coll-
iculi are slightly larger than the inferior.
2. Four colliculi are separated from each other by
a cruciform sulcus which presents a vertical and
98
a horizontal limb crossing each other at a right
angle.
3. Upper end of vertical limb presents a small
depression to lodge pineal gland.
4. From inferolateral aspect of inferior colliculus of
midbrain, a pair of compact band of white matter
goes downwards, backwards and laterally to the
cerebellum. This is superior cerebellar peduncle.
5. A thin lamina of white matter connects the medial
sides of two superior cerebellar peduncles, thus
forming the upper part of roof of 4th ventricle of
brain. This is called superior medullary velum.
6. Lower end of vertical limb of cruciform sulcus is
continued vertically downwards across the midline
of superior medullary velum in the form of a thin
ridge. It is called frenulum veli.
7. On either side of frenulum veli, 4th cranial nerve
(trochlear nerve) comes out of brainstem piercing
superior medullary velum.
It is to be noted at this stage that, out of last 10
pairs of cranial nerves (3rd12th), only trochlear
nerve comes out of brainstem from its dorsal surface.
Finally, trochlear nerve goes forwards curving
round the posterolateral aspect of superior cerebellar
peduncle.
Exit of cranial nerves (3rd12th) form brainstem
(Figs 5.6 and 5.7):
All of last 10 pairs of cranial nerves (3rd12th) except
4th (trochlear), come out of brainstem from ventral
surface (Fig. 5.7). Trochlear nerve comes out from
dorsal surface (Fig.5.6).
Site of attachment of roots of these cranial nerves on
the surface of the brainstem will be better understood
and remembered if noticed in reverse order (i.e. 12th
3rd) as follows:
l 12th cranial nerve (hypoglossal) comes out through
multiple rootlets, from anterolateral sulcus between
pyramid and olive.
l 9th (glossopharyngeal), 10th (vagus) and 11th
(accessory) nerves comes out in vertical row from
above downwards through posterolateral sulcus bet-
ween olive and inferior cerebellar peduncle.
l From medial to lateral at pontomedullary junction,
6th (abducent), 7th (facial) and 8th (vestibulocochlear)
nerves comes out from the level of upper end of olive.
Motor root of facial nerve (VII) is medial to its sensory
root.
l 5th cranial nerve (trigeminal) comes out from
midpontine level at the junction of basilar part of
pons and middle cerebellar peduncle. The nerve
comes out in the form of superomedial motor root and
inferolateral sensory root.
l 4th cranial nerve (trochlear) is the exception which
comes out from dorsal surface of brainstem. The
nerve comes out piercing superior medullary relum
lateral to frenulum veli. Finally the nerve comes in
 Brainstem

Oculomotor nerve (III)

Trochlear nerve (IV)

Trigeminal nerve (V)

Abducent nerve (VI)

Facial nerve (VII)

Glossopharyngeal
Vestibulocochlear nerve (VIII)
nerve (IX)
Vagus nerve (X)

Accessory nerve (XI)

Hypoglossal nerve (XII)

Fig. 5.7 Exit of cranial nerves (III to XII) from brainstem

front winding round posterolateral aspect superior
cerebellar peduncle (Fig. 5.6).
l 3rd cranial nerve (oculomotor) emerges from
medial surface of crus cerebri of cerebral peduncle.
Arteries related to surface of brainstem (Fig. 5.8)
Arteries of vertebrobasilar system are related to
ventral surface of brainstem.
Right and left vertebral arteries run verti-
cally from below upwards winding round the
posterolateral aspect of medulla oblongata. In the
midline of pontomedullary junction two vertebral
arteries unite to form basilar artery. Basilar artery
run vertically upwards along the length of basilar
sulcus.
At the upper end of pons, basilar artery bifurcates
into right and left posterior cerebral arteries.
5 sets of branches from vertebral artery and 5
sets of branches from basilar artery are related to the
ventral surface of brainstem as seen in Figure 5.8.
5 sets of branches of vertebral artery:
1. Meningeal arteries
2. Medullary arteries
3. Anterior spinal artery
4. Posterior spinal artery
5. Posterior inferior cerebellar artery.

Posterior cerebral artery

Superior cerebellar artery

Labyrinthine artery Pontine arteries

Anterior inferior cerebellar artery

Posterior inferior cerebellar artery
Two vertebral arteries unite to
form basilar artery Meningeal arteries

Medullary arteries

Posterior spinal artery

Anterior spinal artery

Fig. 5.8 Arteries related to ventral surface of brainstem

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Diencephalon
Telencephalon
Mesencephalon
Diencephalon
Metencephalon
Mesencephalon

Rhombencephalon Myelencephalon
] Rhombencephalon

Spinal cord

Fig. 5.9 Components of neural tube Fig. 5.11 Differentiation of 3 components of developing brainstem

5 sets of branches of basilar artery:
1. Pontine arteries
2. Labyrinthine artery
3. Anterior inferior cerebellar artery
4. Superior cerebellar artery
5. Posterior cerebral artery.
Embryological Background of Brainstem
Internal structure of brainstem is not only important,
it is very interesting. For its better understanding,
a reader must have a basic concept of embryological
background of brainstem.
Three components of brainstem, midbrain,
pons and mudulla oblongata develop from two of
three brains vesicles. These are midbrain vesicle
(mesencephalon) and hindbrain vesicle (rhomben-
cephalon) (Figs 5.9 and 5.10).
Rhombencephalon is further divided into proximal
metencephalon and distal myelencephalon (Fig. 5.11).
Pons is developed from ventral part of metence-
phalon, dorsal part forming cerebellum. Medulla
oblongata is developed from myelencephalon. Prox-
imal part of myelencephalon, which is adjacent to
pons is wider and, in due course of time, will follow
the developmental characteristics as that of pons (see
below). Distal part of myelencephalon, adjacent to
spinal cord will remain narrower and in future will
show structural pattern more like spinal cord. So, mid-
brain and hindbrain vesicles are differentiated into
following four parts (Fig. 5.12).
1. Mesencephalon will form midbrain
2. Ventral part of
Metencephalon will form pons
3. Proximal part of
Myelencephalon will form upper wider part of
medulla oblongata
4. Distal part of
Myelencephalon will form lower narrower part
of medulla oblongata

Neuroectodermal lining 1 Neuroectodermal lining

Mesencephalon (midbrain)
Midbrain vesicle
2
Metencephalon (ventral
Hindbrain vesicle part to form pons)
3 Upper wider part

4 ] Myelencephalon
Lower narrower part (medulla oblongata)

Spinal cord

Fig. 5.10 Caudal two components of 3 brain vesicles to from Fig. 5.12 Differentiation of part of neural tube to form various
future brainstem components of brainstem
100
 Brainstem

Alar lamina (alar plate)

Ependymal layer

Mantle zone formed by

Basal lamina (basal plate)
nerve cells

Marginal zone formed

by nerve fibers

Fig. 5.13 Formation of mantle zone and marginal zone due to proliferation of neuroectoderm layer of cells, which remains as ependymal layer

But all these four components of primitive brain-
stem will follow the common (similar) embryological
steps as follows:
1. Initially, all components will be lined by single
layer of neuroectodermal cells (Fig. 5.12).
2. Cells of this single layer proliferate by mitosis.
The newer cells (daughter cells) are pushed to the
periphery and form a definite layer called mantle
zone (Fig. 5.13).
Two different types of cells, neuroblasts and
spongioblasts in mantle zone will form neurons
and neuroglia (macroglia) respectively.
3. Original lining cells will form outline of the cavity
of these parts of neural tube, called ependymal
cells.
4. The processes of developing neurons in the mantle
zone will be pushed to the periphery outside the
mantle zone to form marginal zone (Fig. 5.13).
However, this interrelationship between inner
mantle zone (gray matter) and outer marginal
zone (white matter) will not persist in all the
components of developing brainstem. Ultimately
there will be intermingling of gray and white
matter (see below).
5. Midlines of dorsal and ventral aspects of epen-
dymal layer present roof plate and floor plate
respectively.
6. Each half (right and left) of mantle zone is
divided into dorsal and ventral components by a
linear sulcus called sulcus limitans. Dorsal part
is called alar lamina (alar plate) and ventral part
is called basal lamina (basal plate). Neurons
of alar lamina will be sensory in function and
those of basal lamina will be motor in function
(Fig. 5.14).

Alar plate Roof plate

Central canal Sulcus limitans

Floor plate
Basal plate
Midbrain

Pons

Upper wider part of

medulla oblongata

Lower narrower part of

medulla oblongata

Fig. 5.14 Developing brainstem showing its components

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Alar lamina (dorsolateral)
Basal lamina (ventromedial)
Pons developing from ventral part of
metencephalon
Upper part of medulla oblongata
Fig. 5.15 Pons and upper wider part of medulla oblongata show stretching of roof plate
Dissimilarity in Development in Different
Components of Brainstem
l Mesencephalon (midbrain) remains compara-
tively stunted in growth, thus remaining as short
segment of brainstem. Its central cavity becomes
very narrow to be named as aqueduct of Sylvius.
Alar lamina is dorsal and basal lamina is ventral in
position (Fig. 5.16).
l Caudal or lower part of myelencephalon (medulla
oblongata), continuous below with spinal cord remain
narrow and tubular like spinal cord. Its central canal
becomes narrow. Alar lamina and basal lamina are
related dorsoventrally (Fig. 5.16).
l Metencephalon (pons) and proximal or upper
part of myelencephalon (medulla oblongata) show
following changes (Figs 5.15 and 5.17).
a) Roof plate is stretched outwards on both side.
b) That is why cavity of this part of neural tube
(pons and upper part of medulla oblongata) is
widened which will form 4th ventricle of brain.
c) Dorsal aspect of cavity of 4th ventricle of brain
will be lined only by ependymal layer as a
result of stretching of roof plate.
Alar plate
Mantle zone
{ Basal plate
Fig. 5.16 Similar relationship of differents layers of developing brainstem at the level of midbrain and lower half of medulla oblongata
102
Stretched out roof plate at the level of
pons and upper part of medulla oblongata
Widening of cavity forms 4th
ventricle of brain
Lower narrower part of medulla oblongata
Narrow central canal with dorsoventral
relation of alar and basal laminae
d) Basal and alar laminae are thereby not vent-
rodorsally related. Alar lamina becomes dorso-
lateral to basal lamina.
Organization of Internal Structure at Different
Level of Brainstem
Central cavity of brainstem show different charact-
eristics and names at different level. At lower end of
medulla it is a narrow canal continuous below with
central canal of spinal cord. At the level of pons and
upper half of medulla oblongata, it becomes wide
to form the cavity of 4th ventricle of brain. At the
level of midbrain it is a narrow slit called aqueduct
of Sylvius.
Fundamentally, neurons of basal plate are motor
and those of alar plate are sensory in function. Thro-
ughout the whole length of developing brainstem,
initially, many neurons of both basal as well as alar
plate will form number of continuous columns of cells
which are as follows:
n In basal plate (from medial to lateral) (Fig. 5.18)
1. Somatic efferent
Ependymal layer
Marginal zone
 Brainstem

Rhombic lip grows from alar

plate to form cerebellum

Cavity of hindbrain (4th ventricle)

Sulcus limitans
Dorsolateral alar plate

Ventromedial basal plate

Marginal zone

Fig. 5.17 Relationship of different layers of developing brainstem at the level of pons and upper half of medulla oblongata

Somatic afferent
Alar plate
Special visceral afferent

General visceral afferent

General visceral efferent

Special visceral efferent

Basal plate
Somatic efferent

Fig. 5.18 Cell columns forming cranial nerve nuclei in developing brainstem where central canal is narrow (midbrain and lower half of
medulla oblongata)

2. Branchial efferent (special visceral efferent) in open part, i.e. pons and upper part of medulla
3. General visceral efferent. oblongata (Fig. 5.19).
n In alar plate: From medial to lateral in closed 1. Somatic afferent
part of brainstem, i.e. midbrain and lower end of med- 2. Branchial afferent (special visceral afferent)
ulla oblongata (Fig. 5.18) and, from lateral to medial 3. General visceral afferent.
Stretched out roof plate
(lined by ependyma only) Cavity of 4th ventricle of
brain

Somatic afferent
Alar plate
Special visceral afferent

General visceral afferent

General visceral efferent
Special visceral efferent
Basal plate
Somatic efferent

Fig. 5.19 Cell columns forming cranial nerve nuclei in developing brainstem where roof plate is outstretched widening central canal to
form fourth ventricle of brain (at the level of pons and upper half of medulla oblongata)
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nucleus gracilis
Nucleus cuneatus

Alar plate

Basal plate
} Mantle zone

Marginal zone

Fig. 5.20 Dorsal migration of cells of alar plate of lower closed part of medulla oblongata leads to development of nucleus gracilis and
nucleus cuneatus

Ultimately, neurons of all these columns will
persist in some level and disappear in some level.
So they will no longer be present in the form of
continuous cell column althrough. These cell groups
will form different motor and sensory nuclei of 3rd to
12th (last 10) cranial nerves.
n Migration of neurons of alar lamina: Apart
from formation of sensory (afferent) nuclei of cranial
nerves, neurons of alar plate will migrate from its
original position either ventrally or further dorsally
to form some other named nuclei in different level of
brainstem (described below). This nuclei, as migrated,
will intermingle with the components (white matter)
of marginal zone.
n Derivatives of marginal zone: It is already und-
erstood that, marginal zone is composed of processes
of nerve cells of mantle zone. These processes will
form different groups of bundles of nerve fibers which
are basically of following two types
1. Vertical: These are either ascending (afferent) or
descending (efferent) tracts of nerve fibers conn-
ecting spinal cord with various higher centers.
Basal plate
Alar plate
2. Horizontal: These are fiber bundles connecting
various centers of central nervous system with
cerebellum in both direction, passing through 3
cerebellar peduncles.
n Migration of cells of alar plate to form various
nuclei: As already stated, neurons of alar plate form
various sensory neclei of last 10 pairs (3rd12th) of
cranial nerves. Besides, neurons from alar plate migrate
either ventrally or further dorsally to form various
nuclei in different levels of brainstem as follows.
1. At the level of lower closed part of medulla
oblongata (Fig. 5.20): Cells of alar plate migrate
further dorsally on either side of posterior median
sulcus to form two nuclei.
a) Medial: Nucleus gracilis
b) Lateral: Nucleus cuneatus.
2. At the level of upper half of medulla oblon-
gata: Cells of alar plate migrate ventrally in the
peripheral plane of marginal zone in the form of
following nuclei (Fig. 5.21).
Cavity of hindbrain (4th ventricle)
Ependymal roof

Migration of cells of
alar plate forms

Inferior olivary nucleus

and

Arcuate nucleus

Fig. 5.21 Ventral migration of cells of alar plate in upper half of medulla oblongata forms inferior olivary nucleus and arcuate nucleus
104
 Brainstem
Cavity of hind brain Ependymal roof
(4th ventricle)
Rhombic lip to form
cerebellum

Migration of cells of
alar plate
Alar plate
Mantle zone
{ Basal plate

Pontine nucleus

Marginal zone forming

basilar part of pons

Fig. 5.22 Migration of cells of alar plate of developing pons leads to formation of: VentrallyPontine nucleus DorsallyRhombic lip for
development of cerebellum

a) Medial: Arcuate nucleus, placed ventral to
vertical descending bundle of corticospinal (py-
ramidal) tract fibers.
b) Lateral: Inferior olivary nucleus, placed lateral
to corticospinal (pyramidal) tract fibers.
These nuclei develop from the alar plate cells which
are called bulbopontine extension (caudal part).
3. At the level of pons (Fig. 5.22): The cells of
alar plate at this level migrate in two different
directions:
a) Ventrally: These cells migrate ventrally in the
plane of marginal zone of pons. These are the
cells of cephalic part of bulbopontine extension.
These neurons are present in scattered fashion
intermingled with white matter developed
from marginal zone. This is nucleus pontis or
pontine nucleus.
b) Dorsally: These cells migrate dorsally over the
ependymal lining of 4th ventricle of brain from
both sides which finally fuse together. This is
called rhombic lip. This will form cerebellum.
4. At the level of midbrain (Fig. 5.23): As in
other parts of brainstem, neurons of alar plate
of midbrain form sensory nuclei of some cranial
nerves. Some of the neurons migrate in following
two directions to form specific nuclei of midbrain.
a) Ventrally: These cell groups migrate ventrally
beyond basal plate into marginal zone to
form two nucleiRed nucleus and Substantia
nigra. Red nucleus is present in upper half of
midbrain, whereas substantia nigra extends
throughout its whole length.

Central canal gets narrowed

to form aqueduct of midbrain

Tectum

Alar plate
Mantle zone
{ Basal plate
Migration of cells of
alar plate
Substantia nigra

Red nucleus

Marginal zone

Fig. 5.23 Migration of cells of alar plate in developing midbrain form various nuclei as following, Ventrally = Red nuclens and
substantia nigra, Dorsally = Tectum (nuclei of superior and inferior colliculi)
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Alar plate
{
Mantle
zone
Basal plate
Marginal zone
Fig. 5.24 Neural tube forming spinal cord gives rise to four cell columns. Basal plateSomatic efferent and general visceral efferent,
Alar plateSomatic afferent and general visceral afferent
b) Dorsally: Some of cells of alar plate migrate
further dorsally to form two pairs of bulged
area called superior and inferior colliculi which
form dorsal part of midbrain called tectum.
Cranial Nerve Nuclei in Brainstem
A spinal nerve is formed by union of ventral and
dorsal roots which are functionally motor (efferent)
and sensory (afferent) components respectively. Mo-
tor fibers in the ventral root are of two types, somatic
motor (somatic efferent) and visceral motor (general
visceral efferent) (Fig. 5.24). Somatic efferent fibers
supply skeletal (voluntary) muscles and general
visceral efferent fibers supply smooth (involuntary)
muscles and exocrine glands. Again, sensory fibers
in the dorsal root of spinal nerve are two types
somatic sensory (somatic afferent) and visceral
sensory (general visceral afferent) (Fig. 5.24). Somatic
afferent fibers carry somatic sensations liketouch,
pressure, pain, temperature (exteroceptive) and sense
of position and movements (proprioceptive). General
visceral afferent fibers carry sense of stretch, pain,
distension, compression from the viscera. Cell bodies
of these types of neuronal processes are present in the
form four cell columns in the spinal cord gray matter.
In embryonic period, initially all these columns used
to extend throughout the whole length of developing
spinal cord. Both of the motor or efferent columns
exist in basal plate. Somatic efferent is medial and
general visceral efferent is lateral (Fig. 5.24). Both
the sensory or afferent columns exist in alar plate
of mantle zone throughout whole length of spinal
cord. Somatic afferent column is medial to general
visceral afferent column (Fig. 5.24). But ultimately,
general visceral efferent and general visceral afferent
columns persist only in T1L2 segments (forming
106
First order sensory neurons in
posterior root ganglia developed
from neural crest cells
4. Somatic afferent
3. General
visceral
afferent
2. General visceral
efferent
1. Somatic efferent
sympathetic center) and S2S4 segments (forming
parasympathetic center). But both somatic centers
(efferent and afferent) extend althrough the segments
of spinal cord.
A cranial nerve (3rd12th), unlike the spinal
nerve is not always a mixed nerve. It may be mixed,
motor or sensory. However, a cranial nerve out
of last 10 pairs, may not only contain all the four
functional components as spinal nerve, it may contain
in addition, another two components, one motor and
one sensory. These are called special visceral efferent
(branchial efferent) and special visceral afferent
(branchial afferent).
So, for clear understanding of functional compo-
nents of cranial nerve, background knowledge of
special visceral efferent and special visceral afferent
components is important as well as interesting as
stated below.
In embryonic life, six pairs of mesodermal arches
(branchial arches or pharyngeal arches) embrace
ventrolateral aspects of primitive pharynx. Out
of these six, fifth (5th) arch disappears. Muscular
elements of existing five pairs of branchial arches give
rise to some muscles in the region of head and neck.
All of which are voluntary muscles (but not somatic
muscle). Some of these voluntary muscles are even
related to wall of some viscera like palate, larynx and
pharynx. So these muscles developed from branchial
arch mesoderm, not developed from paraxial mesod-
ermal somites, being voluntary in nature, of which
some related to viscera, are called branchial arch
muscle. These muscles lying in the head and neck
region, need inervation from cranial nerves. So some
of cranial nerves (between 3rd12th), need to have
an additional component to supply branchial arch
muscles which is called branchial efferent or special
visceral efferent.
 Brainstem

Somatic afferent

Alar plate Special visceral afferent

General visceral afferent

General visceral efferent

Basal plate
Special visceral efferent

Somatic efferent

Fig. 5.25 Neural tube forming brainstem (midbrain and lower closed part of medulla) prescents six (3 + 3) columns of cells forming
nuclear components of cranial nerves

Again from some viscera liketongue, soft palate
and upper end of pharyngeal wall, special sense,
liketaste (gustatory) sensation, need to be carried
by special components of some cranial nerves. These
component is called special visceral afferent or
branchial afferent.
So, in comparison to four functional components
of spinal nerve, six functional components of cranial
nerves are the neuronal processes of following six
functional columns of cell groups
3 in basal plate (from medial to lateral) are as
follows (Fig. 5.25):
1. Somatic efferent
2. Special visceral efferent
3. General visceral efferent.
3 in alar plate (from medial to lateral where deve-
loping brainstem is a closed canal, e.g. midbrain and
lower end of medulla oblongata are as follows (Fig. 5.25):
1. Somatic afferent
2. Special visceral afferent
3. General visceral afferent.
In the parts of developing brainstem, where roof
plate is stretched, e.g. pons and upper part of medulla
oblongata, above three afferent columns are related
lateral to medial (Fig. 5.26).

Alar plate Somatic afferent

(Dorsolateral)

Special visceral
afferent

General visceral
afferent

General visceral
efferent
Basal plate Special visceral
(ventromedial) efferent
Somatic efferent

Fig. 5.26 Developing brainstem at the level of pons and upper part of medulla oblongata present six (3 + 3) columns of cells which form
different functional components of cranial nerves
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Functional components of cranial nerve nuclei in dif-
ferent level of brainstem
Before the positions of various nuclei of 3rd12th
cranial nerve in different levels of brainstem is
studied, it is very important to note the following two
points.
i. Somatic afferent columns in developing brainstem
are of two types (Fig. 5.27 inset)
n General somatic afferent column: These cell
groups will form general somatic afferent nuclei which
will receive general somatic sensation liketouch,
pressure, pain and temperature (exteroceptive) and
sense of position and movements from muscles and
joints (proprioceptive).
n Special somatic afferent column: These cell
groups will form special somatic afferent nuclei which
Floor plate Basal plate Sulcus limitans
will receive special somatic sensation likesense of
hearing (exteroceptive) and sense of equilibrium or
balance of body (proprioceptive).
ii. All the 7 cell columns (3 motor and 4 sensory)
will finally not remain continuous althrough the
brainstem. In case of each column, somewhere
the cells will persist and in some level, cells will
disappear or degenerate. So, continuity of the
cells in the columns will be interrupted, leading to
formation of various cranial nerve nuclei.
Location and function of cranial nerve nuclei in
different level of brainstem
Considering stretching of root plate, which results
abduction of alar plate, various functional groups of
cranial nerve nuclei are positioned from medial to
lateral as follows (Fig. 5.27):
Alar plate

Gen som Sp som

aff aff
Som eff Sp visc Gen visc Gen visc Sp visc
eff eff aff aff Ex Prop Ex Prop

3 Mes.N
Midbrain 3
EWN
5
4

5
PSN S
Pons 5 D
6 7 7 SSN 8
5 8 L
9 NTS M
ISN V
9 7 SP.N I Vest.N
12 Coch.N
Medulla 10 NA 9 5
oblongata 10
DN 10 DN 10
11

Spinal cord 11 C2

C5
NTSNucleus tractus solitarius
NA Nucleus ambiguous
PSNPrincipal sensory nucleus
EWN Edinger Westphal nucleus
(superior sensory nucleus) Sulcus limitans
SSN Superior salivatory nucleus
SP.N Spinal nucleus of trigem Nr.
ISN Inferior salivatory nucleus Sp. somatic afferent
Mes N. Mesencephalic nucleus of
DN Dorsal nucleus of vagus
trigem nerve
General somatic
afferent
Sp. visceral afferent
Floor plate Gen. visceral afferent
Gen. visceral efferent
Sp. visceral efferent
Somatic efferent

Fig. 5.27 Functional components of cranial nerve nuclei in brainstem

108

}
1. Somatic efferent
2. Special visceral efferent In the basal plate (between
(Branchial efferent) floor plate and sulcus
3. General visceral efferent limitans)
}
4. General visceral afferent
5. Special visceral afferent In the alar plate (lateral to
6. General somatic afferent sulcus limitans)
7. Special somatic afferent
Somatic efferent nuclei
These are motor nuclei of some of the cranial nerves
which send axons to supply the skeletal muscles
developed from somites of preoccipital and occipital
myotomes.
Muscles developed from preoccipital myotome are
all extrinsic muscles of eyeball, i.e.
i. Levator palpebrae Elevator of upper
superioris eyelid
}
ii. Superior rectus
iii. Inferior rectus
iv. Medial rectus 4 Recti muscles
v. Lateral rectus
vi. Superior oblique
vii. Inferior oblique } 2 Oblique muscles
These extrinsic muscles of eyeball are supplied by
fibers (axons) of following somatic efferent nuclei
1. IIIrd (oculomotor) nerve nucleus: Situated in
upper half midbrain supplies all extrinsic muscles
listed above except
a) Superior oblique
b) Lateral rectus.
2. IVth (trochlear) nerve nucleus: Situated in
lower half of midbrain, supplies superior oblique.
3. VIth (abducent) nerve nucleus: Situated in
lower part of pons, supplies lateral rectus.
Muscles developed from occipital myotome are all
the muscles of tongue except palatoglossus. These mus-
cles are supplied by axonal fibers of
4. XIIth (hypoglossal) nerve nucleus: It is the
nucleus of somatic efferent column and situated
in upper two-thirds of medulla oblongata. Axonal
processes of this nerve supply all muscles of
tongue except palatoglossus, which are developed
from occipital myotome.
All the above four somatic efferent nuclei of
brainstem (IIIrd, IVth, VIth and XIIth nerve nuclei)
are in the line with and homologous to anterior horn
cells of all segments of spinal cord which supply
somatic segmental muscles of body.
Special visceral efferent (Branchial efferent) nuclei
These are the motor nuclei of some of cranial nerves
which, through their axons (outgoing motor fibers)
Brainstem
supply muscles developed from mesoderm of five (1st
to 4th, and 6th) branchial arches.
These nuclei are as follows
1. Vth (trigeminal) nerve nucleus: This is the only
motor nucleus of trigeminal nerve. It is situated
in upper half of pons. Motor fibers (axons) arising
from this nucleus supply all the muscles developed
from 1st branchial arch.
Muscles developed from first branchial arch are 8
in number (4+2+2) which are
4 Muscles of mastication: i) Masseter
ii) Temporalis
iii) Lateral pterygoid
iv) Medial perygoid
2 Tensor muscles: v) Tensor palati (tensor
of soft palate)
vi) Tensor tympani
(tensor of tympanic
membrane of ear)
2 Companion muscles
in neck: vii) Anterior belly of
digastric
viii) Mylohyoid
2. VIIth (facial) nerve nucleus: This motor nuc-
leus of facial nerve is situated in lower half of pons.
Motor fibers (axons) arising from this nucleus are
branchial efferent or special visceral efferent fibers
of facial nerve and these fibers supply muscles
developed from mesoderm of second branchial
arch.
Muscles developed from second branchial arch are
following:
1. Muscles of scalp Occipitofrontalis
2. Extrinsic as well as intrinsic muscles of auricle
3. All muscles of facial expression with platysma
4. A small muscle in middle ear cavity Stapedius
5. Two companion muscles in neck Posterior belly
of digastric and stylohyoid.
3. Nucleus ambiguous: This is a composite nuc-
leus of branchial efferent or special visceral effer-
ent column present in medulla oblongata and
extending upto upper 5 cervical segments of spinal
cord.
Nucleus ambiguous is composed of following 4
parts of which first 3 parts lie in medulla oblongata
and last part lies in spinal cord.
l 1st part: Nucleus of IXth cranial (glossopharyngeal)
nerve. It supplies one muscle developed from 3rd
branchial arch which is stylopharyngeus.
l 2nd part: Nucleus of Xth cranial (vagus) nerve. It
supplies one muscle developed from IVth branchial
arch which is cricothyroid.
l 3rd part: This is the nucleus of XIth cranial (acce-
ssory) nerve. As it lies in medulla oblongata (part
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
of brain), it is called cranial nucleus of accessory
nerve which supplies muscles developed from
mesoderm of 6th branchial arch.
These muscles are
a) All muscles of soft palate except tensor palati
b) All muscles of pharynx except stylopharyngeus
c) All muscles of larynx except cricothyroid.
l 4th part: This part is also nucleus of 11th cranial
(accessory) nerve. It is called spinal nucleus
of accessory nerve as it is formed by central
group of anterior horn cells of first five cervical
segments of spinal cord. This component of
nucleus ambiguous supplies two muscles of neck
named sternomastoid and trapezius which are
also considered to be muscles developed from
mesoderm of 6th branchial arch.
General visceral efferent nuclei
Cranial nerve nuclei of this column of brainstem
form the centers for parasympathetic system in brain
(brainstem).
Cell group of these nuclei send axons (motor fibers)
to i) Smooth muscles and ii) exocrine glands.
These nuclei are following:
1. Edinger-Westphal nucleus: This is general visc-
eral efferent nucleus of IIIrd cranial (oculomotor)
nerve. Axons of this nucleus supply two smooth
muscles of eyeball Ciliaris and sphincter pupillae.
Being the part of oculomotor nerve nucleus, it is
situated in upper part of midbrain.
2. Superior salivatory nucleus:
n It is the general visceral efferent nucleus of VIIth
cranial (facial) nerve. This nucleus is so called as
it gives fibers which supply secretomotor fibers
to the two out of three salivary glands. These are
submandibular and sublingual glands.
n This nucleus has a component called lacrimatory
nucleus which gives out secretomotor fibers to lacri-
mal gland.
n Preganglionic secretomotor fibers for mucous
glands of palate, nasal cavity and upper part of
pharynx also arise from this nucleus.
Superior salivatory nucleus is situated in lower
part of pons.
3. Inferior salivatory nucleus: It is situated in upper
part of medulla oblongata. This general visceral
efferent nucleus supplies secretomotor fibers to
another salivary gland, i.e. parotid gland.It is the
nucleus of IXth cranial (glossopharyngeal) nerve.
4. Dorsal nucleus of vagus: This is the general
visceral efferent nucleus of Xth cranial (vagus)
nerve. It is situated in lower part of medulla oblon-
gata. Vagus nerve is a very long cranial nerve
having extensive course in head and neck, thorax
and abdomen. Through this nerve, fibers from
dorsal nucleus of vagus are distributed to
110
i. Smooth muscles of tracheobronchial tree.
ii. Smooth muscles (myocardium) of heart.
iii. Smooth muscles of gut (foregut and midgut)
upto right two-thirds of transverse colon.
iv. Mucous glands of tracheobronchial tree and
above mentioned parts of gut.
General visceral afferent nucleus
Nucleus of this column of brainstem receives incom-
ing nerve fibers which carry general sensation from
viscera, e.g. sensation of pain (due to ischemia),
stretch, distension or compression.
In this column there is one and only one nucleus
which is dorsal nucleus of vagus (sensory component).
Dorsal nucleus of vagus nerve is a composite nucleus
which is composed of a motor and a sensory part. It
lies in the lower part of medulla oblongata. Sensory
part of dorsal nucleus of vagus nerve receives
incoming sensory fibers of vagus nerve which carry
visceral sensations as stated above from wall of
tracheobronchial tree and, gastrointestinal tract upto
right two-thirds of transverse colon.
Special visceral afferent nucleus
Nucleus of cranial nerve of this column receives
incoming sensory (afferent) fibers which carry special
sensation from the viscera, e.g. tongue, palate and
upper part of pharynx, that is taste.
In this column there is only one composite nucleus
which is named
n Nucleus tractus solitarius: It is a composite
nucleus of special visceral afferent column situated in
medulla oblongata. This nucleus is composed of three
parts as follows
l Upper part: It is the nucleus of seventh cranial
(facial) nerve which receives the incoming sensory
fibers carrying taste sensation from anterior two-
thirds of tongue soft palate and upper part of pharynx.
l Middle part: It is the nucleus of ninth cranial
(glossopharyngeal) nerve which receives the incoming
sensory fibers carrying taste sensation from posterior
one-third of tongue.
l Lower part: It is the nucleus of tenth cranial (va-
gus) nerve which receives the incoming sensory fibers
carrying taste sensation from posterior most part of
tongue, vallecula and epiglottis.
General somatic afferent nuclei
Sensory nuclei of cranial nerves of this group receive
general somatic sensations from the area of face
including forehead.

General somatic sensations are of two types, which
are carried to the respective nuclei. They are
Exteroceptive Proprioceptive
This nucleus receives This nucleus
exteroceptive receives proprioceptive
sensations from the sensations from some
area of face which muscles and joints
are touch, pressure, in the area of head
pain and temperature. which are
i. Muscles of
mastication
ii. Muscles of eyeball
iii. Muscles of facial
expression
iv. Roots of teeth
v. Temporomandibular
joint.
Both the above types are sensory nuclei of Vth
cranial (trigeminal) nerve.
Names of these general somatic afferent nuclei of
trigeminal nerve are
Brainstem
ceptive sensations from muscles of mastication,
muscles of eyeball, muscles of face, roots of teeth and
temporomandibular joint.
n Special point to note: Cells of mesencephalic
nucleus posses a special characteristic. In case of
all other sensory pathway, cell bodies of 1st order of
neuron lie outside the central nervous system and
their central processes enter the central nervous
system to relay in second order of neurons which
constitute the corresponding sensory nucleus. But
mesencephalic nucleus of trigeminal nerve is made
up of cell bodies of 1st order of sensory neurons lying
inside the central nervous system which carries
proprioceptive sensation from the end organs as
stated above.
Special somatic afferent nuclei
Nuclei of this group of cranial nerve receive sensory
fibers which carry special somatic sensation.
All these nuclei are situated in pontomedullary
junction.
All of these are nuclei of VIIIth cranial (vestibulo-

}
i. Nucleus of spinal tract of trigeminal nerve Exteroceptive cochlear) nerve.
nuclei These nuclei are of following two groups:
ii. Superior (principal) sensory nucleus
iii. Mesencephalic nucleus of trigeminal nerve
Proprioceptive nucleus Exteroceptive Proprioceptive
In the brainstem these three nuclei are as follows Dorsal and ventral Four vestibular nuclei
from below upwards. cochlear nuclei. named superior,
1. Nucleus of spinal tract of trigeminal nerve These nuclei receive inferior, lateral and
(Spinal nucleus of trigeminal nerve) incoming fibers medial vestibular nuclei.
This nucleus presents three components: of cochlear part of These nuclei receive
i. Middle or main component: Extends throughout vestibulocochlear incoming fibers of
the whole length of medulla oblongata nerve which carry vestibular part of
ii. Upper end: Extends into lower end of pons sense of hearing vestibulocochlear nerve
iii. Lower end: Continued in upper two cervical (cochlear sensation). which carry sense of
segments (C1, C2) of spinal cord. equilibrium (balance).
Nucleus of spinal tract of trigeminal nerve receives n Important guideline: While studying IIIrd
all the incoming sensory (afferent) fibers of trigeminal XIIth (last 10) cranial nerves in the chapter of cranial
nerve which carry pain and temperature sensations
nerve, a reader must consult the text, as well as
from same side of whole area of face.
figures of the following components of the chapter of
2. Superior (principal) sensory nucleus of trige-
Brainstem as described here.
minal nerve
This nucleus is situated in pons. i. Embryological background of brainstem.
Superior sensory nucleus receives all the incoming ii. Functional components of cranial nerve nuclei
sensory (afferent) fibers of trigeminal nerve which in different level of brainstem.
carry touch and pressure sensations from same half Reader must develop a clear concept on Figure
of the whole area of face. no. 5.27. He/she must practice drawing of this figure
3. Mesencephalic nucleus of trigeminal nerve again and again till to have a confidence to draw the
It is so named because this nucleus is situated in same from memory without any help.
midbrain (mesencephalon). Reader must study the Figure no. 5.27 to find the
Mesencephalic nucleus of trigeminal nerve is the answers of following questions:
proprioceptive sensory nucleus. It receives incoming i. What are the types of IIIrdXIIth cranial nerve
sensory fibers of trigeminal nerve which carry proprio- motor, sensory or mixed?
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
ii. What are the functional components of the
cranial nerves, from IIIrdXIIth?
iii. What are the cranial nerve nuclei in a
particular functional column?
For example: Somatic efferent column present
nuclei of IIIrd, IVth, VIth and XIIth cranial
nerve.
iv. What are the motor nuclei (nuclei in the basal
plate) and what are the sensory nuclei (nuclei
in alar plate)?
v. What are the cranial nerve nuclei present in
each of the three segments of brainstem? i.e.
in midbrain, pons and medulla oblongata.
For example: In midbrain lies somatic efferent
nuclei of IIIrd and IVth cranial nerve, general
visceral efferent nucleus of IIIrd nerve (EWN)
and somatic afferent nucleus (mesencephalic
nucleus) of Vth cranial nerve.
vi. What are the motor and/or sensory components
of a cranial nerve, from IIIrd to XIIth?
Internal Structures of Brainstem
n Fundamental points: Internal structure will be
crystal-clear to a reader if one goes thoroughly with
the previous parts of chapter of Brainstem.
Internal structure of brainstem, at any level,
shows intermingling of gray matter and white
matter unlike spinal cord, cerebellum and cerebrum.
It may be remembered, in spinal cord, white matter
is peripheral and gray matter is central, whereas
in cerebellum as well as cerebrum, arrangement is
reverse.
Any level of brainstem shows following components
of internal structure
1. White matter:
a) Vertical fibers two types
i. Ascending (Afferent): Passing from a lower
center to a higher center.
ii. Descending (Efferent): Passing from a higher
center to a lower center.
b) Horizontal fibers: In each of the three components
of brainstem, passing horizontally through respe-
ctive cerebellar peduncles, e.g.
i. In midbrain: Passing through superior cere-
bellar peduncle.
ii. In pons: Passing through middle cerebellar
peduncle.
iii. In medulla oblongata: Passing through inferior
cerebellar peduncle.
2. Gray matter: It is present in the form of following
two varieties of nuclei
a) Various named nuclei of brainstem: These are cell
stations of ascending or descending tracts passing
through the brainstem. These are developed from
112
cells of alar plate. Many of them are migrated
from their original position ventrally to the region
of basal plate, e.g. olivary nucleus of medulla
oblongata. Some of these are migrated further
dorsally, e.g. tectum of midbrain.
b) Cranial nerve nuclei (IIIrdXIIth): Motor nuclei
of these cranial nerves are developed from cells of
basal plate and the cells of alar plate give rise to
sensory nuclei.
Internal Structure of Medulla Oblongata
Internal structure of medulla oblongata is studied in
following three levels (Fig. 5.28)
1. At the lower end of medulla oblongata: Below the
bulge of pyramid, where decussation of motor
fibers of pyramidal tract (corticospinal tract),
passing through the pyramid, takes place (at the
plane of motor decussation).
2. Above the middle of medulla oblongata, at the level
of middle of bulge of pyramid. At this level sensory
fibers from nucleus gracilis and nucleus cuneatus
decussate before these sensory tracts pass further
upwards (At the plane of sensory decussation).
3. At the upper end of medulla oblongata, close to
pontomedullary junction.
Medulla oblongata at its lower end (at the plane of
motor decussation) (Fig. 5.29)
Structural characteristics
1. At this level structure of medulla oblongata is
almost similar to the structure of spinal cord, with
centrally positioned gray matter and peripheral
white matter.
2. Ventral horn of gray matter gets separated from
main mass due to decussation of pyramidal tract fib-
ers which pass backwards and laterally to approach
lateral white column before passing downwards to
the spinal cord.
7 Level of superior colliculus
6 Level of inferior colliculus
5 Upper half of pons
4 Lower half of pons
3 At upper end of medulla oblongata
2 At the level of pyramid
1 Lower end of medulla
oblongata
Fig. 5.28 Different level of brainstem to study internal structure

Reticular formation
Decussating fibers
of lower end of
pyramid form lateral
corticospinal tract
Lateral spinothalamic tract
Anterior spinothalamic tract
Fig. 5.29 Internal structure of lower end of medulla oblongata (below pyramidal elevation at the level of motor decussation)
Structural detail
n Gray matter:
1. Central gray matter is traversed by more dorsally
pushed central canal lined by ependyma.
2. Apex of posterior horn of spinal cord is represented
at this level by nucleus of spinal tract of trigeminal
nerve. On either side it is directed backwards and
laterally with further abduction.
3. Medial to nucleus of spinal tract of trigeminal
nerve, gray matter shows, on either side, two small
bulge of gray matter, nucleus gracilis (medial) and
nucleus cuneatus (lateral) which receive the fibers
of fasciculus gracilis and fasciculus cuneatus
respectively, which are the ascending tracts in
posterior column of white matter.
4. Anterior gray horn becomes detached from main
mass of gray matter by decussating fibers of corti-
cospinal (pyramidal) tract.
Topographically, cells of anterior horn is a part of
gray matter of medulla oblongata. But functionally,
these are upwards continuation of cells of anterior
horn of upper cervical segments of spinal cord. These
cells form following two nuclei.
a) Supraspinal nucleus of first cervical nerve: It
is the upward continuation of anterior horn
cells of first cervical segments of spinal cord.
Axons of these neurons pass downward and
are distributed along the ventral root of first
cervical nerve.
b) Ascending nucleus: It is the upward contin-
uation of spinal nucleus of accessory nerve
which is continuous below up to fifth cervical
segment of spinal cord. Above it is continuous
with nucleus ambiguous.
Brainstem
Nucleus gracilis appears
deep to fasciculus gracilis
Nucleus cuneatus appears
deep to fasciculus cuneatus
Spinal nucleus and spinal
tract of trigeminal nerve
Dorsal spinocerebellar
tract
Ventral spinocerebellar
tract
Detached anterior
grey horn
n White matter: Pattern of three white columns
(funiculi) of spinal cord, namely anterior, lateral and
posterior, is grossly maintained.
1. Anterior column: On either side of ventral median
fissure, area of anterior white column mainly pres-
ents the bundle of pyramidal tract fibers which
shows decussation of fibers at this level.
Through anterior column, also traverse tectospinal
tract, vestibulospinal tract, anterior spinothalamic tract.
2. Lateral Column:
a) Peripherally: Dorsal and ventral spinocereb-
ellar tracts.
b) Centrally: i) Lateral corticospinal tract which
is formed at this level after decussation of
fibers of pyramid.
ii) At the center of lateral white column, a
scattered group of nerve cells intermingled
with nerve fibers form brainstem reticular
formation.
iii) Lateral spinothalamic tract.
3. Posterior column: It present upward continua-
tion of fasciculus gracilis and fasciculus cuneatus
of posterior white column of spinal cord. As
already mentioned earlier, these two tracts will
relay in next order of neurons in nucleus gracilis
and nucleus cuneatus which are seen to appear
at this level of medulla oblongata, ventral to the
corresponding tracts.
Medulla oblongata at its middle (at the plane of
sensory decussation) (Fig. 5.30)
Structural characteristics
1. There is no more existance of gray matter area
which is homologous to anterior horn.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nucleus tractus solitarius
Dorsal nucleus of vagus
Dorsal spinocerebellar
tract
Hypoglossal
nerve nucleus
Medial longitudinal
fasciculus
Ventral spino-
cerebellar tract
Medial lemniscus
Fig. 5.30 Internal structure of medulla oblongata at the level of sensory decussation
2. Gray matter of posterior horn presenting nucleus
gracilis, nucleus cuneatus and spinal nucleus
of trigmenial nerve gets detached from central
gray matter. This detachment is because of the
arched fibers arising from nucleus gracilis and
nucleus cuneatus which decussate ventrally to
form ascending fiber tract which is called medial
lemniscus.
3. Central canal surrounded by central gray matter
is pushed more dorsally. Central gray matter
presents appearance of cranial nerve nuclei.
4. It is the plane of medulla oblongata from where
upward typical relationship of central gray ma-
tter and peripheral white matter of spinal cord
is lost. It results intermingling of gray and white
matters.
Structural details
1. On either side of ventral median fissure bulge of
pyramid presents sections through descending
(efferent) fibers of pyramidal (corticospinal) tract.
2. Lateral to fibers of pyramid, inferior olivary nucl-
eus starts appearing. It looks like a small irregular-
walled sac whose cavity opens backwards and
medially.
Inferior olivary nucleus is the most prominent
part of olivary nuclear complex of human brain.
Rudimentary components are dorsal and medial oliv-
ary nuclei which together are known as accessory
olivary nuclei.
3. Ascending (afferent) tracts, e.g. dorsal and ventral
spinocerebellar tracts, lateral and anterior spino-
114
Internal arcuate fibers
from nucleus gracilis
Spinal nucleus
and spinal tract of
trigeminal nerve
Internal arcuate
fibers from nucleus
cuneatus
Lateral
spinothalamic tract
Reticular formation
Inferior olivary nucleus
Medial lemniscus
Pyramid
thalamic tracts are found to be in corresponding
positions as noticed in previous section of medulla
oblongata.
4. Nucleus gracilis and nucleus cuneatus are seen to
be more prominent in this section. These nuclei
receive fibers from fasciculus gracilis and fasciculus
cuneatus which carry conscious proprioceptive
sensation and sense of tactile discrimination from
lower and upper halves of body respectively.
5. Dorsolateral to nucleus cuneatus, a smaller
accessory cuneate nucleus is seen. It receives
fibers of fasciculus cuneatus which carry same
sensations from uppermost part (head-end) of
body. Cuneocerebellar tract from this nucleus end
in cerebellum as spinocerebellar pathway above T1
spinal cord segment.
6. Central core of the section presents scattered
nerve cells and reticulum (network) of fibers to
form brainstem reticular formation.
7. Posterior gray horn separated from central gray
matter is represented by spinal nucleus of trige-
minal nerve which is capped on the surface by
fibers of sensory root of trigeminal nerve carrying
pain and temperature sensation, called spinal
tract of trigeminal nerve.
Nucleus gracilis and nucleus cuneatus are the
medial and lateral mass of gray matter on either
side of posterior median septum. These are also the
components of posterior gray horn which are detached
from central gray matter.
Reason for separation of spinal nucleus of trige-
minal nerve, nucleus gracilis and nucleus cune-
atus from central gray matter is due to following

characteristic of structure of medulla oblongata at
this level.
Fasciculus gracilis and fasciculus cuneatus are the
two ascending tracts of posterior column of spinal cord
which carry sense of conscious proprioception and
tactile discrimination from lower and upper halves
of body respectively. Reaching the medulla oblongata
upto this level, fibers of these two tracts relay in
corresponding nuclei lying ventrally. Processes of
next order of neurons in nucleus gracilis and nucleus
cuneatus, before ascending further upwards to relay
in thalamus, decussate to cross the midline. During
decussation, these fibers presents following three
characteristics.
1. Fibers of both nucleus gracilis and nucleus cune-
atus pass forwards arching along the lateral
aspect of central gray matter horizontally in a
curved fashion that is why they are called internal
arcuate fibers.
2. After decussation, the fibers form a compact bundle
just behind the bulge of pyramid, before this compact
bundle of fibers ascend upwards to reach thalamus.
This bundle is known as medial lemniscus (Plural
Lemnisci).
3. During formation of medial lemnisci, fibers from
nucleus gracilis (carrying sensations from lower
half of body) are positioned anterior to the fibers
from nucleus cuneatus (carrying sensation from
upper half of body).
Behind medial lemniscus, pass tectospinal tract
medial longitudinal fasciculus.
n Central gray matter: It encircles the central
canal of medulla oblongata which is pushed more
posteriorly. It presents following cranial nerve nuclei
which are interrelated ventrolaterally.
Dorsal nucleus of vagus
Hypoglossal nerve nucleus
Nucleus tractus solitarius
Nucleus ambiguous
Medial longitudinal fasciculus
Reticular formation
Lateral spthalamic tract
Medial lemniscus
Hypoglossal nerve
Pyramidal tract
Arcuate nucleus
Fig. 5.31 Internal structure of medulla oblongata at the level of olive
Brainstem
i. Hypoglossal nerve nucleus (XII): It is the
nucleus of somatic efferent column, lying
ventral to central canal of medulla oblongata.
ii. Nucleus ambiguous (IX, X, XI): It is the nuc-
leus of special visceral efferent column, lying
ventrolateral to central canal of medulla
oblongata.
iii. Dorsal nucleus of vagus (X): It is the nucleus
having both general visceral efferent as well
as general visceral afferent components, lying
ventrolateral to central canal.
iv. Nucleus tractus solitarius (VII, IX, X): It is the
nucleus of special visceral afferent column,
lying lateral to central canal.
Medulla oblongata at the level of olive (close to pon-
tomedullary junction) Fig. 5.31
Structural characteristics
1. Stretching of roof plate at this plane of medulla
oblongata in embryonic life causes outward
deviation (abduction) of alar plate. This results
widening of central canal to form cavity of fourth
ventricle. Stretched dorsal surface of medulla
oblongata forms floor of fourth ventricle.
2. Central gray matter presenting the cranial nerve
nuclei pushed more dorsally to lie just beneath the
dorsal surface of medulla oblongata.
3. Fibers from medulla oblongata which will connect
cerebellum will form compact bundle of inferior
cerebellar peduncle seen to be present in poste-
rolateral part.
4. Bulge of olive containing inferior olivary nucleus
is related to anterolateral and posterolateral sulci
on it medial and lateral sides respectively.
Tectospinal tract
Vestibular nucleus
Dorsal cochlear nucleus
Inferior cerebellar peduncle
Ventral cochlear nucleus
Dorsal spinocerebellar tract
Spinal nucleus and spinal
tract of trigeminal nerve
Parolivary nuclei
Vagus nerve
Inferior olivary nucleus
115
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Structural detail
1. On either side of ventral median fissure, beneath
the bulge of pyramid, fibers of pyramidal (cortic-
ospinal) tract from compact bundle.
2. Ventromedial surface of pyramid presents a nar-
row semilunar strip of gray matter, called arcute
nucleus. It is the detached part of pontine nuclei.
3. Lateral to pyramid, bulge of olive contains inferior
olivary nucleus. It is irregular walled sac-like
mass of gray matter. Open mouth of the sac faces
medially and backwards.
Adjacent to inferior olivary nucleus, medial and
dorsal components of assessory olivary nucleus are
seen.
4. Dorsolateral aspect of medulla oblongata at
this level presents bulge of inferior cerebellar
peduncle. It is a compact bundle of white matter
connecting medulla oblongata with cerebellum in
both directions.
5. Different fiber tracts in central core
a) Medial: From before backwards close to the
midline
i. Medial lemniscus: Formed by internal arcu-
ate fibers, situated behind pyramid. This
ascending tract passes upwards to reach
thalamus.
ii. Tectospinal tract: Descending tract from
tectum of midbrain to spinal cord.
iii. Medial longitudinal bundle: It is the fiber
bundle connecting vestibular nucleus with
motor nuclei of IIIrd, IVth, VIth and XIth
cranial nerves.
b) Lateral: Important ascending tracts passing
from below upward
i. Ventral and dorsal spinocerebellar tracts.
ii. Ventral and lateral spinothalamic tracts.
iii. Spinal tract of trigeminal nerve.
6. Medullary part of brainstem reticular formation:
Scattered nerve nuclei with reticulum (network)
of fibers.
7. Cranial nerve nuclei (in central gray matter):
Beneath the dorsal surface of medulla oblongata
i. Hypoglossal nerve nucleus: Situated on either
side of midline, just beneath the dorsal surface
(on the floor of 4th ventricle) and behind medial
longitudinal bundle.
This is the somatic efferent nucleus which gives
out fibers of hypoglossal nerve to supply muscles of
tongue developed from occipital myotome. Intraneural
(intramedullary) part of hypoglossal nerve pass from
behind forward through whole depth of medulla
oblongata between pyramid and medial lemniscus me-
116
dially and inferior olivary nucleus laterally. Finally
the nerve comes out in the form of multiple rootlets
through anterolateral sulcus.
ii. Dorsal nucleus of vagus: This nucleus is situ-
ated lateral to hypoglossal nerve nucleus. It is a
mixed nucleus having general visceral efferent
as well as afferent components which supply
motor, secretomotor and sensory fibers to thor-
acic and abdominal viscera (upto midgut).
iii. Nucleus tractus solitarius: This is a composite
nucleus of special visceral afferent column. It
is ventrolateral to dorsal nucleus of vagus and
receives taste sensation through sensory fibers
of VIIth, IXth and Xth cranial nerves from
anterior two-third and posterior one-third of
tongue and also vallecula and epiglottis.
It is important as well as interesting to note
here that nucleus tractus solitarius also receives
general visceral afferent fibers through vagus nerve
which caries visceral sensation from thoracic and
abdominal viscera (upto midgut).
iv. Nucleus ambiguous: This nucleus is placed
more ventrally. This is also a composite nucl-
eus of special visceral efferent group which
gives out motor fibers through IXth to XIth
cranial nerves to supply muscles developed
from mesoderm of IIIrd, IVth and VIth
branchial arch respectively.
It is already understood that two composite
nuclei, namely nucleus tractus solitarius and nucleus
ambiguous are made up of components belonging to
multiple cranial nerves. The former is made up of
nuclei of VIIth, IXth and Xth and the later is formed
by nuclei of IXth, Xth and XIth cranial nerve. It is
also important to remember at this stage that these
nerves come out of brainstem through different sites.
Figure 5.31 shows the fibers of vagus nerve which is
made up of following components coming out from
respective nuclei.
l General visceral efferent: From motor part of
dorsal nucleus.
l General visceral afferent: From sensory part of
dorsal nucleus.
l Special visceral afferent: From nucleus tractus
solitarius.
l Special visceral efferent: From nucleus ambiguous.
The fibers of vagus nerve are seen to come out
through posterolateral sulcus between olive and
inferior cerebellar peduncle.
v. Vestibular nucleus of VIIIth cranial nerve:
It is proprioceptive type of special somatic
afferent nucleus of vestibulocochlear nerve. It

is present in lateral angle of dorsal surface of
pontomedullary junction. Vestibular nucleus
is made up of four partssuperior, inferior,
lateral and medial.
vi. Cochlear nucleus of VIIIth cranial nerve: It is
exteroceptive type of special somatic afferent
nucleus of vestibulocochlear nerve. It is
composed of dorsal and ventral components in
close relation to inferior cerebellar peduncle.
vii. Spinal nucleus (and spinal tract) of trigeminal
nerve: It is situated medial to inferior cerebellar
peduncle. Spinal tract is made up of bundles of
those sensory fibers of trigeminal nerve which
carry pain and temperature sensation from
the skin of face. The fibers of spinal tract relay
in cells of spinal nucleus of trigeminal nerve.
Internal Structure of Pons (Figs 5.32 and 5.33)
Throughout the whole length, internal structure of
pons is broadly composed of two parts.
Ventral Basilar part
Dorsal Tegmental part.
Structural characteristics
Basilar part
It presents similar features throughout its whole len-
gth.
The basilar part contains both gray matter as well
as white matters as follows:
i. Gray matter: It is scattered cluster of nerve
cells called pontine nuclei which intermingles
with fibers of white matter. Neurons of pontine
nuclei are as many as 20 millions in number
which is the reason for ventral bulging of
basilar part.
ii. White matter: Made up of two types of fibers
a) Vertical: Fibers of descending (motor) tracts
b) Horizontal: Fibers of pontine nuclei passing
through middle cerebellar peduncle to the
opposite half of cerebellum.
Tegmental part
Unlike the basilar part, it presents different features
in lower and upper halves of pons.
Fundamentally, in both the levels, tegmentum of
pons shows following structure
i. Gray matter: Nuclei of cranial nerves
ii. White matter: a) Ascending tracts as well as
b) some descending tracts.
Structural Details
Internal structure of pons is studied under the
following 3 headings (Figs 5.32 and 5.33):
Brainstem
1. Basilar part (identical structure in both lower as
well as upper levels)
2. Tegmental part in lower half
3. Tegmental part in upper half.
Basilar part (Figs 5.32 and 5.33)
As already stated, basilar part of pons presents
similar feature at all levels as follows.
n Gray matter: This is present in the form of
multiple, small-sized scattered masses, intermingled
with white matter, called pontine nuclei. This is
developed from ventrally migrated cells of alar plate.
Fibers from all the lobes of cerebral cortex (cortico-
pontine tracts) relay in pontine nuclei of same side.
Axons of pontine nuclei cross the midline and pass
through opposite middle cerebellar peduncle to the
contralateral cerebellar hemisphere to complete cort-
icopontocerebellar tract.
At the time of development of brainstem, some of
the cells of pontine nuclei migrate caudally towards
ventral aspect of medulla oblongata to form arcuate
nuclei.
n White matter: These are fiber tracts of following
two kinds
1. Vertical: Descending or motor (efferent) tracts
a) Corticospinal tract: Goes down to pass through
pyramid of medulla oblongata.
b) Corticonuclear (Corticobulbar) tract: To relay
in contralateral motor nuclei of cranial nerves
present in pons and medulla oblongata.
c) Corticopontine tract: It passes from cerebral
cortex to same sided pontine nuclei.
2. Horizontal: These are decussating fibers of ponto-
cerebellar tract which pass horizontally to pass
through the middle cerebellar peduncle to opposite
half of cerebellum.
Tegmental part at lower half of pons (Fig. 5.32)
n Gray matter: Some cranial nerve nuclei and
nuclei of pontine part reticular formation.
l Abducent nerve nucleus: It is the nucleus of somatic
efferent group. Fibers of abducent (VIth cranial)
nerve arising from this nucleus supply lateral rectus
muscle of eyeball which is developed from preoccipital
myotome of paraaxial mesoderm. This nucleus is situ-
ated deep to a paramedian bulge adjacent to posterior
median sulcus. The bulge is called facial colliculus
because the surface of abducent nucleus is winded by
fibers of facial nerve.
l Motor nucleus of facial nerve: This is the nucleus
of special visceral efferent column which supplies
muscles developed from mesoderm of second branchial
arch.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Motor nucleus of facial nerve
Superior salivatory nucleus
Abducent nerve
nucleus
Lateral lemniscus
Spinal lemniscus
Trigem lemniscus
Medial lemniscus
Trapezoid body
Superior salivatory nucleus Motor nucleus of facial nerve
Fig. 5.32 Transverse section through lower end of pons adjacent to pontomedullary junction
Facial nerve nucleus (nucleus of motor nerve of
face) originally used to be situated in embryonic life,
lateral to abducent nerve nucleus more superficially.
Spinal nucleus of trigeminal nerve, which is sensory
nerve for skin of face, is situated in deeper plane of
tegmentum of pons. To facilitate quicker reflex cont-
raction of facial muscles, facial nerve nucleus moves
deeper to come in close relation to sensory nucleus for
sensation of facial skin, i.e. spinal nucleus of trige-
minal nerve. This becomes possible by elongation
of motor fibers of facial nerve nucleus which winds
round the abducent nerve nucleus. This process is
known as neurobiotaxis.
l Superior salivatory nucleus: It is general visceral
efferent nucleus of facial nerve, situated lateral to
motor nucleus of facial nerve. It has a component
called lacrimatory nucleus. Parasympathetic secre-
tomotor fibers from these nuclei are directed to supply
to submandibular and sublingual salivary glands,
and lacrimal gland.
l Spinal nucleus of trigeminal nerve: This is exte-
roceptive variety of general somatic afferent nucleus
of trigeminal nerve, which receives pain and temp-
erature sensation from skin of face. Though called
spinal nucleus, main part of this nucleus extends
throughout whole length of medulla oblongata. Its
lower end extends upto 2nd cervical segments of
spinal cord and upper end extends to the lower half
of pons. This nucleus is situated in the lateral part of
tegmentum of lower end of pons. It receives sensory
fibers of trigeminal nerve which caps dorsal aspect of
the nucleus to form spinal tract of the nerve.
118
Vestibular nucleus
Medial longitudinal fasciculus Dorsal cochlear
nucleus
Inferior cerebellar
peduncle
Sp. nucl. and sp. tract
of trigeminal nerve
Ventral cochlear
nucleus
Facial nerve
Pontocerebellar
Pontine
nuclei
fibers
Bundles of descending
fibers
} Basilar
part of
pons
Abducent nerve
l Vestibular nucleus of vestibulocochlear nerve:
This is proprioceptive type of special somatic afferent
nucleus of vestibulocochlear nerve. It is composed of
superior, lateral, medial and inferior parts. Vestibular
nucleus is situated partly in lower part of pons and
upper part of medulla. It is placed in superficial plane
at the lateral angle of pontomedullary junction. This
nucleus receives afferent fibers which are nothing
but vestibular fibers of VIIIth cranial nerve carrying
sense of equilibrium or balance. Efferent fibers are
i. Vestibulocerebellar fibers
ii. Vestibulospinal fibers
iii. Medial longitudinal bundle: Which connect vesti-
bular nucleus with nuclei of IIIrd, IVth, VIth and
XIth cranial nerves and anterior horn cells of
upper cervical segments of spinal cord. It causes
reflex movement of eyeball and head and neck in
response to change of position body.
l Cochlear nucleus of vestibulocochlear nerve: It is
exteroceptive type of special somatic afferent nucleus
of cochlear component of vestibulocochlear nerve. It
is made up of dorsal and ventral components lying
dorsal and ventral to inferior cerebellar peduncle
fibers at the level of pontomedullary junction.
n Connections of cochlear nuclei:
l Afferent: Fibers of cochlear component of vesti-
bulocochlear nerve carrying sense of hearing from
receptors (organ of Corti) at internal ear relay in
dorsal and ventral cochlear nuclei.
l Efferent: Axons of cochlear nuclei will have to
reach upto corresponding thalamic nuclei to carry
impulse to sensory area of cerebral cortex. While
ascending through central core of brainstem to reach
the thalamus, at the level of lower end of pons, relay

in a nucleus, called nucleus of trapezoid body. Before
the relay, axons of both dorsal and ventral cochlear
nuclei partly remain in the same side, partly cross
the midline to relay in nucleus of trapezoid body of
opposite side. In horizontal section, the fibers show a
trapezoid shape, for which the decussating and non-
decussating fibers are called trapezoid body, so the
nucleus is also accordingly named.
n White matter:
1. Trapezoid body: Axonal process of dorsal and
ventral cochlear nuclei before ending in thal-
amic level, i.e. in medial geniculate body (metath-
alamus), show following change
Before ascending through upper half of pons
further upwards, fibers pass forwards and medially
towards central tegmentum of midbrain. While doing
so, some fibers may remain in same side, some cross
the opposite side to form a trapezoid outlined area,
called trapezoid body.
In the trapezoid body, fibers relay in nucleus of
trapezoid body.
Then the fibers will run upwards to form lateral
lemniscus.
2. Medial lemniscus: This is a compact bundle of
fibers already formed at the level of medulla as a
continuation of internal arcuate fibers from nucleus
gracilis and nucleus cuneatus, carrying sense
of dirscriminative touch, sense of position and
movement and vibration sense. Medial lemniscus
is situated close to midline, behind basilar part of
pons. Fiber bundle is rotated for 90, wtih fibers
from lower half of body placed medially. So fibers
from upper half are placed laterally.
3. Spinal lemniscus: This compact bundle of fiber is
the continuation of lateral spinothalamic tract.
Axons from trigeminal nucleus form another
Cavity of fourth ventricle
Medial longitudinal bundle
Principal nucleus of V
nerve
Motor nucleus of V nerve
Tectospinal tract
Rubrospinal tract
Middle cerebellar
peduncle
Fig. 5.33 Transverse section through upper end of pons (close to its junction with midbrain)
Brainstem
compact bundle called trigeminal lemniscus which
is placed between medial and spinal lemnisci.
4. Medial longitudinal fasciculus (bundle): It is a
compact bundle of fibers passing through cent-
ral tegmental core of brainstem. These fibers
interconnect nuclei of IIIrd, IVth, VIth and XIth
nerves with vestibular nucleus and anterior
horn cells of upper cervical segments of spinal
cord. Functionally this fasciculus causes reflex
movement of eyeball, head and neck during
alteration of equilibrium or balance of body.
5. Tectospinal tract: It is placed ventral to medial
longitudinal fasciculus.
6. Rubrospinal tract: It lies in front of tectospinal
tract.
These two fiber bundles are extrapyramidal tracts,
in the group of noncorticospinal tract.
7. Spinal tract of trigeminal nerve: These are fiber
bundles which form a cap over the dorsal aspect of
spinal nucleus trigeminal nerve. Spinal nucleus of
trigeminal nerve present along the whole length of
medulla oblongata extends upwards in the lower
end of pons. Spinal tract is made up of incoming
sensory fibers of trigeminal nerve vertically
disposed in brainstem. These fibers relay in the
sensory nuclei of trigeminal nerve. Axons of next
order of neurons, i.e. the sensory nuclei will ascend
upwards as trigeminal lemniscus placed between
medial lemniscus and spinal lemniscus.
8. Inferior cerebellar peduncle: Fibers of middle cere-
bellar peduncle runs horizontally lateralwards
from basilar part of pons. Behind this, cross section
of vertically running fibers of inferior cerebellar
peduncle is seen.
Superior medullary velum
Superior cerebellar peduncle
Lateral lemniscus
Spinal lemniscus
Trigeminal lemniscus
Medial lemniscus
Trigeminal nerve
Bundles of descending
tracts
Pontine nuclei
Decussating pontocerebellar fibers
]
Basilar
part of
pons
119
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Tegmental part at upper half of pons (Fig. 5.33)
Fundamental differences with the lower half of pons
are the following:
1. At the upper end of pons, middle cerebellar
peduncles are passing more obliquely lateralwards
than horizontally. So the fibers of this peduncle
are seen more on cross section than longitudinal,
at lateral side of junction of basilar part and
tegmental part.
2. As upper end of pons approaches towards midbrain
upwards, behind the tegmental part of pons, roof
of fourth ventricle of brain is found to be formed
by thin lamina of white matter called superior
medullary velum extending between medial sides
of two superior cerebellar peduncles.
3. Trapezoid body disappears as the fibers run
vertically upwards forming a compact bundle of
ascending tract called lateral lemniscus.
4. Cranial nerve nuclei seen in lower half of pons
disappear. Motor as well as superior sensory nuclei
of trigeminal nerve are seen to appear.
n Gray matter: Tegmentum of upper half of pons
shows only gray matter in the form of motor and
superior (principal) sensory nuclei of trigeminal
nerve.
1. Motor nucleus of trigeminal nerve: It is the special
visceral efferent or branchial efferent nucleus of
trigeminal nerve situated deep to floor of fourth
ventricle of brain, in the central core. Efferent
fibers from this nucleus supply muscles developed
from mesoderm of first pharyngeal arch.
2. Superior (principal) sensory nucleus of trigeminal
nerve: It is situated lateral to motor nucleus and
continuous below with spinal nucleus of trigeminal
nerve. This nucleus is of general somatic afferent
type and receives touch and pressure sensation
from the skin of face.
Fibers from motor and sensory nuclei of trigeminal
nerve traverse tegmentum forwards and laterally and
comes out as motor and sensory roots of the nerve
at the junction of basilar part of pons and middle
cerebellar peduncle. Motor root is medial to sensory
root.
n White matter:
1. Ascending tracts as lemnisci: Just behind basilar
part of pons, from medial to lateral, pass four
compact bundles of ascending fibers which are
medial lemniscus, trigeminal lemniscus, spinal
lemniscus and lateral lemniscus.
Among these, medial and spinal lemnisci are
already well-developed from a lower level. Trigeminal
lemniscus is made up of fibers of trigemino-thalamic
tract which extends from spinal nucleus of trigeminal
120
nerve to thalamus. Lateral lemniscus is made up of
bundle of fibers which are axonal processes of superior
olivary nucleus and nucleus of trapezoid body. It
forms a part of auditory pathway.
As trapezoid body of lower half of pons is continuous
upwards as vertical bundle of lateral lemniscus, it
disappears at upper half of pons.
2. Other fiber bundles: Beneath the floor of fourth
ventricle, just on either side of midline, following
fiber tracts are existent from behind forwards.
a) Medial longitudinal fasciculus
b) Tectospinal tract
c) Rubrospinal tract.
3. Middle cerebellar peduncle: Internal structure
of upper half of pons, shows fibers of middle
cerebellar peduncle which are more vertically
sectioned, rather than horizontal direction, lateral
to junction of basilar part and tegmental part of
pons.
4. Superior cerebellar peduncle: Dorsolateral part
of section shows fibers of superior cerebellar
peduncles of both sides which are bridged by a thin
lamina of white matter called superior medullary
velum.
Internal Structure of Midbrain
Structural characteristics (Fig. 5.34)
1. A little behind its center, midbrain is traversed by
its narrow central canal, called aqueduct of Sylvius
or cerebral aqueduct. This narrow channel is
lined by ependyma and communicates with third
ventricle above and fourth ventricle below.
2. An imaginary line passing side to side through
cerebral aqueduct bisects interior of midbrain in
smaller posterior part and larger anterior part.
3. Smaller posterior part is known as tectum. Tect-
um is made up of, as seen externally, two pairs of
round elevations. Upper pair, opposite upper half
of midbrain, are called superior colliculi (Sing-
ular colliculus). Lower pair, opposite lower half of
midbrain are accordingly called inferior colliculi.
Each colliculus is a round mass of gray matter.
4. Larger anterior part, in front of cerebral aqueduct,
is known as cerebral peduncle. Cerebral peduncle
is made up of following three components from
before backwards
i. Crus cerebri: Compact bundle of white matter.
ii. Substantia nigra: A strip of pigmented gray
matter.
iii. Tegmentum: Central core of midbrain with
admixture of both gray as well as white matter.
 Brainstem

Tectum

Aqueduct of Sylvius

Tegmentum
Periaqueductal
gray matter

Substantia Cerebral
nigra peduncle

Crus cerebri

Fig. 5.34 Basic structural components of midbrain

5. Therefore, from the above description, it is clear
that, internal structure of midbrain is divided into
following broad based components from before
backwards.
l Descending fibers passing through crus cerebri
are following
1. Corticospinal: From cerebral cortex to anterior
horn cells of spinal cord.
2. Corticobulbar (Corticonuclear): From cerebral

}
i. Crus cerebri
ii. Substantia nigra
In front of cerebral aqueduct
iii. Tegmentum
iv. Tectum (colliculi) Behind cerebral aqueduct
6. Guidelines for study of structural detail
Internal structure of midbrain is studied at two
levels. These are at the levels of superior colliculus
and inferior colliculus.
l Internal structure of anterior two components,
i.e. crus cerebri and substantia nigra is similar on
both levels.
l Internal structure of posterior two components, i.e.
tegmentum and tectum is dissimilar on two levels.
Therefore, structural details of midbrain are to be
studied under following headings.
a) Crus cerebri.
b) Substantia nigra.
c) Tegmentum and tectum of the level of inferior
colliculus.
d) Tegmentum and tectum at the level of superior
colliculus.
Structural details
Crus cerebri (Figs 5.35 and 5.36)
l It extends throughout whole length of midbrain.
It is made up of compact bundle of descending
fibers.
l Right and left halves of crus cerebri are separated
by a midline sulcus on ventral surface of midbrain.
Crus cerebri is related posteriorly to substantia
nigra.
cortex to motor nuclei of cranial nerves.
3. Corticopontine: From all the four lobes of cerebral
cortex to pontine nuclei. These are the fibers of
corticopontocerebellar pathway. These are of four
groupsfrontopontine, parietopontine, occipitopo-
ntine and temporopontine.
Crus cerebri is divided into following three parts
transmitting different types of fibers.
1. Intermediate 3/5th: Corticospinal and cortico-
bulbar (corticonuclear) fibers.
2. Medial 1/5th: Frontopontine group of cortic-
opontine fibers.
3. Lateral 1/5th: Parietopontine, occipitopontine and
temporopontine groups of corticopontine fibers.
Substantia nigra (Figs 5.35 and 5.36)
Substantia nigra is a large mass of gray matter
extending throughout whole length of midbrain.
This nucleus of extrapyramidal system is composed
of medium sized multipolar neurons, cytoplasm of
which is composed of melanin pigment granules.
It is crescent (curved) in shape with cocavity
facing backwards towards tegmentum. It is broader
medially.
Substantia nigra is made up of dorsal and ventral
part. Dorsal part presents smooth, concave posterior
surface and is known as pars compacta, being packed
up with cells. Ventral part is known as pars reticularis
where loosely arranged neurons are intermingled
with reticulum (network) of fibers.
121
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Trochlear nerve nucleus
Exit of trochlear nerve
Reticular nuclei
Lateral lemniscus
Spinal lemniscus
Trigem lemniscus
Medial lemniscus
Decussation of superior
cerebellar peduncle
Substantia nigra
Fig. 5.35 Internal structure of midbrain at the level of inferior colliculus
Melanin pigment granules are polymers of dopa-
mine. Dopamine, released from cell of substantia nig-
ra is transported to corpus striatum (basal ganglia)
through the course of nigrostriate fibers.
Substantia nigra is connected to cerebral cortex,
basal ganglia (corpus striatum), hypothalamus and
spinal cord.
Function of substantia nigra is concerned with
maintenance of muscle tone.
Tegmentum and tectum at the level of
inferior colliculus (Fig. 5.35)
Tegmentum
It is central core of midbrain. It is composed of groups
of neurons in the form of nuclei (gray matter) and
white matter in the form of ascending (afferent) and
descending (efferent) fiber bundles.
n Gray matter (of tegmentum):
1. Periaqueductal gray matter: It contains follo-
wing two cranial nerve nuclei.
l Trochlear nerve nucleus: It is the nucleus of som-
atic efferent column present in periaqueductal gray
matter ventral to cerebral aqueduct behind medial
longitudinal fasciculus. Fibers of trochlear nerve
arising from nucleus winding round lateral aspect of
aqueduct, run backwards and come out of midbrain
from its posterior aspect below inferior colliculus
piercing superior medullary velum where the fibers
decussate.
l Mesencephalic nucleus of trigeminal nerve: It is the
proprioceptive sensory nucleus of trigeminal nerve
present through whole length of midbrain. The nucleus
122
Nucleus of inferior
colliculus
Mesencephalic
nucleus of V nerve
Medial longitudinal
fasciculus
Tectospinal tract
Parietopontine,
occipltopontine and tem-
]
poropontine fibers
Crus cerebri
Corticospinal and
corticonuclear fibers
Frontopontine fibers
is situated lateral to cerebral aqueduct and receives
proprioceptive sensation from muscles of mastication,
temporomandibular joint, roots of teeth, muscles of
eyeball and face.
2. Reticular nuclei: Nuclei of reticular formation
are less prominent than those of pons and medulla
oblongata. These are scattered in the central
tegmental area ventral to periaqueductal gray.
n White matter (of tegmentum):
1. Decussation of fibers of superior cerebellar
peduncle: Ventral spinocerebellar tract is a
crossed tract at the level of formation in spinal
cord. It ascend through the brainstem upto this
level of midbrain as a contralateral tract. But
fibers of this tract will have to cross for the second
time before reaching ipsilateral half of cerebellum.
Decussation of these fibers are present in anterior
most part of tegmentum of midbrain following
which fibers will pass through superior cerebellar
peduncle.
2. Lemnisci: Lateral to decussation of fibers of
superior cerebellar peduncle, all the four lemnisci,
namely medial, trigeminal, spinal and lateral, are
placed medial to lateral in such a curved fashion
that lateral lemniscus is placed posterior to spinal
lemniscus infront of inferior colliculus. It is to be
noted here that fibers of lateral lemniscus will
terminate in inferior colliculus.
3. Medial longitudinal fasciculus: This bundle
of fibers is paramedian in position in front of
periaqueductal gray matter.
4. Tectospinal tract: This descending noncorti-
cospinal tract is placed in front of medial longi-
tudinal fasciculus.

Motor nucleus of oculomotor
nerve
Nucleus of superior
colliculus
Reticular nucleus
Medial longitudinal
fasciculus
Decussation of
tectospinal tract
Red nucleus
Substantia nigra
Decussation of rubrospinal tract
Fig. 5.36 Internal structure of midbrain at the level of superior colliculus
5. Rubrospinal tract: This is another noncorti-
cospinal tract descending in front of tectospinal.
It is placed either in front or behind decussation of
fibers of superior cerebellar peduncle.
n Tectum (inferior colliculus): Beneath this round
bulge, compact mass of neurons forms nucleus
of inferior colliculus. This nucleus forms the cell
station in cochlear pathway. Many of the fibers of
lateral lemniscus relay in this nucleus. Efferent
fibers from nucleus of inferior colliculus pass via
inferior brachium to medial geniculate body.
Inferior colliculus cells are also considered to form
the center of spinoauditory reflex which helps in
localizing the source of sound.
Tegmentum and tectum at the level of superior
colliculus (Fig. 5.36)
n Tegmentum: Like inferior collicular level,
tegmentum at the level of superior colliculus
fundamentally presents following features
l Gray matter: In the form of cranial nerve nuclei
and, reticular nuclei. Additionally a nucleus of extrap-
yramidal system called red nucleus.
l White matter: In the form of ascending (lemnisci)
and descending tracts and, decussating fibers of some
descending tract.
n Gray matter (of tegmentum):
1. Periaqueductal gray matter: Gray matter surroun-
ding cerebral aqueduct presents following cranial
nerve nuclei.
Brainstem
EdingerWestphal nucleus
Mesencephalic nucleus of
Vnerve
Protectal nucleus
Spinal lemniscus
Trigeminal lemniscus
Medial lemniscus
Parietopontine, occipitopontine
and temporopontine fibers
Corticospinal and
corticonuclear fibers
Frontopontine fibers
Oculomotor nerve
l Somatic efferent nucleus of oculomotor nerve: It is
the main motor nucleus of oculomotor nerve which
supplies majority of extraocular muscles. It is situated
in ventromedial part of periaqueductal gray matter.
The nucleus of both sides is closely apposed to each
other forming a triangular nuclear complex ventral to
aqueduct.
l EdingerWestphal nucleus: It is general visceral
efferent nucleus of oculomotor nerve which gives out
preganglionic fibers passing through oculomotor nerve
to supply two smooth muscles of eyeball, constrictor
pupillae and ciliary muscle. This nucleus is situated
dorsolateral to somatic efferent nucleus.
l Mesencephalic nucleus of trigeminal nerve: As
stated earlier, this proprioceptive sensory nucleus
of trigeminal nerve extends throughout whole
length of midbrain. It is situated on lateral part of
periaqueductal gray lateral to cerebral aqueduct.
This nucleus receives proprioceptive impulse from
muscles of mastication, temporomandibular joint,
roots of teeth, muscles of eyeball and face.
2. Reticular nuclei: This part of brainstem reticular
formation is less prominent and situated in lateral
part of tegmentum.
3. Red nucleus: It is so called because it is red or
reddish brown in color due to more vascularity and
iron containing pigment in neuronal cytoplasm.
It is ovoid in length and round in cross section.
This nucleus is situated dorsal to medial end of
substantia nigra. Red nucleus extends only in
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
upper half of midbrain at the level of superior
colliculus. It is one of the centers of extrapyramidal
system.
n Connections of red nucleus: Red nucleus
functions as intermediate cell station for following
pathways.
1. Corticorubrospinal tract:
Afferent: From motor and premotor area of cere-
bral cortex (Area 4 and 6) of same side.
Efferent: To anterior horn cells of spinal cord (only
upper cervical segments) of opposite side.
2. Corticorubrobulbar tract:
Afferent: From motor and premotor area of
cerebral cortex (Area 4 and 6) of same side.
Efferent: To motor nuclei of IIIrdVIIth cranial
nerves of opposite side.
3. Cerebellorubrothalamic tract:
Afferent: From dentate nucleus of cerebellum of
opposite side.
Efferent: To thalamic nucleus.
4. Pallidorubrothalamic tract:
Afferent: From globus pallidus of same side.
Efferent: To thalamic nucleus of opposite side.
n White matter (of tegmentum):
1. Emerging fibers of oculomotor nerve: Both
somatic efferent and general visceral efferent
(parasympathetic) fibers of oculomotor nerve,
arising from respective nucleus, traverse through
tegmentum of midbrain at the level of superior
colliculus. While doing so, oculomotor nerve
traverses through red nucleus and comes in
close relation to crus cerebri through which pass
corticospinal (pyramidal) tract fibers.
2. Decussation of rubrospinal tract fibers: It is known
that rubrospinal tract is a crossed tract. Fibers
arising from red nucleus decussate immediately at
the level of superior colliculus ventromedial to the
nucleus, and then descend towards spinal cord.
This is known as anterior (ventral) tegmental
decussation of Forel.
3. Decussation of tectospinal tract fibers: Like
rubrospinal tract, tectospinal tract is also a
contralateral tract arising from tectum of mid-
brain. At the level of superior colliculus, fibers of
tectospinal tract decussate, posteromedial to red
nucleus before descending towards spinal cord. It
is called posterior (dorsal) tegmental decussation
of Meynert.
4. Compact bundle of ascending tract (as lemniscus):
Out of the four lemnisci found of the level of
inferior colliculus, lateral lemniscus was found to
end in inferior colliculus. So, at the level of sup-
erior colliculus, three lemnisci, namely medial,
trigeminal and spinal, are placed medial to lateral.
124
These fiber bundles are situated lateral to red
nucleus.
5. Medial longitudinal fasciculus: It is the uppermost
end of this fiber bundle which is situated just in
front of oculomotor nucleus.
n Tectum (superior colliculus): It is a part of
bulge on the dorsal aspect of upper half of midbrain.
Beneath this round elevation, dorsal part of midbrain
(behind cerebral aqueduct) presents concentric layers
of gray and white matters. Neurons of the gray matter
form nucleus of superior colliculus which forms cell
stations for spinovisual reflex.
n Connections of nucleus of superior colliculus:
Afferent: Fibers of optic tract relay in lateral
geniculate body. Some of the fibers from neurons of
lateral geniculate body, passing through superior
brachium end in superior colliculus.
Efferent: These are tectobulbar and tectospinal
fibers passing to motor nuclei of cranial nerves in
brainstem and anterior horn cells of spinal cord
respectively.
Nucleus of superior colliculus acts as a center for
spinovisual reflex or visual body reflex pathway.
CLINICAL ANATOMY OF BRAINSTEM
MEDULLA OBLONGATA
n General consideration: Traumatic, ischemic,
infective, degenerative or neoplastic lesions of med-
ulla oblongata may lead to wide range of clinical
manifestations because
i. It contains various cranial nerve nuclei.
ii. Medulla oblongata is the part of brainstem
which contains vital centers those regulates
cardiovascular and respiratory functions.
iii. Through medulla oblongata pass many ascen-
ding and descending tract which may be
affected in demyelinating diseases, neoplasm
or vascular disorder.
Herniation of Medulla in Increased
Intracranial Pressure
Any tumor or space occupying lesion (SOL) in posterior
cranial fossa will lead to increase in intracranial
pressure. As a result, to compromise this tension,
medulla oblongata with cerebellar tonsil will be
pushed downwards and forwards causing herniation
through foramen magnum.
Clinical manifestations
l Headache
l Neck stiffness or neck rigidity

l Effect of lesion of lower four cranial nerves due to
their traction (IXXIIth).
Complication
Lumbar puncture, to release the raised intracranial
pressure, is contraindicated. Because it may lead to
further herniation of medulla (so also brain) through
foramen magnum which may cause sudden failure of
vital functions.
n Arnold Chiari malformation: It is a congenital
disorder associated with craniovertebral anomalies
and spina bifida.
Pathology: Herniation of cerebellar tonsil and
medulla oblongata through foramen magnum.
Effect: Herniation of medulla as well as cere-
bellum will cause obstruction of foramen of Magendie
and foramen of Luschka on the roof of fourth ventricle
which communicate subarachnoid space with cavi-
ties (ventricles) of brain. So it will cause internal
hydrocephalus.
n Medial (ventral) medullary syndrome:
It is one of the vascular disorder of medulla oblo-
ngata. In this case of vascular lesion ventral part of
medulla is damaged due to obstruction (thrombosis) of
medullary branch (branches) of vertebral artery.
This syndrome is also known as Crossed paralysis
as it will cause
1. Contralateral hemiplegia: It is due to lesion of
pyramid through which passes pyramidal tract
before decussation.
As it is upper motor neuron lesion, it is chara-
cterized by contralateral spastic paralysis with incre-
ased muscle tone and exaggerated tendon jerks.
2. Ipsilateral paralysis of tongue: It means that
paralysis of muscles of tongue of same side because
of lesion of hypoglossal nerve of same side which
emerges from medulla close to pyramid. Due to
this defect, as same sided genioglossus with other
tongue muscles is paralyzed, unopposed action of
genioglossus of normal side will push the tip of
tongue, when protruded, to the paralyzed side.
3. Additional sensory deficit: At this level of med-
ulla (pyramidal level), medial lemniscus is situated
behind pyramid. So, if the lesion is deeper, damage
to medial lemniscus will cause loss of sense of
position and movement (due to loss of proprioceptive
sensation from muscles, tendons and joints) and
loss of discriminative touch of opposite side.
n Lateral medullary (Wallenberg) syndrome:
This is a clinical condition which occurs in thrombosis
of posteroinferior cerebellar artery, a branch of vert-
ebral artery. It leads to lesion in posterolateral part
Brainstem
of medulla oblongata with a part of cerebellum. It is
characterized by various manifestations due to lesion
of many nuclei and fiber tracts which are as follows.
Area of lesion Clinical manifestations
1. Spinal lemniscus (lateral Loss of pain and temperature
spinothalamic tract) sensation of opposite half of body.
2. Spinal nucleus and spinal Loss of pain and temperature of
tract of trigeminal nerve same side of face.
3. Nucleus ambiguous Dysphagia (difficulty in
swallowing) and dysphonia
(difficulty in phonation) due to
paralysis of muscles of soft
palate, pharynx and layrynx.
4. Ventral and dorsal spino- Cerebellar ataxia associated
cerebellar tract, inferior with incoordination of
cerebellar peduncle and movements and in gait affecting
part of cerebellum limbs.
5. Vestibular nuclei Vertigo, nausea, vomiting and
nystagmus (incoordination in
conjugate deviation of eyeball).
6. Descending sympathetic Horners syndrome characterized
fibers by ptosis, miosis, enophthalmus
and anhidrosis with flushing of
same side of face.
n Traumatic lesion of medulla oblongata:
Sudden hyperextension injury of neck leading to
fracture dislocation of axis (second cervical vertebra)
causes damage to medulla oblongata. Typical example
is Hangmans fracture of axis which presses over
medulla oblongata leading to suppression of functions
of various functional area including vital centers
which ultimately results to death following hanging.
PONS
Pons is the infratentorial part of brainstem which is
lodged in posterior cranial fossa and closely related
to cerebellum with middle cerebellar peduncle and
fourth ventricle of brain. Lesion of pons is commonly
due to following two reasons
1. Vascular: Pons is supplied by
i. Pontine arteries
ii. Anterior inferior cerebellar artery
iii. Superior cerebellar artery.
All are branches of basilar artery.
Range of vascular lesion may be mild, moderate
or severe. Accordingly it may affect a small area or
whole of pons which causes bilateral manifestations.
Nature of vascular lesion may be thrombosis or
hemorrhage leading to infarction.
2. Neoplastic: Neoplasm (tumor) of pons may be
a) Acoustic neuroma: It is a tumor at cerebello-
pontine angle (CP angle) developed from
Schwann cell sheath of statoacoustic (vestibu-
locochlear) nerve.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
b) Astrocytoma: It is the tumor originating from Site of lesion Clinical manifestations
astrocytes. Incidence is common in children. 1. Vestibulocochlear nerve Vertigo, nausea, vomiting,
n Vascular lesion in paramedian area of basilar tinnitus and progressive deafness.
part of pons may be due thrombosis or infarction due 2. Middle cerebellar peduncle Cerebellar ataxia with intention
to involvement of short multiple pontine branches of tremor and staggering gait.
basilar artery. It will cause contralateral cerebellar 3. Spinal nucleus and spinal Ipsilateral loss of pain and
tract of trigeminal nerve temperature sensation of face.
ataxia with intention tremor due to lesion of cortico-
pontocerebellar pathway. Contralateral hemiplegia 4. Emerging fibers of facial Ipsilateral infranuclear facial
nerve paralysis.
will result due to damage to corticospinal tract
passing through basilar part of pons. n Pontine hemorrhage: It is extensive and bila-
n Millard Gubler Syndrome: It is the clinical teral in nature so that clinical condition will cause
condition which results due to occlusion of paramedian bilateral type of all manifestations as stated above.
pontine branches of basilar artery feeding lower and In addition, it will present following two specific
ventral part of pons. manifestations.
It involves basilar part of pons through which 1. Pinpoint pupil: Due to involvement of ocular sym-
pathetic fibers.
traverses corticospinal tract and emerge fibers of VIth
2. Hyperpyrexia: It is because of severe lesions in pons
and VIIth cranial nerve.
which disconnect the body from heat regulating
Clinical manifestations
center in hypothalamus.
i. Contralateral hemiplegia
ii. Ipsilateral lower motor neuron type (nuclear or
MIDBRAIN
infranuclear) facial paralysis.
iii. Ipsilateral medial strabismus (squint) due to Causes of lesion in midbrain may be
unopposed action of medial rectus as a result 1. Traumatic
of paralysis of lateral rectus supplied by 2. Neoplastic
abducent (VIth cranial) nerve. 3. Ischemic
n Extensive vascular lesion or expanding 4. Obstructive.
tumor (astrocytoma) of pons will cause widespread
motor and sensory deficits depending on different Traumatic Lesion
areas of gray and white matter affected as follows Midbrain, the short proximal part of the stalk, forms
Area of lesion Clinical manifestations
supratentorial part of brainstem. While becoming
continuous with infratentorial part, midbrain is rela-
1. Corticospinal tract Contralateral hemiparesis or
hemiplegia
ted to tentorial notch formed by sharp free margin of
tentorium cerebelli. Sudden lateral movement of the
2. Corticonuclear tract Weakness of muscles of face, jaw
of opposite side
head may lead to a vulnerable injury, when midbrain
(its cerebral peduncle) may be torn, stretched, twisted
3. Pontocerebellar fibers Cerebellar ataxia
or bent against free margin of tentorium cerebelli.
4. Medial and spinal lemnisci Contralateral sensory deficit of In this case most obvious feature will be invo-
trunk and limbs
lvement of oculomotor nerve at its exit. Depending
5. Superior (principal) Contralateral loss of tactile upon severity of injury, trochlear nerve and other
sensory nucleus of sensation of face, pain and
trigeminal nerve temperature sensations are
areas of midbrain will be affected.
preserved as spinal nucleus of
Vth nerve is not affected. Neoplastic Lesion
6. Abducent nerve nucleus Medial strabismus (squint) due
to unopposed action of medial
Tumors pressing and infiltrating neural tissue of
rectus muscle. midbrain may be internal or external. Any space
occupying lesion (SOL) in the vicinity will have effect
7. Vestibular nuclei Vertigo, nausea, vomiting and
nystagmus. on following structural components of midbrain.
1. Important ascending and descending tracts: For
8. Cochlear nuclei Impairment of hearing.
example Medial and spinal lemnisci, corticospinal
n Cerebellopontine angle (CP angle) tumor: It and corticobulbar (corticonuclear) tracts, medial
is the acoustic neuroma which occurs due to tumor longitudinal fasciculus.
arising from Schwann cell sheath of vestibulocochlear 2. Nuclei of cranial nerves: Like oculomotor and troc-
nerve. hlear nerves.
126

3. Reflex centers in colliculi
4. Red nucleus and substantia nigra: Which possesses
remarkable influence on motor function.
Vascular Lesion
It occurs due to occlusion of a branch of posterior
cerebral artery. Depending upon extent of lesion
clinical syndromes are of following two types:
1. Weber syndrome: It is also known as Crossed
oculomotor paralysis. This lesion damages cortic-
ospinal and corticobulbar (corticonuclear) tracts
and emerging fibers of oculomotor nerve. Effects
of this vascular lesion are following.
Brainstem
Side of lesion Clinical manifestations
1. Corticospinal tract Contralateral hemiplegia.
2. Corticobulbar tract Paresis of lower part of face,
tongue (contralateral half).
3. Oculomotor nerve fibers Ptosis, lateral squint, proptosis
with diplopia, dilatation of pupil
wih its no reaction to light and
accommodation.
2. Benedikt syndrome: This vascular lesion of
midbrain is more extensive additionally affecting
medial and spinal lemnisci as well as red nucl-
eus. So clinical findings of Weber syndrome is
associated with contralateral sensory impairment
and some involuntary movements.
127
 Cerebellum
Midbrain
Brainstem Pons
Medulla
oblongata
Fig. 6.1 Cerebellum in relation to brainstem (lateral view)
INTRODUCTION
Cerebellum is the dorsal part of hindbrain (rhom-
bencephalon) (Fig. 6.1). Among the three components
of hindbrain with pons and medulla oblongata.
Cerebellum is the largest in volume.
Cerebellum is considered as motor component of
brain. Though it does not initiate voluntary move-
ment, but it exerts a control on it in a subconscious
state.
In contrast to cerebrum, cerebellum is known as
little brain.
Cerebellum exerts ipsilateral control on body.
6
Superior cerebellar peduncle
Cerebellum
Middle cerebellar peduncle
Inferior cerebellar peduncle
POSITION AND RELATIONS (FIGS 6.1 AND 6.2)
Cerebellum is situated in posterior cranial fossa,
where it is lodged on cerebellar fossa of squamous
part of occipital bone.
Cerebellum is situated below occipital lobe of
cerebrum from which it is separated by tentorium
cerebelli.
Cerebellum is anteriorly related to dorsal surface
of pons and medulla oblongata from which it is
separated by fourth ventricle of brain (Fig. 6.2).
Three components of brainstem, midbrain, pons
and medulla oblongata are connected to cerebellum
by paired superior, middle and inferior cerebellar
peduncles respectively (Fig. 6.1).

Third ventricle of brain
Midbrain
Pons
Medulla oblongata
Fig. 6.2 Cerebellum in relation to fourth ventricle of brain (sagittal sectional view)
PRINCIPLE OF FUNCTIONS
It has already been mentioned, though cerebellum is
not concerned with initiation of voluntary movement,
it regulates normal motor activities unconsciously. It
acts as a playback singer or trainer of a musical troop.
Functions of cerebellum is explained in following
three stages.
Stage I
Cerebellum receives various kinds of sensory inf-
ormations either through direct pathway like spino-
cerebellar or indirect pathway like spinothalamo-
cortical and corticopontocerebellar tracts.
Sources of informations are as follows
1. Proprioceptive general somatic sensation: From
end organs of muscles, tendons, joints.
2. Exteroceptive general somatic sensations: Mainly
from end organs for touch and pressure.
3. Proprioceptive special somatic sensation: From
end organ for balance, i.e. vestibular apparatus.
4. Exteroceptive special somatic sensation: From end
organs for sight (photoreceptors) and end organs
for hearing (cochlear apparatus).
Stage II
All sensory informations are analyzed and coordinated
or integrated.
Stage III
After integration of all sensory inputs, a regulatory
effect is exerted by cerebellum, in a subconscious or
Cerebellum
Aqueduct of midbrain
Cerebellum
Fourth ventricle of brain
Central canal of medulla
unconscious state, on brainstem, spinal cord and
cerebral cortex for
1. Maintenance of equilibrium or balance of body
through postural adjustment.
2. Maintenance of muscle tone for desired sense of
position and movements.
3. Coordinated and smooth muscular activities to
proper range, extent and direction.
GROSS ANATOMY (FIG. 6.3)
Funamental Components
Cerebellum is fundamentally composed of inter-
mediate part called vermis and two lateral halves
called cerebellar hemispheres. Vermis is so called
because it is somewhat like worms in appearance.
This terminology can be compared to the word verm-
iform appendix. Centrally situated vermis is narrow
and constricted. It is continuous on either side with
rounded and expended cerebellar hemispheres.
Surface views Superior and inferior
When viewed from superior surface, area of vermis
seen is called superior vermis, which presents antero-
posteriorly directed midline ridge, which slopes late-
rally to become continuous with superior surface of
cerebellar hemispheres.
Inferior aspect of cerebellum shows comparatively
independent appearance of vermis which is called
inferior vermis which is more deeply placed as com-
pared to cerebellar hemisphere. The depression on
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Section of midbrain
Superior vermis
Cerebellar
hemisphere
Vallecula lodging
inferior vermis
Fig. 6.3 Posterosuperior view of cerebellum
which inferior vermis is lodged is called vallecula.
Vallecular sulcus separates vermis on either side
from inferior aspect of cerebellar hemisphere.
Cerebellar notches
Cerebellum, when viewed from above, present a
notch in the midline on its anterosuperior aspect to
accommodate collicular bulge of midbrain. It is called
superior cerebellar notch. Posteroinferior aspect of
two cerebellar hemisphere are separated by posterior
cerebellar notch which is related to free crescentic
margin of Falx cerebelli.
Surface features Folia and fissures
Surface of cerebellum (both hemisphere as well as
vermis) presents very narrow and shallow parallel
linear depressions. These are called fissures. These
fissures extending from one side of cerebellar hemi-
sphere to the other side crossing over the vermis,
present V shaped or U shaped appearance, angle or
concavity of which is directed forwards. One fissure
intervenes between two adjacent thin and linear ridge
like leafy elevations which are parallel to each other
serially. These are called folia (Singularfolium).
PRIMARY FISSURE AND LOBES OF CEREBELLUM
Cerebellum is primarily divided into 3 lobes by
primary fissures which are comparatively deeper. horizontal fissure, is bent on itself inferiorly round the
These lobes are known as:
1. Anterior lobe
2. Middle lobe
130
Superior cerebellar peduncle
connecting cerebellum with
midbrain
Superior half of cerebellar
hemisphere above horizontal
sulcus
Horizontal sulcus
Inferior half of cerebellar hemisphere
below horizontal sulcus
Vallecular sulcus
3. Flocculonodular lobe.
Each of the lobe has a portion of vermis (midline
part) and two lateral extensions on cerebellar hemi-
sphere.
Anterior lobe and middle lobe (also called posterior
lobe) are separated by a V shaped fissure at the junction
of anterior 1/3rd and posterior 2/3rd of superior surface.
It is the primary fissure or fissura prima. Antero-
inferior part of cerebellum is cut off by another primary
fissure called posterolateral fissure (sulcus). The part
of cerebellum anterior to this sulcus is called Flocculo-
nodular lobe. Superior and inferior halves of middle
lobe (posterior lobe) are separated by a prominent deep
fissure called horizontal fissure which is not functionally
primary fissure, though primary in origin.
Each of the lobe made up of lobules: Lobes of
cerebellum, namely anterior and posterior, are further
divided by secondary fissures into smaller units,
called lobules. Each lobule presents a component
in the vermis and its lateral extensions in both the
cerebellar hemisphere.
Before the lobules are studied through following
table, it is important to note at this stage that,
during development of cerebellum all the lobules of
cerebellum used to be simply placed in cephalocaudal
direction on the dorsal aspect of pons and medulla
intervened by cavity of fourth ventricle (Fig. 6.4).
But ultimately, part of it, caudal to the level of future
tent-shaped roof of 4th ventricle as seen in Figure 6.4,
to form inferior vermis and inferior part of cerebellar
hemisphere.
 Cerebellum
Anterior lobe

Primary sulcus
Middle (posterior) lobe
Horizontal sulcus

Posterolateral sulcus

Flocculonodular lobe

Fig. 6.4 Cephalocaudal relationship of different components (lobules) of cerebellum. Fig also shows rostroventral bending of caudal part
of cerebellum (part caudal to horizontal sulcus) to form its inferior part

Lobules of cerebellum (Fig. 6.5): Horizontal fissure divides cerebellum into superior
and inferior halves. Lobules listed above, which are
Vermis Lateral extension in
proximal to horizontal fissure form superior half

}
cerebellar hemisphere
1. Lingula No lateral extension
and those distal to the fissure form inferior half of
2.
Central lobule Ala Anterior
cerebellum.

}
Primary 3. Culmen Anterior quadrangular lobule lobe
fissure PHYLOGENETIC CLASSIFICATION OF CEREBEL-
4. Declive Posterior quadrangular lobule LUM (FIGS 6.5 AND 6.6)
Horizontal 5. Folium Superior semilunar lobule
fissure (lobulus simplex)
In reference to the stages of evolution, cerebellum is
made up of following three phylogenetic components
6. Tuber Inferior semilunar lobule
which are also functionally different.
7. Pyramid Biventral lobule Posterior
Posterolat- 8. Uvula Tonsil lobe
eral sulcus Archicerebellum
9. Nodule Flocculus Flocculo- It is the most primitive part of cerebellum which is
nodular lobe
the only component present in fishes and amphibians.

1
Anterior lobe
2 2
Primar fissure
3 3

Archicerebellum 4
4
Posterior
lobe 5 5
Horizontal fissure
Paleocerebellum
(sulcus)
6 6

Neocerebellum 7 7

8 8

9 Posterolateral fissure
Flocculonodular 9 (sulcus)
lobe

Fig. 6.5 Lobes, lobules and fissures of cerebellum

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Primary fissure
Cerebral aqueduct 3 4
2
5

Midbrain 1 Horizontal fissure

6
Pons

9 7
8
Posterolateral fissure
Medulla oblongata

Cavity of fourth
ventricle of brain
Central canal of lower half of medulla oblongata

Fig. 6.6 Midsagittal section of vermis component of cerebellum (with 4th ventricle and brainstem) contributing to lobular elements.
1. Lingula, 2. Central lobule, 3. Culmen, 4. Declive, 5. Folium, 6. Tuber, 7. Pyramid, 8. Uvula, 9. Nodule

Composition mals, where development of central nervous system

is characterized by telencephalization, which means
Lingula and flocculonodular lobe.
differentiation of telencephalon in the brain.
Connection Composition
Vestibular nuclei through vestibulocerebellar fibers. The largest middle (posterior) lobe of cerebellum
except pyramid and uvula of inferior vermis.
Function
Connection
Maintenance of equilibrium or balance.
It receives afferent connections from cerebral cortex
Paleocerebellum via corticopontocerebellar pathway.

It is the part of cerebellum which is superadded in Function

lower vertebrates with limbs, e.g. bird and reptiles.
Composition
1. Central lobule and ala
2. Culmen and anterior quadrangular lobule
3. Pyramid, i.e. only vermis portion
4. Uvula, i.e. only vermis portion.
Connection
Receives connection from spinal cord via spinocere-
bellar fibers.
Function
Maintenance of muscle tone and posture.
Neocerebellum is concerned with a coordination of
voluntary movement so that it is smooth and skilled,
and it is performed in right direction and within
proper range.
INTERNAL STRUCTURE OF CEREBELLUM (FIG. 6.7)
Cerebellum is structurally made up of following two
fundamental zones.
1. Outer layer of gray matter called cerebellar cortex.
2. Inner central core of white matter which presents a
pattern like branching of a tree projecting superfi-
cially beneath the cortex of each and every folium,
called arbor vitae cerebelli.
Inside the substance of white matter are embedded
mass of gray matter called cerebellar nuclei.

Neocerebellum Structure of Cerebellar Cortex

This component of cerebellum is the most recently Cortex is made up of following cerebellar neurons
evolved part which is well-developed in higher mam- arranged in three layers.
132
 Cerebellum

Stellate cell

Molecular layer
Busket cell

Purkinje cell layer

Purkinje cell

Golgi cell

Granular layer
Granule cell
Glomerulus

Climbing fibers

Mossy fibers

White matter Cerebellar

afferents

Neurons of cerebellar
nuclei

} Cerebellar efferents

Axon of some Purkinje cells leave cerebellum

directly as cerebello (fastigio) vestibular fibers

Fig. 6.7 Cytoarchitecture of cerebellum showing afferent and efferent fibers and interrelationship of neurons

1. Outer molecular layer: Stellate cells and busket
cells.
2. Intermediate layer of Purkinje cells: Purkinje cells.
3. Inner granular layer: Granule cells and Golgi
cells. Neuroglia are present in all the layers.
Fundamental structural and functional basis of
cortical architecture
Principal cells of cortex are Purkinje cells. It receives
afferent input entering cerebellum through following
two different routes.
1. Some of cerebellar afferent relay in Purkinje cells
reaching upto superficial molecular layer.
2. Some afferent reaching the innermost granular
layer relay in granule cells which pass further
superficially to relay in Purkinje cells dendrites in
molecular layer.
Through both the ways Purkinje cells receive ex-
citatory impulse continuously. This excitatory im-
pulse in relayed to neurons of cerebellar nuclei in
deeper white matter. Axons of cerebellar nuclei pass
out as efferent to carry the same excitatory impulse.
But this impulse is limited time to time by inhibitory
influence of stellate cells, busket cells and Golgi cells
of cortex on Purkinje cells, so also on cells of cerebel-
lar nuclei.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
STRUCTURAL DETAIL OF CEREBELLAR CORTEX
(FIG. 6.7)
Molecular Layer
This outermost layer of cortex receives cerebellar
afferent called climbing fibers. Among all afferents
to cerebellum, these are only olivocerebellar fibers.
Entering through inferior cerebellar peduncle and
traversing through white matter these fibers climb up
to the outermost layer of cortex. These fibers divide
into numerous branches which wrap around the bush-
like dendritic tree of Purkinje cells in molecular layer.
These are called climbing fibers as they look like a
vine on a tree. One climbing fiber forms synaptic
connections with dendritic tree of 110 Purkinje
neurons through which all the times excitatory
sensory inputs are discharged on Purkinje cells.
Neurons present in molecular layer are stellate
cells and busket cells. Stellate cells are small star-
shaped superficially placed cells. Axons of these
cells relays in dendritic spines of Purkinje cells to
produce inhibitory effect. Busket cells are placed in
deeper part of molecular layer. These are so called
because multiple axon terminals give a busket-like
appearance to hold the Purkinje cell body. Through
this connection excitatory impulse of Purkinje cells
are limited.
Molecular layer also receives axons of granule
cells situated in granular layer. In this layer long
axons of granule cells divided into T-shaped manner.
Two limbs of T-shaped axon of granule cells run in
opposite direction which synapse with Purkinje cell
dendritic spines.
Purkinje Cell Layer
This layer is made up of single row of cells called
Purkinje cells. These are large, flask-shaped Golgi
type I neurons. Dendrites of these cells are like tree
bush showing primary, secondary and tertiary or final
branching. Final branches present dendritic spines.
Whole dendritic process extend into superficial
molecular layer.
Long axons of Purkinje cells acquire myelin sheath
on entering granular layer. These pass further deeper
to relay in neurons of cerebellar nuclei.
Axons of a few Purkinje cells end directly to vesti-
bular nuclei, without relaying in cerebellar nuclei.
Granular Layer
This layer is so called because it is filled with densely
packed, small sized, multipolar neurons called granule
cells. The cells present scanty cytoplasm with deeply
stained nuclei. Granule cells are intermediate in
134
position between all the afferent fibers to cerebellum
other than olivocerebellar group and the Purkinje cells.
These cerebellar afferent fibers are known as Mossy
fibers. Granule cells present four to five dendrites
which present claw-like endings. Mossy fibers, which
are all the afferents, other than olivocerebellar fibers
(climbing fibers) reach upto granular layer where
they show multiple branching. These fiber terminals
form synaptic connection with claw-like dendrites
of granule cells. One mossy fiber forming synaptic
connection with thousand of Purkinje cells, thus
producing diffuse excitatory effect.
Axons of granule cells are long enough to reach
upto superficial molecular layer traversing through
Purkinje layer. Terminal end of granule cell axons
divide in T shaped manner, ends of which run in
opposite direction which are called parallel fibers.
Ends of parallel fibers form synaptic connection with
dendritic tree of Purkinje cells at right angle.
Second type of neurons in granular layer are Golgi
cells. Their dendrites are spread out in molecular
layer and axon split up into branches which form
synapses with dendrites of granules cells at the site of
their junction with mossy fiber terminals which form
glomerulus.
Neuroglial cells are also abundant in whole gran-
ular layer.
MECHANISM OF CEREBELLAR CORTICAL CIRCUIT
Purkinje cells receive constantly the excitatory inputs
entering cerebellum through afferent fibers. The
afferent fibers are of two types. Climbing fibers are
only the olivocerebellar fibers among all afferent fibers
to cerebellum. These fibers are longer to wrap around
and to relay in dendritic spines of Purkinje cells at
molecular layer. Mossy fibers are all other afferents,
which also produce excitatory affect on Purkinje cells
through granule cells. Axons of Purkinje cells leave
the cortex to reach deeper white core of cerebellum
where they excite neurons of cerebellar nuclei. Axons
of the nuclear neurons leave cerebellum as efferents
via superior and inferior cerebellar peduncles to reach
centers in brainstem, spinal cord and cerebral cortex.
So, it clear till now that, receiving all sensory inputs
through climbing as well as mossy fibers, excitation of
Purkinje cells is conveyed via cerebellar nuclear axons
for motor activities, maintenance of equilibrium, muscle
tone and muscular activity coordination. But for this
motor activity, to reach upto optimum range, proper
extent and right direction, time to time modification
or limitation of excited state of Purkinje cells conveyed
to cerebellar nuclear axons as efferent fibers are
necessary. This becomes possible by inhibitory whip

of stellate cells, busket cells of molecular layer and
Golgi cells of granular layer. It is to be recalled that
axons of stellate cells form synaptic connection with
dendrites, and axons of busket cells come in contact
with cell bodies of Purkinje cells. Through these
connections both these cells exert inhibitory effect
on Purkinje cells. In granular layer, axons of Golgi
cells form synaptic contact with dendrites of granule
cells, through which inhibitory influence is exerted
on Purkinje cells, so on axons of neurons of cerebellar
nuclei coming out as efferent fibers from cerebellum.
So, it is clear that inhibitory impulse from stellate
cells, busket cells and Golgi cells are transmitted by
Purkinje cells to the cerebellar nuclei, axons of which in
turn, projecting on motor centers of brainstem, spinal
cord and cerebral cortex modify or limit muscular
activity for maintenance of equilibrium, muscle tone
and coordination of smooth and skilled movements.
Neurotransmitters: Climbing as well as mossy
fibers release glutamate or gamma-aminobutyric
acid (GABA) as excitatory transmitter on dendrites
of Purkinje cells. Axons of stellate cells, busket cells
and Golgi cells release norepinephrine and serotonin
which are inhibitory transmitter to have effect on
Purkinje cells.
Afferents from vermal (median) zone of
cortex to fastigial nucleus
B B
Fig. 6.8 A. Intracerebellar nuclei, B. Afferents from vermal (median), paravermal (medial) and later zones of cerebellar cortex relaying
to respective nuclei, C. Efferents from three phylogenetic groups of nuclei leaving for different destinations
Cerebellum
WHITE MATTER OF CEREBELLUM
Small amount of white matter present in vermis looks
like trunk and branches of a tree. It is called arbor
vitae cerebelli. Cerebellar hemispheres present larger
amount of white matter.
White matter is made up of following three groups
of fibers.
1. Afferent fibers: These are climbing and mossy
fibers as already described. These form the main
bulk of cerebellar fibers which enter mostly
through middle and inferior cerebellar peduncles.
2. Efferent fibers: These fibers leave cerebellum
through superior and inferior cerebellar peduncles.
Most of these efferent fibers from cerebellum are
axons cerebellar nuclei neurons. Some of axons of
Purkinje cells of flocculonodular lobe and part of
vermis pass, bypassing cerebellar nuclei, directly
as cerebellar efferents.
3. Intrinsic fibers: These are so called as they exist
within the cerebellum. It means these fibers,
being the processes of different cerebellar neurons
interconnect with each other.
NUCLEI OF CEREBELLUM (FIG. 6.8)
These are small but compact masses of gray matter
embedded in central core of white matter. Axons
Afferents from paravermal (medial) zone to
nucleus interpositus
Afferents from lateral zone of cerebellar
cortex to dentate nucleus
Efferents from dentate nucleus to thalamus
for dentatothalamocortical pathway
Efferents from nucleus interpositus to red
nucleus for cerebellorubrospinal pathway
Efferents from fastigial nucleus to
Vestibular nucleus for fastigiovestibular
(fastigiobulbar) pathway
Reticular nucleus for fastigioreticular pathway
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
of neurons of these nuclei, as already discussed,
leave out of cerebellum through either superior or
inferior cerebellar peduncles as cerebellar efferents.
Cerebellar nuclei are four in number on either side of
midline from vermis to cerebellum hemisphere. From
lateral to medial the nuclei are
1. Dentate nucleus (Nucleus dentatus) D
2. Emboliform nucleus (Nucleus emboliformis) E
3. Globose nucleus (Nucleus globossus) G
4. Fastigial nucleus (Nucleus fastigius) F
Nucleus emboliformis and nucleus globossus are
together known as nucleus interpositus.
Dentate Nucleus
Dentate nucleus is the most lateral and largest
among the four nuclei of cerebellum. It is most prom-
inent in higher animals, specially in human brain.
Phylogenetically it is the latest in evolution and
obviously related to neocerebellum. Dentate nucleus,
on section, looks like a folded bag with its opening
(concavity) facing medially. From the concave side
emerge efferent fibers from the nucleus. Efferent fibers
leave cerebellum through superior cerebellar peduncle.
Emboliform Nucleus
Emboliform nucleus is oval in outline. It is situated
just medial to dentate nucleus and may be closely
approximated to concavity (hilum) of dentate nucleus.
Globose Nucleus
It is round in shape and sometimes may be more than
one in number.
Globose and emboliform nuclei are closely apposed
to each other and interposed between dentate nucleus
laterally and fastigial nucleus medially. That is why
they together are named as nucleus interpositus.
Nucleus interpositus is related to paleocerebellum.
Fastigial Nucleus
Fastigial nucleus is close to midline and thereby lies
in the white core of vermis. It is ovoid or elliptical
in outline and intermediate in size between dentate
nucleus and nucleus interpositus. This nucleus is
related to archicerebellum.
RELATIONSHIP BETWEEN CEREBELLAR NUCLEI
AND MEDIOLATERAL SUBDIVISIONS OF
CEREBELLAR CORTEX (FIG. 6.8)
It is already understood that cerebellar nuclei receive
afferents, all of which are axons of Purkinje cells. Of
course, axons of some Purkinje cells leave cerebellum
straightway to end in vestibular nuclei as cerebello-
vestibular fibers. Efferents from cerebellar nuclei
pass as their axons. They go out through superior and
inferior cerebellar peduncles to
136
i. Vestibular and reticular nuclei of brainstem
ii. Via red nucleus to spinal cord
iii. Via thalamus to motor and premotor areas of
cerebral cortex.
It is interesting to note at this stage that fastigial
nucleus, nucleus interpositus and dentate nuclei
receive afferent (Purkinje cell axons) from three
components of cerebellar cortex which are subdivided
from medial to lateral as follows:
1. Medial (vermal): Cortex of vermis
2. Intermediate (paravermal): Cortex of medial half
of hemisphere
3. Lateral: Cortex of lateral half of hemisphere.
So, afferent from three mediolaterally divided
portions of cortex to three phylogenetic types of
cerebellar nuclei and their efferents in three different
destination are related as follows.
Afferents Cerebellar Efferents
from nucleus
1. Vermal (medial) Fastigial Fastigiovestibular tract
zone of cerebellar nucleus to vestibular nuclei
cortex
2. Paravermal Nucleus Cerebellorubrospinal
(intermediate) zone interpositus tract to anterior horn
of cerebellar cortex cell of spinal cord
3. Lateral zone Dentate Dentatothalamocortical
of cerebellar cortex nucleus tract to motor and prem-
otor area of cerebral cortex
CEREBELLAR PEDUNCLES
Superior, middle and inferior cerebellar peduncles
connecting midbrain, pons and medulla oblongata
with the cerebellum respectively, are the bridges
through which pass fibers to and from the cerebellum
(cerebellopetal and cerebellofugal).
Middle cerebellar peduncle is thickest and superior
cerebellar peduncle is thinnest, while inferior is
intermediate.
Middle cerebellar peduncle, though thickest, is
composed of afferent (cerebellopetal) fibers only which
are only the fibers of pontocerebellar tract. Superior
and inferior cerebellar peduncles are composed of
both afferent (cerebellopetal) as well as efferent (cere-
bellofugal) fibers.
Composition of Cerebellar Peduncles
Inferior cerebellar peduncle
Afferent
1. Dorsal spinocerebellar tract
2. Anterior external arcuate fibers: From arcuate
{ nucleus
3. Posterior external arcuate fibers: From acc-
essory cuneate nucleus (cuneocerebellar tract)

{
4. Par olivocerebellar tract: From medial and
superior (dorsal) olivary nuclei
5. Olivocerebellar tract: From inferior olivary
nucleus
{ 6. Vestibulocerebellar tract
7. Reticulocerebellar tract
(A reader can remember the fibers in groups as
above).
Efferent
1. Cerebelloolivary tract
2. Cerebellovestibular (fastigiovestibular or fast-
igiobulbar) tract
3. Cerebelloreticular (fastigioreticular) tract.
A reader can remember three efferents as reverse of
last three afferents.
Middle cerebellar peduncle
It is composed of only afferent fibers. These fibers
are pontocerebellar fibers of corticopontocerebellar
pathway.
Superior cerebellar peduncle
Afferent
1. Ventral spinocerebellar tract
2. Tectocerebellar tract.
Efferent
1. Dentatorubral tract: For dentatorubrospinal path-
way
2. Dentatothalamic tract: For dentatothalamocorti-
cal pathway.
CLINICAL ANATOMY
As cerebellum has ipsilateral control on body, lesion
of one half of cerebellum leads to clinical effect on
same half of body.
To study the effect of lesion of cerebellum or
cerebellar dysfunction, functions of cerebellum are to
be briefly recapitulated which are as follows:
1. Maintenance of equilibrium or balance of body
through all reflex activities and voluntary move-
ments.
2. Harmonization of muscle tone and maintenance of
normal body posture.
3. Cerebellum, though not concerned with initiation
of voluntary movements, coordinates smooth,
precise movement upto right extent and range in
right direction maintaining the economy of force.
Causes of Cerebellar Lesion
1. Congenital: Hypoplasia or dysgenesis
2. Traumatic
Cerebellum
3. Ischemic: Vascular occlusive disorder, e.g. throm-
bosis of any of the three cerebellar arteries.
4. Degenerative: For example multiple sclerosis.
5. Neoplastic: Expanding tumors, medulloblastoma
in children.
Cerebellar Lesion May be Compensated by
Other Parts of Nervous System
Cerebellar lesions may be acute due to trauma or
sudden vascular occlusion when the symptoms
are severe. In chronic lesion, like slowly expanding
tumor, clinical features are less severe. But it has
been seen in many cases of the lesion, either acute or
chronic, patient recovers from the clinical deficits due
to compensation of cerebellar dysfunction by other
parts of nervous system.
Cerebellar Syndrome
Cerebellar syndrome is defined as combination of
signs and symptoms which are manifested due to
lesion of cerebellum for any cause. Fundamental of
cerebellar syndrome is motor dysfunction without
motor paralysis. Following are the two types of
cerebellar syndromes.
1. Archicerebellar syndrome
2. Neocerebellar syndrome.
Depending upon the nature and extent of lesion in
cerebellum, a patient may present combination or
overlapping of clinical findings of two cerebellar
syndromes.
Neocerebellar syndrome presents the symptoms
and signs due lesion of both paleocerebellum and
neocerebellum.
Archicerebellar Syndrome
It is due to lesion of archicerebellum which is com-
posed of Flocculonodular lobe and lingula. It affects
vermal zone or area of vermis. That is why it is also
called vermis syndrome. Commonest example is med-
ulloblastoma in children.
Archicerebellar syndrome is characterized by
group of clinical findings which are due to disorders in
equilibrium manifested by some motor dysfunctions
which are as follows.
n Unsteadiness in stance: Due to impaired
balance, while standing, the patient will have a
tendency to fall. He or she will try to compensate this
difficulty by overcontraction of muscles of lower limb
which presents stiffed legs. The disability will also be
compensated with the help of vision and the patient
will stand on a broad base with legs and feet being
always wide apert. When the patient is asked to close
137
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
eyes while standing, he or she will have a tendency to
fall. It is known as positive Rombergs sign.
n Unsteadiness in gait: Gait is the pattern or
style of walking of an individual. In archicerebellar
syndrome, due to impairment of balance, patient will
sway from side to side in an attempt to maintain
balance of body. This is called staggering gait.
n Unsteadiness of trunk of body: This is evident
in vermis syndrome in case of children suffering from
medulloblastoma. The child will be unable to keep
head erect due to imbalance of head and neck. Due
to impairment of balance of trunk, while walking,
body of the patient will move to and fro forwards and
backwards.
Neocerebellar Syndrome
It is the combined effect of lesion of paleocerebellum
and neocerebellum.
IMPAIRED FUNCTION OF PALEOCEREBELLUM
Hypotonia: This is manifested as following
1. On palpation, muscle is found to have loss of resil-
ience.
2. In an attempt for passive movement of a joint,
diminished resistance by the patient is felt.
3. Muscle get fatigued early. Defect is known as ast-
henia.
4. During shaking of a limb, excessive movement of
terminal joints is observed due to loss of influence
of cerebellum on stretch reflex.
Postural Defect
1. Head is rotated and flexed.
2. Shoulder is on a lower level on the affected side.
Pendulous Knee Jark
In case of normal individual, normal jerky movement of
knee joint is self-limited after taping patellar tendon,
which is due to normal stretch reflex under regulation
of cerebellum. When influence of cerebellum on
stretch reflex is lost, a series of pendulous flexion and
extension movement of knee joint occurs while knee
jerk is elicited.
IMPAIRED FUNCTION OF NEOCEREBELLUM
Fundamental effect is incoordination or asynergy
of smooth and precise voluntary movement with its
138
failure to reach in right direction, upto proper extent
with optimum force. The basic defect is termed as
cerebellar ataxia characterized by following mani-
festations.
1. Intention tremor: Tremor is defined as abnormal,
undesired, repetitive oscillatory movement affe-
cting distal part of limbs, especially hands and
fingers. In case of neocerebellar syndrome tremor
is noticed when the patient attempts or intends for
finer hand movements, like picking up an object,
attempts for writing or buttoning clothes. That is
why it is called intention tremor.
2. Dysmetria: This disability is due to loss of know-
ledge to assess the range of movement. It is elicited
by finger nose test. Patient is asked to touch the
tip of nose with tip of finger. While attempting for
this, either the finger tip fails to reach tip of nose
or it overshoots (pastpointing) the target. Patient
suffers from loss of harmonization of movement
of different groups of muscles which results in
decomposition of movements.
3. Dysdiadochokinesia: This is the effect of incoor-
dination between antagonist groups of muscles.
It is elicited by asking the patient to perform
repeated pronation and supination movements of
forearm. When attempted, it is found to occur in
slow, jerky and incoordinated manner.
4. Dysarthria: This is the disorder in articulation of
speech due to incoordination of muscles of larynx,
tongue and lips. During speech, two major defects
are observed.
i. Use of unnatural force for muscle action.
ii. Unusual or abnormal separation of syllables
leading to slurred speech.
This disorder will have a best example when the
patient is asked to pronounce the word cerebellum.
Because of disability, patient will pronounce as CEH-
RREH-BEH-LLUHM.
5. Nystagmus: This disorder is the result of incoo-
rdination of movement of extraocular muscles.
It is characterized by rhythmical oscillation of
eyeball in an attempt to fix the gaze (vision) for an
object of interest for a longer time. Incoordination
of eye movement also occurs during horizontal
side to side movement. When the gaze is returned
back after horizontal movement, sudden jerk is
observed in eyeball at the end of movement.
 Fourth Ventricle of Brain
Fourth ventricle of brain is the cavity of hindbrain.
This cavity, being a dilated part of original neural
tube, is lined by ependyma and contains cerebrospinal
fluid (Fig. 7.1).
Fourth ventricle is situated behind pons and upper
half of medulla oblongata and in front of cerebellum.
Shape of fourth ventricle is like that of a tent.
Walls of the cavity are following
1. Floor: Formed by dorsal surfaces of pons and
upper part of medulla oblongata. It is flat like
ground of a tent.
2. Roof: It is made up of two slopes-like roof of a
tent. It projects toward white core of cerebellum.
3. Lateral walls, where roof meets with floor.
n Morphological components: Fourth ventricle
presents following three parts morphologically.
7
1. Upper part: It is narrower part opposite the level
of rhombencephalic isthmus.
2. Middle part: At the level of pons.
3. Lower part: At the level of upper half of medulla
oblongata.
Communications
A. With other parts of cavity of central
nervous system
Above, through aqueduct of midbrain, fourth ventricle
communicates with cavity of third ventricle of brain.
Below it communicates with central canal of
spinal cord through narrow canal of lower closed part
of medulla oblongata.

Cavity of third ventricle of brain

Aqueduct of midbrain
Cerebellum

Pia mater
Fourth ventricle of brain
Pons
Foramen of Magendie
Medulla oblongata
Central canal of lower closed
part of medulla

Fig. 7.1 Fourth ventricle of brain seen in sagittal section

 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Superior cerebellar peduncle Superior medullary velum (white matter

forming superolateral boundary lamina) forming upper part of roof

Ependyma of inferior medullary velum

{
Inferior cerebellar forming lower half of roof
peduncle
Foramen of Magendie in lower
Inferolateral Cuneate tubercle ependymal half of roof
boundary
Gracile tubercle

Fig. 7.2 Upper and lower halves of roof of fourth ventricle show different nature of formation
B. With subarachnoid space (Fig. 7.2)
Cavity of fourth ventricle communicates with suba-
rachnoid space through three apertures. One is in the
midline on lower part of roof and two are present in
lateral angles. These apertures are as follows:
1. Foramen of Magendie: This is a midline foramen
present in lower part of roof where it is lined by
ependyma only (see below)
2. Foramen of Luschka: They are present at the end
of lateral recesses placed at lateral angle of cavity
(Fig.7.4).
Recesses (Fig. 7.3)
Recesses of fourth ventricle of brain are small conical
outpouching from its cavity as following.
1. Dorsal recess: This is the apex of conical tent-shaped
roof projecting into white core of cerebellum.
2. Dorsolateral recesses: These are bilateral and
project dorsolaterally on either side of dorsal recess.
Dorsal recess is found to be proximal to nodule of
cerebellum, dorsolateral recesses are lateral to it.
3. Lateral recesses (Fig. 7.4): These are also bilateral
which projects between inferior cerebellar peduncle
ventrally and peduncle of floccules dorsally. End of
the recess presents an aperture at cerebellopontine
angle. Ventricular system communicates through
this aperture with subarachnoid space which has
already been mentioned.
Boundaries of Fourth Ventricle
n Lateral boundaries: One each side, it is the side
where roof meets with the floor.
Caudal part is bounded by two inferior cerebellar
peduncles which from lower angle, pass upward
and laterally. On either side of midline, lower angle
of inferolateral boundary is formed by gracile and
cuneate tubercles, where former is inferomedial to
later (Fig. 7.2). Proximal part of lateral boundary is
formed by two superior cerebellar peduncles which
pass downwards and laterally from upper angle.

Flocculus

Dorsal
recess Lateral
recess

Dorsolateral
Foramen of
recesses
Luschka

Lateral recess opening in

lateral apertureForamen
of Luschka Inferior cerebellar peduncle

Fig. 7.4 Lateral recess projects between inferior cerebellar

peduncle (deep) and flocculus of flocculonodular lobe of cerebellum
Fig. 7.3 Recesses of tent-shaped fourth ventricle cavity (superficial)
140

Trochlear
nerve
Frenulum
veli
Superior
medullary
velum
Ependyma
Fig. 7.5 Features of roof of fourth ventricle
Roof or Dorsal Wall (Fig. 7.5)
Roof is like that of a tent. So it presents two slopes
which are upper (proximal) and lower (distal). Apex of
the roof projects into the cerebellum (Fig. 7.6).
Superior half of the roof is formed by a thin lamina
of white matter called superior medullary velum. It
bridges between medial margin of two superior cere-
bellar peduncles.
Superior medullary velum presents a thin ridge
along the midline which is called frenulum veli. On
either side of frenulum, superior medullary velum is
pierced by trochlear nerve emerging from brainstem.
White matter of superior medullary velum cont-
ains some fibers of tectocerebellar tract.
Caudal end of superior half of roof is related to
lingula of superior vermis of cerebellum in the midline
(Figs 7.5 and 7.6).
Fourth Ventricle of Brain
Inferior half of the roof is further thinner than
superior half. It is made up of nonneural elements.
This thin lamina is called inferior medullary velum
which is nothing but simple ependymal lining of the
ventricle covered on its surface by pia mater forming
tela choroidea.
Lingula of
In the midline of upper end, dorsal surface of
cerebellum inferior medullary velum is related to nodule of
inferior vermis of cerebellum (Figs 7.5 and 7.6).
Lower part of inferior medullary velum present
Nodule of
an aperture in the midline which is named foramen
cerebellum
of Magendie through which ventricular cavity
Foramen of
Magendie communicates with subarachnoid space.
Lateral angle of the roof presents lateral recess
which ends in lateral opening called foramen of
Luschka through which also ventricular cavity opens
into subarachnoid space.
It is important to notice at this stage that cereb-
rospinal fluid is constantly synthesized and initially
poured in the cavity of ventricular system of brain.
The fluid circulates from ventricular system into
subarachnoid space from where it is absorbed also
constantly. That is why communication between
ventricular cavity and subarachnoid space through
above mentioned 3 foramina in the lower ependymal
part of roof of 4th ventricle is important.
Choroid Plexus and Tela Choroidea on Roof
(Fig. 7.7)
On the lower-half of roof of fourth ventricle, pia mater
from cerebellum is reflected back to form double
layer. This double layered pia mater contributed by
fine network of blood vessels which are branches of
posterior inferior cerebellar artery, lines over the
ependyma to form tela choroidea.
Choroid plexus is formed by the highly vascular
tela choroidea. It is T-shaped. Longitudinal limb of
Cavity of fourth ventricle
Choroid plexus
Lingula

Cavity
of fourth
ventricle
Pons

Cerebellum
Tela
choroidea
Nodule
Medulla
oblongata Olive

Pyramid
Fig. 7.6 Upper and lower half of midline roof of fourth ventricle
related to lingula and nodule of cerebellum Fig. 7.7 Choroid plexus projecting from roof of fourth ventricle
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Median sulcus
Substantia ferrugenia
Superior fovea
Stria medullaris
Sulcus limitans
Inferior fovea
Funiculus seperens
Obex
Calamus scriptorius
Fig. 7.8 Floor of fourth ventricle (Rhomboid fossa)
T is double. The choroid plexus invaginates through
ependyma lined lower-half of roof towards the cavity
of ventricle to secrete cerebrospinal fluid.
Floor or Rhomboid Fossa (Fig. 7.8)
Floor of fourth ventricle is formed by dorsal surfaces
of pons and upper-half of medulla oblongata.
It is called rhomboid fossa because it is rhomboid
in outline. The area is outlined superolaterally by
superior cerebellar peduncles and inferolaterally
by inferior cerebellar peduncles. At the inferior
angle, on either side of midline, floor is limited by
gracile tubercle and superolateral to it lies cuneate
tubercle.
Whole area of rhomboid fossa is lined by
ependyma, just beneath which lie different areas of
gray matter, which are more precisely some cranial
nerve nuclei.
Floor of fourth ventricle is divided by a vertically
running midline sulcus called median sulcus.
Each half of the floor is again subdivided into a
medial part called medial eminence and a lateral part
called vestibular area by a narrower sulcus limitans.
Just above the horizontal line of pontomedullary
junction, medial eminence presents a round elevation
called facial colliculus. It is so called because, efferent
facial nerve fibers from motor nucleus of facial nerve
loop around abducens nucleus beneath this bulge.
Above the level of facial colliculus, sulcus limitans
presents a small depression called superior fovea.
Above the level of superior fovea, sulcus limitans
becomes flattened and forms lateral limit of floor of
fourth ventricle. This area is bluish gray in color
and named locus coeruleus (to be pronounced
142
Free margin of superior medullary velum
Locus coeruleus
Facial colliculus
Vestibular triangle
Tinea
Hypoglossal triangle
Vagal triangle
Area postrema
ceruleus). Beneath this area, the group of neurons,
containing melanin pigment, is called substantia
ferrugenia. These neurons are rich in noradrenaline
(norepinephrine).
Lateral to sulcus limitans, rhomboid fossa presents
a wide triangular area known as vestibular area or
vestibular triangle. Vestibular nuclei are situated
beneath this area.
Just below the level of facial colliculus, fine
strands of nerve fibers are found to pass beneath
ependyma, in mediolateral direction, from median
sulcus across medial eminence towards lateral
angle. These are known as stria medullaris. These
are efferent fibers from arcunate nucleus present on
ventral aspect from pyramid. These fibers initially
pass in ventrodorsal direction across whole thickness
of medulla oblongata to reach rhomboid fossa, where
they bend at right angle and cross the median sulcus
to pass horizontally towards lateral angle. Finally the
fibers reach opposite half of cerebellum via inferior
cerebellar peduncle (Fig. 7.9).
Below the level of stria medullaris, medial emin-
ence presents a triangular area with apex directed
downward. This area is known as hypoglossal triangle
beneath which lies nucleus of hypoglossal nerve.
Lateral to hypoglossal triangle, lower end of sulcus
limitans presents a small depression called inferior
fovea.
Below inferior fovea, lateral to apical part of
hypoglossal triangle, a smaller triangular area is
present with the apex directed upward. This is called
vagal triangle as beneath this area lies dorsal nucleus
of vagus.
Inferolateral to vagal triangle, just above the
upper end of central canal of medulla oblongata, a

Ependyma lining floor of fourth Stria medullaris
ventricle
Inferior
cerebellar
peduncle
Arcuate nucleus
Fig. 7.9 Formation of stria medullaris by the axons from arcuate
nucleus which, after decussation, pass beneath ependyma of floor
and enter cerebellum through inferior cerebellar peduncle
narrow area is called area postrema. This narrow
area contains some neurons covered by thickened
ependyma.
Area postrema is separated from vagal triangle by
a ridge of ependyma called funiculus seperans.
Lower angle of floor of fourth ventricle looks
like a pens nib for which it is known as calamus
scriptorius.
Following features are not parts of floor of fourth
ventricle, but are closely related to it.
1. Inferolateral boundary of rhomboid fossa, which is
formed by inferior cerebellar peduncle is crossed
by tranverse ridge of white matter called tinea.
2. Tinea from both sides converge inferomedially
towards the lower apex of fourth ventricle to form
a thin fold called obex. It forms the roof of lower
apex of fourth ventricle.
CLINICAL ANATOMY
Clinical importance of knowledge of fourth
ventricle
Knowledge of fourth ventricle of brain is clinically
important because
1. Many vital centers are present in pons, medulla
oblongata and cerebellum which surround fourth
ventricle cavity.
Fourth Ventricle of Brain
2. Foramen of Magendie and foramen of Luschka in
the wall of fourth ventricle permit cerebrospinal
fluid to circulate freely from ventricular system
to subarachnoid space. This communication thus
maintains the balance or harmony between secr-
etion and absorption of cerebrospinal fluid.
Tumors Adjacent to Fourth Ventricle
Very often tumors may arise in cerebellopontine angle
(CP angle) which is related to cavity of fourth ventricle.
These are classically named as CP angle tumors.
Tumors may arise also from ependyma lining the
floor of fourth ventricle. It is called ependymoma.
In case of children medulloblastoma is very common.
It is an expanding tumor arising from undifferentiated
neuroectodermal cells of vermis of cerebellum.
These tumors presents the following effects.
1. Effects due to cerebellar lesion which is fundamen-
tally manifested by disorder in equilibrium or
balance, hypotonia and incoordination of move-
ments.
2. Effect due to pressure on vital centers with
hypoglossal and vagal triangles. It may cause
disorders in cardiovascular functions, difficulty in
respiration, swallowing and movements of tongue,
when the patient needs artificial life support.
Blockage of Flow of Cerebrospinal Fluid
Foramen of Magendie and foramen of Luschka may
be occluded due to following reasons.
1. Obstruction by expanding tumors in the vicinity.
2. Obstruction due to fibrous adhesion in arachnoid
mater in close proximity of foramina following
meningitis.
Obstruction of the foramina will interfere with
free circulation of cerebrospinal fluid from ventricular
system of central nervous system to subarachnoid
space. It will lead to dilatation of ventricular system
due to over accumulation of cerebrospinal fluid. It
is called internal hydrocephalus. This condition will
have a pressure effect on surrounding neural tissue
and finally lead to atrophy of brain.
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 CerebrumCortical Gray Matter
INTRODUCTION
Cerebrum (telencephalon) is the largest part of
the brain. It is largest in size because of maximum
proximalization of various motor as well as sensory
centers of human brain. It means that, during evo-
lution, many motor and sensory centers of central
nervous system have shifted to cerebrum from
lower brain.
Left cerebral hemisphere
Cerebrum is widest a little
behind the middle
Fig. 8.1 CerebrumSpherical in outline when viewed from above
8
n The whole cerebrum a sphere (Fig. 8.1): The
total cerebrum, when seen from above, looks like a
sphere which is slighty broader in its posterior part.
Its maximum diameter is opposite the level of an
imaginary line joining two parietal tuberosities skull.
n Outer gray matter and inner white matter:
Superficial part of cerebrum is made up of grayish
colored neuronal cell bodies which forms gray matter.
Right cerebral hemisphere
Sulcus
Gyrus
Median longitudinal
fissure dividing
cerebrum into two
cerebral hemispheres

This constitutes cerebral cortex. Deep inner or central
core is made up of process of neurons which are whitish
myelinated nerve fibers. This component of cerebrum
is called white matter or medullary substance.
n Gyrus (Plural gyri) and Sulcus (Plural
sulci) of cerebral cortex: Since fetal life cerebrum
grows within the limited volume of cranial cavity.
There appears need for increase of surface area of
cerebral cortex which finally attains 2000 sq cm in
adult brain. That is why surface of cerebral cortex
(gray matter) presents foldings or convolutions which
are called gyri (Singular gyrus). Adjacent gyri are
separated from each other by fissures which are called
sulci (Singular sulcus). Formation of convolutions or
gyri increase the surface area of cerebral gray matter
3 times. Its one-third is visible on the surface and
two-third is hidden on the walls and floor of sulci.
n Sphere of cerebrum divided into right and left
symmetrical halves (Fig. 8.2): Spherical cerebrum
is divided into two (right and left) symmetrical halves
with the help of a deep, anteroposteriorly running
midline cleft called median longitudinal fissure. This
fissure completely divides the cerebrum into two
halves from anterior, superior and posterior aspect
of cerebrum. Each half of the sphere of cerebrum is
called thereby Cerebral Hemisphere. However, both
the hemispheres are not separated from each other on
the inferior aspect where they together form the base
of the brain because,
i. At the bottom of median longitudinal fissure,
a curved C shaped structure transversely
running across the midline links or connects
identical areas of both cerebral hemispheres
which is called corpus callosum (Fig. 8.2).
ii. Inferiorly, both cerebral hemispheres, merging
with each other, form base of the brain which
is continuous with ventral diencephalon (hypo-
thalamus and subthalamus) and brainstem.
Medial surface of right
cerebral hemisphere
Fig. 8.2 Cerebral hemisphere (Rt) seen from medial side
CerebrumCortical Gray Matter
CEREBRAL HEMISPHERES
Gross Surface Features
Initially cerebral hemispheres are to be studied under
the heading of following gross surface features.
Poles
3 in numbers as follows (Figs 8.3 to 8.5).
1. Frontal pole: It is the more rounded anterior end
of cerebral hemisphere. It lies beneath medial part
of superciliary arch of frontal bone.
2. Occipital pole: It is the more pointed posterior
end of cerebral hemisphere. This pole lies beneath
occipital bone a little superolateral to external occ-
ipital protuberance.
3. Temporal pole: It is the anteroinferior end of
cerebral hemisphere. It is lodged into anterior end
of middle cranial fossa.
Embryologically, temporal pole is the posteriormost
end of developing cerebrum, which is curved ventrally
during rotational growth of brain (Fig. 8.6).
Surfaces
Primarily, cerebral hemispheres presents 3 surfaces.
1. Superolateral surface (Fig. 8.3)
It is the convex and widest surface. Its convexity fits
with the concavity of corresponding half of cranium.
2. Medial surface (Fig. 8.4)
It is flat and corresponds to paramedian vertical
plane. Most important features of this surface are
i. Compact section through horizontally running
fibers in the form of C shaped band with its
convexity upwards. It is corpus callosum.
Outer (superolateral) surface
Corpus callosum, a thick compact
band of fibers crossing midline to
connect two cerebral hemisphere
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Lateral sulcus Central sulcus

Frontal lobe
Parietal lobe

Parietooccipital sulcus
Frontal pole

Temporal pole Occipital pole

Temporal lobe Occipital lobe

Fig. 8.3 Superolateral surface of cerebrum showing poles and lobes

ii. Below corpus callosum, smooth medial surface
of diencephalan (thalamus) of corresponding
side.
3. Inferior surface (Fig. 8.5)
Outline of temporal pole divides this surface into two
parts.
i. Anterior: It is smaller and anterior to temporal
pole. It is flat and called orbital surface as it
rests on the roof of orbit formed by anterior
cranial fossa of skull.
ii. Posterior: It is elongated and slightly concavo-
convex lying behind temporal pole. It is called
tentorial surface because it rests on a hori-
zontal fold of dura mater (outermost covering
of brain) called tentorium cerebelli.
Borders
Borders are to demarcate (separate) adjacent surface.
These are as follows:
Fornix Corpus callosum Septum pellucidum
Superomedial
border
In total, borders are six in number. Before going
to study and recognize the borders, readers are to
understand following points.
First 3 borders separate superolateral surface
from medial surface (1 border) and inferior surface (2
borders).
Next 3 borders separate medial surface from
inferior surface. These borders together are known as
inferomedial border.
1. Superomedial border: It separate superolateral
surface from medial surface (Figs 8.4 and 8.6).
2. Inferolateral border: This border separates
superolateral surface from posterior tentorial
part of inferior surface. It extends from temporal
pole to occipital pole (Fig. 8.5). A little in front of
occipital pole, this border presents a notch called
preoccipital notch.
3. Superciliary border: This is a small curved
border which separates superolateral surface from
anterior orbital part of inferior surface (Fig. 8.5).
Frontal pole
Superciliary
Medial orbital
border
border Temporal pole
Optic

}
chiasma Orbital
Infundibulum surface
Inferior
of pituitary
surface
Mammillary Tentorial
body surface
Posterior
Hippocampal
perforated
border
substance
Midbrain

Medial occipital Inferolateral

border border
Occipital pole Thalamus Temporal pole Frontal pole Occipital pole

Fig. 8.4 Medial surface of cerebral hemisphere Fig. 8.5 Inferior surface of cerebral hemisphere
146

Superomedial border
Medial surface
Medial border
Fig. 8.6 Borders and surfaces of cerebral hemisphere on coronal section
Medial surface of cerebral hemisphere is separated
from 3 components of inferior surface by following
3 borders (Fig. 8.5).
4. Medial orbital border: It separates medial sur-
face from anterior, frontal part of inferior surface
(orbital surface).
5. Hippocampal border: It separates medial sur-
face from middle, temporal part (hippocampal
gyrus) of interior surface.
6. Medial occipital border: It separates medial
surface from posterior, occipital part of inferior
surface.
Gyri and Sulci
Gyri, so also sulci are present in human brain and brain
of higher mammals. These are called gyrencephalic
brain. Cerebral cortex of lower mammals, birds and
reptiles, presents smooth surface called lissencephalic
brain.
Sulci of cerebral cortex are of variable length and
depth. A suclus separates two adjacent gyri (Fig. 8.7).
Sulcus
Gyrus
Gyrus
White
matter
Fig. 8.7 Interrelation of gyrus and sulcus
CerebrumCortical Gray Matter
Superolateral surface
Inferior surface
Inferolateral border
It has two adjacent walls and floor which are lined
by layer of gray matter overlying the core of white
matter.
Some important sulci
Sulci of cerebral hemisphere are many. Some are
named and some are unnamed. It is not yet the stage
of this chapter to know the names of all the sulci. But
it is the time to be acquainted with some of the sulci
which are important embryologically and functionally.
1. Lateral sulcus (Fig. 8.8A)
Lateral sulcus is also called fissure of Sylvius. It is
most prominent sulcus recognized between temporal
pole and orbital surface from where it begins as stem.
The stem passes upwards and backwards on the
superolateral surface. Immediately then, at a point
known as sylvian point, it divides into 3 limbs as
follows
i. Anterior horizontal limb: 2.5 cm in length,
passes horizontally forwards.
ii. Anterior ascending limb: Also 2.5 cm in length,
passes vertically upwards.
iii. Posterior limb: 7.5 cm long, passes upwards
and backwards. Its end is curved and directed
upwards.
2. Central sulcus of Rolando (Fig. 8.8A)
On the superolateral surface, central sulcus begins
by cutting superomedial border 1 cm behind the
midpoint between frontal and occipital poles. It runs
downwards and forwards on the superolateral surface
making an angle of 70 with superomedial border. It
ends a little above posterior ramus of lateral sulcus.
Upper end of the sulcus extends for 12 cm on the
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Posterior ramus of
lateral sulcus
Anterior vertical
ramus
Anterior horizontal
ramus
Stem of lateral
sulcus A
Parietooccipital sulcus
Postcalcarine sulcus
B
Figs 8.8 A and B A.Some important sulci on superolateral surface, B. Some important sulci on medial surface
medial surface of cerebral hemisphere. A learner may
easily identify central sulcus as it is the sulcus cutting
superomedial border. Besides, other sulci in front and
behind, can easily be identified with its help.
3. Parietooccipital sulcus (Fig. 8.8B)
This sulcus is present on the medial surface of cerebral
hemisphere. It starts by cutting superomedial border
5 cm in front of occipital pole and runs downwards and
forwards. It ends by joining the junction of calcarine
sulcus and postcalcarine sulcus (see below).
It may extend on the superolateral surface (Fig.
8.8A).
4. Calcarine and postcalcarine sulcus (Fig. 8.8B)
They are continuous with each other and present on
medial surface of cerebral hemisphere. Calca-rine
sulcus starts a little behind and below the posterior
end of corpus callosum (splenium). It then runs
backwards with a convexity upwards and continued
as postcalcarine sulcus, where it is joined by pari-
etooccipital sulcus. Postcalcarine sulcus ends at
occipital pole and extends slightly on superolateral
surface.
148
Central sulcus
Curved upper end of parieto-
occipital sulcus
Curved upper end of
central sulcus
Calcarine sulcus
Types of sulcus
According to the nature and function, sulci of cerebral
cortex are classified in following types.
1. Primary sulcus (Fig. 8.10): Most of the sulci are
of primary type which are developed in embryonic
life just to increase the surface area of the cerebral
cortex.
2. Secondary sulcus (Figs 8.9A and 8.10): Exa-
mple is lateral sulcus. Secondary sulcus is that
sulcus which is developed because of rotational
growth of cerebral hemisphere around it.
3. Complete sulcus (Fig. 8.9B): This is the sulcus
which is complete in depth to extend through whole
thickness of cerebral cortex and medulla to reach
up to the wall of the cavity (ventricle) of cerebrum
where it produces an indentation. Example is
calcarine sulcus (Fig. 8.10B) and collateral sulcus.
4. Limiting sulcus (Fig. 8.9A): This sulcus limits or
separates two different areas in its two walls which
are different functionally as well as structurally.
Example is central sulcus on superolateral surface
which separates motor area (in front) and sensory
area (behind).
5. Axial sulcus (Fig. 8.9B): By nature it is just
opposite to limiting sulcus. It means that, this is
the sulcus bounded by two walls which are similar
functionally and also structurally. Example is
 CerebrumCortical Gray Matter

Central sulcus is an example

of limiting sulcus

Lunate sulcus is an example

of operculated sulcus

Lateral sulcus is an example of

secondary sulcus which is developed
due to rotation growth of cerebrum

Wall of ventricle

Calcarine sulcus is an
example of complete sulcus

Postcalcarine sulcus is an
example of axial sulcus

Figs 8.9A and B A.Varieties of sulcus (superolateral surface), B.Varieties of sulcus (medial surface)

postcalcarine sulcus whose both walls are primary
visual area.
6. Operculated sulcus (Fig. 8.9A): This is the
sulcus where the two lips are two functional
areas and both the walls are lined by third
functional areas. Example is lunate sulcus which
is a small semilunar sulcus present just in front
of the occipital pole on superolateral surface with
concavity backward.
Lobes of Cerebral Hemisphere
Each of the cerebral hemisphere is divided into five
lobes as i) Frontal lobe, ii) Parietal lobe, iii) Occipital
lobe, iv) Temporal lobe and v) Central lobe.
The first four lobes are incompletely separated from
each other by 3 important sulci and two imaginary
lines on superolateral surface of cerebral hemisphere.
The central lobe is submerged at the bottom (floor) of
stem of lateral sulcus.
3 important sulci separating the lobes on
superolateral surface are (Figs 8.3 and 8.11A)
l Central sulcus
l Stem of lateral sulcus and its continuation as
posterior limb.
l Curved upper end of parietooccipital sulcus
extending on to the superolateral surface after cutting
superomedial border.
l 2 lines drawn on superolateral surface are (Fig.
8.11A).
l A vertical line drawn from curved upper end of
parietooccipital sulcus on supermedial border to pre-
occipital notch on inferolateral border.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Primary sulci start appearing to

increase surface area of cerebral
cortex

A Secondary sulcus appears as axis

for rotational growth

B
Formation of temporal lobe starts

Parietal lobe

Frontal lobe

Occipital lobe

Lateral sulcus
C Temporal lobe

Figs 8.10 A to C Stages of development different lobes of cerebral cortex with gradual development of primary and secondary sulci

A horizontal line extending from end of posterior n Embryological backgrounds: It is not the
limb of lateral sulcus up to the vertical line as menti- fifth, rather embryologically it is the first lobe of
oned above. cerebral hemisphere. Around this insula, rotational
The four lobes outlined on superolateral surface overgrowth of the cortex sequentially gives rise to
(Vide Figs 8.3 and 8.11A) are following: formation of frontal, parietal, occipital and temporal
1. Frontal lobe lobes (Fig. 8.10).
2. Parietal lobe n Sulci and gyri of insula (Fig. 8.11B): Whole
3. Occipital lobe of area of insula is surrounded by a circular sulcus.
4. Temporal lobe. A vertical sulcus called central sulcus of insula
subdivides central lobe (insula) into anterior and
Central lobe (Insula or Island of Reil) (Fig. 8.11B) posterior parts both of which present vertical gyri.
Central lobe is also called insula or island of Reil. It Anterior to central sulcus of insula, gyri are shorter
is situated at the bottom or floor of stem of lateral therefore called gyrus brevis which are 34 in number.
sulcus. It is submerged and is visualized when two Posterior group of gyri are longer and 12 in numbers.
lips of stem of lateral sulcus are everted. They are called gyrus longus.
150

Frontal lobe
Temporal lobe
A
Central sulcus
of insula
Gyrus brevis
Two lips of lateral sulcus
separated to expose central
lobe (insula) or island of Reil B
Figs 8.11A and B A. Four lobes of cerebral hemisphere, B. Central lobe (insula) of cerebral hemisphere
n Operculum: Insula is hidden or overlapped by
areas of frontal, parietal and temporal lobes which are
called frontal, frontoparietal and temporal opercula.
Sulci and gyri on three surfaces of cerebral
hemisphere
Superolateral surface (Fig. 8.12)
On this surface, sulci and gyri can be divided according
to four different lobes as follows. (Sulci and gyri of
central lobe or insula has already been described
above).
Frontal lobe
1. Precentral gyrus: This gyrus is situated in
front and parallel to central sulcus which limits
frontal lobe from parietal lobe. Precentral gyrus is
bounded in front by precentral sulcus.
2. Superior, middle and inferior frontal gyri:
These are three anteroposteriorly directed gyri,
parallel to each other, extending forward towards
CerebrumCortical Gray Matter
Parietal lobe
Occipital lobe
Circular sulcus
Gyrus longus
frontal pole. These three gyri are situated in front
of precentral sulcus and are demarcated from each
other by two anteroposteriorly directed sulci called
superior and inferior frontal sulci.
3. Subdivisions of inferior frontal gyrus: Infe-
rior frontal gyrus is divided into three parts by
two limbs of lateral sulcus which are anterior
horizontal and anterior ascending limbs.
i. Pars orbitalis: Part of inferior frontal gyrus
below anterior horizontal limb of lateral
sulcus.
ii. Pars triangularis: It is the part between ante-
rior horizontal and anterior ascending limbs of
lateral sulcus.
iii. Pars opercularis: It is the part of inferior frontal
gyrus between anterior ascending ramus and
posterior limb of lateral sulcus.
Parietal lobe
1. Postcentral gyrus: It is the anterior most
gyrus of parietal lobe running downwards and
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Superior frontal gyrus
Superior frontal sulcus
Middle frontal gyrus
Inferior frontal sulcus
Anterior ascending limb
Anterior horizontal limb
and stem of lateral sulcus
Posterior ramus of lateral
sulcus
Superior temporal gyrus
Superior temporal sulcus
Fig. 8.12 Important sulci and gyri on superolateral surface of cerebral hemisphere
forwards from superomedial border. It is bounded
posteriorly by postcentral sulcus.
2. Superior and inferior parietal lobule: Rema-
ining part of parietal lobe behind postcentral
gyrus is divided in upper and lower segments,
called superior and inferior parietal lobules with
the help of anteroposteriorly directed horizontal
sulcus called intraparietal sulcus.
3. Subdivisions of inferior parietal lobule: These
are two small semilunar gyrus as follows.
i. Supramarginal gyrus: It is anterior of the two,
which caps round the upturned posterior end
of posterior limb of lateral sulcus.
ii. Angular gyrus: It is posterior of the two small
semilunar gyrus which caps over the posterior
end of superior temporal sulcus.
Occipital lobe
1. Occipital pole: It is the posterior end which
is cut from remaining part of occipital lobe by a
small semilunar sulcus which is convex forwards.
This sulcus is known as lunate sulcus. This polar
area of occipital lobe is bisected into anteroinferior
and posterosuperior lips by continuation of post-
calcarine sulcus from medial surface of cerebral
hemisphere on its superolateral surface.
152
Precentral gyrus
Central sulcus
Postcentral gyrus
Intraparietal sulcus
Superior parietal lobule
Parietooccipital sulcus
Supramarginal gyrus
Inferior parietal lobule
Angular gyrus
Lunate sulcus
Upturned posterior end
of postcalcarine sulcus
Inferior temporal gyrus
Inferior temporal sulcus
Middle temporal gyrus
2. Upper and lower occipital lobules: One antero-
posterior sulcus subdivides remaining parts of
occipital lobe anterior to lunate sulcus into upper
and lower occipital lobule. The sulcus is known as
transverse occipital sulcus.
Another small vertical sulcus called lateral occi-
pital sulcus runs vertically for short distance, in front
of parietooccipital sulcus. It divides upper occipital
lobule into anterior and posterior parts.
Temporal lobe
1. Superior, middle and inferior temporal gyri:
These are three anteroposteriorly directed gyri
of temporal lobe situated from above downwards
respectively, below and parallel to stem and
posterior limb of lateral sulcus.
These three gyri are separated by two antero-
posterior sulci called superior and inferior temporal
sulci.
2. Transverse temporal gyri: These are two in
number. These gyri is visualized when two lips of
stem of lateral sulcus are widened with fingers.
They are lateromedially directed on the superior
surface of superior temporal gyrus. Anterior
of two transverse temporal gyri is known as
Heschls gyrus.
 CerebrumCortical Gray Matter
Paracentral lobule Fornix

Central sulcus Septum pellucidum

Isthmus Corpus callosum

Suprasplenial sulcus
Callosal sulcus

Precuneus Cingulate gyrus

Cuneus
Parietooccipital sulcus Medial frontal gyrus
Anterior commissure
Calcarine sulcus
Thalamus
Postcalcarine sulcus Paraterminal gyrus

Lingual gyrus Parahippocampal

gyrus

Rhinal sulcus
Medial temporooccipital gyrus
Uncus
Temporooccipital sulcus
Lateral temporooccipital gyrus Collateral sulcus

Fig. 8.13 Different features (with important sulci and gyri) of medial surface of cerebral hemisphere

MEDIAL SURFACE (FIG. 8.13)
Before going to study the gyri and sulci of medial
surface of cerebral hemisphere, a reader must note
the following two important points.
1. Medial surface presents some prominent stru-
ctures which are other than cortical gyri.
2. Gyri and sulci are not studied in individual
lobewise because some of them are continuous
from one lobe to adjacent lobe.
Structures Other than Cortical Gyri
1. Corpus callosum: It is a C shaped compact band
of white matter (fibers) with convexity directed
upwards, present at the center of medial surface
of cerebral hemisphere.
Fibers passing through all the parts of corpus
callosum cross the midline and connect identical
cortical areas of all the parts of both cerebral hemi-
spheres. This is an example of commissural fibers.
Most rostral (cephalic) part of corpus callosum
is thin and directed downwards and backwards. It
is called rostrum. Next, the bend is known as genu.
Behind genu the main part is known as body which
ends posteriorly into a blunt rounded end called
splenium.
2. Fornix: Below the middle of corpus callosum starts
a white band of fibers which extends downwards
and forwards upto rostral end of corpus callosum.
It is called fornix. Fibers in the fornix connect
different areas of same cerebral hemisphere and is
an example of association fibers.
3. Septum pellucidum: It is a thin bilaminar
membrane bridging between fornix and anterior
part of corpus callosum. Lateral to this septum lies
the cavity of cerebral hemisphere (telencephalon)
called lateral ventricle of brain.
4. Thalamus: Below posterior part of corpus
callosum and behind fornix, medial surface of
thalamus (diencephalon) is visible. On either side
of midline, medial surface of thalamus of both
cerebral hemispheres forms lateral boundary of
third ventricle of brain (cavity of diencephalon).
Thalamus is continuous with hypothalamus below
and in front, and with subthalamus below and
behind.
5. Anterior commissure: It is small cross section
of compact bundle of commissural fibers which is
situated in front of anterior end (anterior column)
of fornix.
Gyri and Sulci on Medial Surface
1. Cingulate gyrus: It is a thick curved gyrus with
convexity upwards, above and surrounding the
curvature of corpus callosum.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
It is separated from corpus callosum by callosal sulcus.
Cingulate gyrus is demarcated above by cingulate
sulcus. This sulcus starts at its anteroinferior end
below rostrum of corpus callosum. Its posterior end is
upturned behind upper end of central sulcus. A small
limb from it extends upwards towards superomedial
border in front of central sulcus.
n End of cingulate gyrus:
l i. Anterior end: It is very narrow end which is
below rostrum of corpus callosum. It is called
paraterminal gyrus.
l ii. Posterior end: It curves round splenium of
corpus callosum and ends at the posterior end
of temporal lobe. It is called isthmus.
Next group of gyri are studied from occipital pole
to frontal pole.
2. Lingual gyrus: It is a curved gyrus with convexity
upwards like that of tongue, situated on lower part
of medial surface of occipital pole. It is bounded
above calcarine and postcalarine sulci.
3. Cuneus: It is a triangular area of cortex bounded
by parietooccipital sulcus and postcalcarine sulcus.
It is situated above posterior end of lingual gyrus.
4. Precuneus: It is the quadrangular area in front
of cuneus. It is bounded behind by parietooccipital
sulcus and in front by posterior limb of curved
upturned end of cingulate sulcus. Inferiorly it is
demarcated from posterior end of cingulate gyrus
by superosplenial sulcus which is a small curved
sulcus posterosuperior to splenium of corpus
callosum.
Olfactory sulcus
Olfactory bulb
Olfactory tract
Gyrus rectus
Lateral olfactory stria
Optic chiasma
Infundibulum
Mammillary body
Posterior perforated substance
Midbrain
Fig. 8.14 Different features (with sulci and gyri) of inferior surface of cerebral hemisphere
154
5. Paracentral lobule: It is another quadrangular
cortical area in front of precuneus.
n Boundaries:
l Behind: Posterior limb of posterior upturned end
of cingulate sulcus.
l In front: Upturned anterior limb of cingulate
sulcus.
l Below: Posterior end of cingulate sulcus.
l Above: Superomedial border of cerebral hemis-
phere.
l Subdivision: Paracentral lobule is bisected by
upward continuation of central sulcus on medial
surface into anterior and posterior parts. These two
parts are upward continuation of precentral gyrus
and postcentral gyrus respectively on medial surface.
6. Medial frontal gyrus: It is the wide, flat and
curved gyrus on medial surface of frontal lobe
starting in front of paracentral lobule, curving
over the frontal pole and ending below genu and
in front of rostrum of corpus callosum.
Gyri and Sulci on Medial Surface of Temporal
Lobe (Consult both Figs 8.13 and 8.14)
These gyri and sulci are continuous from medial
surface to inferior surface (tentorial part) of cerebral
hemisphere which are mentioned below.
Gyri and Sulci on Inferior Surface (Fig. 8.14)
These are divided into two parts
l Gyri and sulci on inferior surfaces of occipital and
temporal lobes (tentorial surface).
}
Anterior
Medial
Orbital gyri
Lateral
Posterior
Anterior perforated substance
Uncus
Parahippocampal gyrus
Medial temporooccipital gyrus
Temporooccipital sulcus
Lateral temporooccipital gyrus
Collateral sulcus

l Gyri and sulci on inferior surface of frontal lobe
(orbital surface).
TENTORIAL SURFACE (FROM MEDIAL TO LATERAL)
1. Parahippocampal gyrus: It is anterior continu-
ation of lingual gyrus extending from medial surf-
ace to inferior surface of temporal lobe. This gyrus
is demarcated laterally by collateral sulcus.
Parahippocampal gyrus presents anteriorly a
hook-like ending known as uncus which is bounded
outwards by a small curved sulcus called rhinal
sulcus.
2. Medial and lateral temporooccipital gyri:
As the name suggests, these two gyri extend
anteroposteriorly and parallel to each other from
temporal lobe to occipital lobe. These two gyri are
separated from each other by the sulcus known
as temporooccipital sulcus. Medial of the two
gyri is separated from parahippocampal gyrus by
collateral sulcus.
ORBITAL SURFACE
1. Gyrus rectus: It is a thin and narrow anterop-
osteriorly running straight gyrus just lateral to
medial border of orbital surface. It is laterally
bounded by an anteroposterior sulcus called
olfactory sulcus. It is so called because it lodges
olfactory tract with its anterior rounded end called
olfactory bulb.
2. Orbital gyri: They are four in number present
lateral to olfactory suclus. They are named as per
their interrelationshipanterior, posterior, medial
and lateral. These four orbital gyri are separated
from each other by a Hshaped orbital sulci.
SOME IMPORTANT POINTS ABOUT CEREBRAL CORTEX
1. As per as evolution concerned, cerebral cortex
indicates the highest stage of development of
human brain.
2. Phylogenetic subdivision:
a) Archicortex: In human brain, phylogenetically
it is the most primitive part of cerebral cortex.
It is composed of parts of rhinencephalon inclu-
ding hippocampus (parahippocampal gyrus).
Therefore, archicortex covers small area of
cerebral cortex.
But in lower vertebrates, archicortex is of
considerable size.
b) Paleocortex: It is intermediate in evolution.
In human brain it is represented by cingulate
gyrus.
CerebrumCortical Gray Matter
c) Neocortex: It is the major part of human ce-
rebral cortex which is evolved latest. It is
represented by 90% of human cortex.
3. Structural composition: Cerebral cortex is
made up of
i. Neurons with chain of synapses.
ii. Neuroglia.
Total number of neurons in human cerebral cortex
is 14000 millions.
Neurons are arranged in stratification of layers.
Maximum number of layers are six (6) in neocortex.
Minimum number are three (3) in archicortex.
4. Gross functions: In reference to both motor com-
mands and sensory responses, cerebral cortex
posseses influence over opposite half of body.
Basic functions of cerebral cortex are as follows:
i. Perception of various sensations.
ii. Reaction or response as per perception of
sensation.
iii. To send motor commands to opposite half of
body.
iv. Various types of higher functions for mental
activities, e.g. memory, intelligence, learning,
creative thinking, etc.
TYPES OF NEURONS IN CEREBRAL CORTEX (FIG. 8.15)
There are five varieties of neurons in cerebral cortex
as stated below. But first two types, namely pyramidal
cells and granule cells are most important.
1. Pyramidal cells: These are so called because of
pyramidal shape. Their long axis are at right angle
to the surface of cortex. In longitudinal section
cells are triangular in appearance with their
apices directed towards the surface and bases face
towards white matter. Dendrites are connected to
the angles. From the bases, long axons arise and
pass to the depth of white matter of cerebrum.
Types of pyramidal cells as per size.
i. Small size 10 um (micron)
ii. Medium size 50 um (micron)
iii. Large size 100 um (micron). These cell group
are also called Betz cells or pyramidal cells of
Betz.
2. Granule cells: These cells are also called stellate
cells as they are small star-shaped cells with many
radiating dendrites and short axon. Diameter of
cell bodies are 8 um (micron). Small cell bodies
give granular appearance of the cortex for which
they are called granule cells.
3. Cells of Martinotti: These are small multipolar
cells present in all the layers of cortex. Figure 8.15
shows their axons projecting towards the surface
of cortex.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

1
Horizontal cell of Cajal

2 Granule (stellate) cell

Gray matter layers 3

Pyramidal cell Granule (stellate)
Cell

4 Cells of
Martinotti

Fusiform cell
5
Betz cell

White matter

Fig. 8.15 Types of neurons in cerebral cortex

4. Horizontal cells of Cajal (pronounce as cahal):
The cells are fusiform in outline with the long axis
of cell body placed parallel to cortical surface. These
neurons are present in all the layers of cortex.
5. Fusiform cells: Cell bodies of these neurons are
spindle-shaped or fusiform in outline with their
long axis placed at right angle to the cortical
surface. They are present in deeper layer of cortex
and their axons projecting towards white matter.
LAYER OF CEREBRAL CORTEX (FIG. 8.16)
Neurons of cerebral cortex are arranged in multiple
numbers of stratum which varies from 3 to 6. When
the neocortex presents 6 layers, archicortex is made
up of 3 layers.
From superficial to deep, six layers of the cortex
are as follows
1. Molecular or plexiform layer: It is made up of
mainly reticulum or network of nerve fibers with
intermingling horizontal cells of Cajal.
2. External granular layer: This layer is made up
of granule cells or stellate cells. Characteristic of
this layer is that cells are densely packed. There is
intermingling of minimum number of fibers.
3. External pyramidal layer: It is made up of small
and medium size of pyramidal cell. Long-axis of the
156
cells are at right of the angle to the plane of the
cortex. Apex of the cells are directed towards the
surface of the cortex and bases are directed towards
the depth. Size of the pyramidal cells gradually
increase from superficial to deeper plane.
4. Internal granular layer: This layer is made up
of closely packed granule cells or stellate cells.
Structurally this layer gives striated appearance
because middle of this layer is traversed by band
of nerve fibers. This band is called external band of
Baillarger. The cortex of this type is called striate
cortex. Example of this type of cortex is visual
cortex on either lip of postcalcarine sulcus.
5. Internal pyramidal layer (ganglionic layer):
This layer is made up of large pyramidal cells of
Betz. Axon of this cells form corticospinal tract.
Basal part of this layer is traversed by band of
horizontally running fibers called internal band of
Baillarger.
6. Multiform layer or polymorphic cell layer: Charact-
eristic of this layer are following
i. It presents neurons of different types, size and
shape.
ii. Cells of this layer are intermingled with nerve
fibers.
iii. This cellular layer merges with white matter
deep to it.
 CerebrumCortical Gray Matter

1. Molecular or plexiform layer Reticulum of fibers and

horizontal cells of Cajal

Densely packed granule or

2. External granular layer
stellate cells

3. External pyramidal layer Small and intermediate

pyramidal cells

Closely packed granule

4. Internal granular layer
(stellate) cells with outer
(external) band of Baillarger

5. Internal pyramidal or Large pyramidal cells of Betz

ganglionic layer and inner (internal) band of
Baillarger

6. Multiform or polymorphic Layer of neurons of various

cell layer types, size and shape inter-
mingled with nerve fiber

Fig. 8.16 Different layers of cerebral cortex

The cortical areas which show all of the above
mentioned six layers of cortex well-defined, are called
homotypical cortex.
In heterotypical cortex, all the six layers are not
equally defined. Even same may have less than six
layers, two main varieties of this cortex are as follows:
i. Granular cortex: In this type, granule cell
layer is well-defined and pyramidal cell layer
is poorly developed. Example is sensory cortex.
ii. Agranular cortex: This cortex shows poor dev-
elopment of granule cell layer with well-defined
pyramidal cell layer. Example is motor cortex.
FUNCTIONAL AREAS OF CEREBRAL CORTEX
It has already been seen that cerebral cortex presents
different named areas in different surface. It has also
been seen many of them are structurally different.
It is the time now to note that they are functionally
different. In the year 1909, Brodmann classified
these areas from number 147 and thereby called
Brodmanns area. It is important to note that these
functional areas are not numbered serially or
sequentially.
So the cortical areas are mentioned below with
their names, Brodmanns numbers and respective
functions (Figs 8.17 and 8.18).
FUNCTIONAL AREAS IN FRONTAL LOBE
Area-4 of Brodmann
Location
It is the precentral gyrus on superolateral surface
of frontal lobe with its extension as anterior part of
paracentral lobule on medial surface.
It is called primary motor area (Fig. 8.17).
Functions
Area 4 (primary motor area) controls or commands
movements of voluntary muscles of opposite half of
body through corticospinal and corticonuclear tracts.
Different parts of the gyrus, starting from lower
end to uppermost end extending to anterior part of
paracentral lobule on medial surface, controls muscle
groups of different part of body.
Different areas of body are represented to the
gyrus in upside down manner. It called inverted
homunculus (Fig. 8.19).
On superolateral surface, from lower end to upper
end, precentral gyrus (area 4) controls voluntary
muscles of following regions of body in inverted
order as pharynx, larynx, tongue, face, neck, hand,
forearm, arm, shoulder, thorax and abdomen.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Primary motor area Primary somatosensory area

Premotor area
Sensory association area for
Frontal eye field stereognosis

4 5
6 3 2
8
Prefrontal area 9 7

1
40
43
44 2
45 41, 4 19 Visual association area
39
22
Brocas area (Motor 18
speech area) 17 Primary visual area

Posterior end of postcal-

Primary auditory area carine sulcus
Wernickes sensory
Secondary auditory area speech area

Fig. 8.17 Functional areas on superolateral surface of cerebral hemisphere

Paracentral lobule Supplementary motor area

4 6
3
1 8
2

23 9
24 Prefrontal area
10

Primary visual area 17

(striate cortex)
17 11

28

Uncus

Parahippocampal gyrus Primary olfactory area

Fig. 8.18 Functional areas on medial surface of cerebral hemisphere

Muscles of perineum and lower limb are controlled
by anterior (motor) components of paracentral lobule
on medial surface which is the continuation of area 4.
It is interesting to note that one part of surface
area of the cortex of area 4 is not directly proportional
to the bulk of the muscle or area of the body it
controls. Rather it coincides with the skill of the
muscle group. For example, Figure 8.19 of inverted
homunculus shows that face with lips and eyeballs
158
coincide with comparatively wider part of precentral
gyrus (area 4).
n Effect of lesion: Like other parts of brain, lesions
of any part of cerebral cortex are mostly vascular
in origin. But it may be traumatic, degenerative or
neoplastic. Lesions of area 4 of Brodmann will cause
loss of function of voluntary muscles (paralysis)
of opposite half of body. It is grossly manifested by
paralysis of contralateral upper and lower limbs. It is
called hemiplegia.
 CerebrumCortical Gray Matter
Functions
Like primary motor area (area 4), the premotor
area (area 6) also gives rise to corticospinal and
Shoulder
Trunk
Hip

Elbow
corticonuclear fibers which project downwards from

Wrist
Kn

nd
ee

An cerebral cortex. Through these projection fibers, very

Ha
kle

Ri le
characteristic function of premotor area is to produce

t
Lit
To

ng
es

Th Inde dle
skilled movements of voluntary muscles, whose

d
x
i
M

Ne mb
movements are planned or designed grossly by cortic-

Br ck
u
Fingers

ow
al
l ospinal and corticonuclear tracts from primary motor
eb
ey area.

ce
d
an

Fa
lid Premotor area is called secondary motor area. Both

LIZATION
ye Lips
E
primary (area 4) and secondary (area 6) motor areas
are together known as primary somatomotor area.
Ja
To w
Sw
VOCA
ng
all
ow
ue n Effect of lesion: Motor dysfunction caused by
ON

ing
lesion of premotor area is called apraxia which is
TI

A
TIC characterized by impairment of skillful movements
M AS
of voluntary muscles, even if primary motor area is
normally functioning.

Frontal Eye Field (Area 8)

Fig. 8.19 Motor humunculus showing somatopical as well as
proportional representation in the primary motor area of cerebral
cortex (Ref. and courtesy W. Penfield T. Rasumussen, 1950)
Area 6, 8, 9 of Brodmann
These areas are located from behind forwards in the
following gyri of frontal lobe.
This area is located in the middle of middle frontal
gyrus in front of area 6. It is so called because
stimulation of this area causes conjugate deviation of
both eyes to the opposite side. It means that, if left
sided frontal eye field is stimulated, both eyeball will
be deviated to the right side by contraction of lateral
rectus muscle of right eye and medial rectus muscle

}
1. Superior frontal gyrus
2. Middle frontal gyrus on superolateral surface of left eye. It is called scanning movement of eyeball.
3. Inferior frontal gyrus n Effect of lesion: From the function of frontal
4. Medial frontal gyrus on medial surface eye field mentioned above, it is clear that, lesion of
this area will cause impairment of deviation of both
In all of the above 4 gyri, area 6, 8 and 9 are located
eyeball to the opposite side. So, unopposed action of
as follows: frontal eye field of normal side will cause deviation of
i. Area 6 in their posterior parts both eyes to the side of lesion.
ii. Area 8 in their middle parts
iii. Area 9 in their anterior parts. Brocas Area or Motor Speech Area (Area 44
These areas are concerned with various functions and 45)
which are mentioned below:
Location
Area 10 and 11 of Brodmann
Most important point is to note that, this area is not
These two areas are located on medial surface of located for functioning in both cerebral hemisphere.
frontal pole as continuation of area 9. In right handed person (about 90%) it is located in left
cerebral hemisphere, so vice versa.
Brocas area for motor speech is located in pars
Premotor Area (Area 6 of Brodmann)
triangularis (area 45) and par opercularis (area 44) of
Location inferior frontal gyrus.

Premotor area is located in posterior parts of superior, Function

middle, and inferior frontal gyri on superolateral Laryngeal muscles, with the assistance of those of
surface of frontal lobe. Therefore it is lying just in lips, tongue, palate are concerned with the production
front of primary motor area (area 4). of voice or phonation. Muscles causing vocalization
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
or formation of words are under the control of Brocas
area or motor speech area (area 44 and 45).
n Effect of lesion: It will cause inability to produce
speech. It is called motor aphasia. However, this pati-
ent posseses the ability of frame the words and even
write the words.
Supplementary Motor Area
Location
It is located on medial frontal gyrus in front of
paracentral lobule on medial surface of cerebral
hemisphere.
Function
This area is concerned with toning of voluntary
muscles for adjustment of posture of trunk and lower
limb.
n Effect of lesion: Lesion of the supplementary
motor area causes hypotonia with no paralysis.
Prefrontal Area
Location
Prefrontal area is in anteriormost part of frontal lobe
in front of premotor area and frontal eye field.
Functions
This area maintains personality of an individual
through following functions:
i. Social awareness
ii. Initiative for any work
It is called primary sensory area.
On superolateral surface, order of Brodmanns
number from above downwards and backwards are as
3, 1 and 2.
Structurally, primary sensory area is an example
of granular cortex with thick population of granule
cells and less pyramidal cells.
Function
Area 3, 1, 2 (primary sensory area) receives following
sensory inputs with the help of various ascending
(sensory) tracts through their relay in thalamus.
1. Exteroceptive sensations: Touch, pressure, pain
and temperature from opposite half of body.
2. Proprioceptive sensations: Vibration sensation,
sensation from muscles and joints of opposite half
of body.
Like primary motor area, contralateral half of
body is represented to the primary sensory area in
an upside down manner for all the somatic sensations
mentioned above. It is called inverted sensory
homunculus (Fig. 8.20). Areas from where finer
sensations are carried, e.g. fingers, hand, lips, tongue
are represented by proportionately larger area of
postcentral gyrus.
Taste sensation (gustatory sensation) is carried to
the small cortical area (area 43) which is adjacent to
lower end of postcentral gyrus.
Trunk
Hip
Neck
Head
Shoulder

Leg
Arm
Elbow
Forearm

iii. Power of judgment

Wrist
Hand

Foot
iv. Concentration and orientation for any work
Lit
Ri ddle

tle

Toes
ng
Mi dex b

v. Emotions. nitalia
In um

Ge
Th

E
No ye Fi
n Effect of lesion: Lesion of prefrontal area is Fa se
ce
ng
er
commonly due to trauma or tumor. Bilateral lesion of s
Uppe
r lip
the area causes degradation of personality through loss Lips
of functions as stated above. It is typically manifested Lower lip

by altered social behavior which is mismatched with Teeth, gums and jaw
surroundings.
Tongue

nx
Phary al
FUNCTIONAL AREAS IN PARIETAL LOBE abd
omin
Intra

Area 3, 1, 2 of Brodmann
Location
It is the postcentral gyrus on superolateral surface of Fig. 8.20 Sensory homunculus showing somatopical as well as
parietal lobe with its extension as posterior part of proportional representation in the primary somatosensory of cerebral
paracentral lobule on medial surface. cortex (Ref. and courtesy W. Penfield and T. Rasmussen, 1950)
160

n Effect of lesion: Lesion of primary sensory
area (area 3, 1, 2) or postcentral gyrus causes loss
of exteroceptive as well as proprioceptive sensations
of opposite half of body. It is called contralateral
hemianesthesia. It is interesting to note that, pain
sensation may not be lost, as once pain fibers reach
upto thalamus, perception of this sensation is not
affected.
Secondary sensory area is located in upper lip of
posterior ramus of lateral sulcus just behind lower
end of postcentral gyrus (primary sensory area). This
area posseses bilateral influence over pain sensation.
Sensory Association Area (Area 5 and 7)
Location
This area is located in anterior (area 5) and posterior
(area 7) segments of superior parietal lobule.
Function
Sensory association area (area 5 and 7) helps an
individual to recognize or identify shape, size, surface
character, texture of an object by handling but without
looking at it, i.e. without help of vision. This power is
known as stereognosis.
n Effect of lesion: Lesion of this area causes ina-
bility to recognize an object without help of vision.
This neurological defect is called astereognosis or
tactile agnosia.
Sensory Speech Area or Wernickes Speech
Area (Area 22, 39 and 40 of Brodmann)
Location
There are three areas of sensory speech located
adjacent to each other on superolateral surface of
cerebral hemisphere close to Brocas area for motor
speech. Like Brocas area, these areas are located
in left cerebral hemisphere in case of right handed
persons.
Area 22 is situated on posterior part of superior
temporal gyrus.
Area 39 is angular gyrus and area 40 is supr-
amarginal gyrus on inferior parietal lobule. All these
areas are interconnected with each other and motor
speech area (area 44 and 45).
Functions
Very simply, Wernickes area can be compared with
a dictionary. This area helps in comprehension of
speech heard and in selection of words to express
ideas.
CerebrumCortical Gray Matter
Area 22 helps in comprehension of spoken lang-
uage and recognition of familiar sounds.
Area 39 is concerned with visual speech and
reading.
Area 40 is concerned for recognition and naming
an object by tactile and proprioceptive sensation.
n Effect of lesion: In lesion of area 22, a patient
speaks without understanding what is spoken. The
defect is called word deafness or fluent aphasia.
Lesion of area 39 causes word blindness. It is
characterized by reading difficulty (alexia) and
writing difficulty (agraphia).
In case of lesion of area 40, the patient suffers
from inability to name an object by touching it. The
defect is named tactile agnosia.
FUNCTIONAL AREAS IN OCCIPITAL LOBE
Area 17 of Brodmann (Primary Visual Area)
Location
Area 17 or primary visual area is located in both upper
as well as lower walls (lips) of postcalcarine sulcus on
medial surface of occipital lobe. This sulcus is also
termed as posterior part of calcarine sulcus.
Very often this area extends around occipital pole
on superolateral surface of occipital lobe, curving
round extended end of postcalcarine sulcus.
Structural characteristics
Macroscopically, cortex of primary visual area (area
17) is characterized by its thinness.
Microscopically, it is an example of granular
cortex where layer IV type of cortical architecture is
evident. Further, it is traversed by fibers called Stria
of Gennari. As it gives a striated appearance, the
visual cortex is also known as striate cortex.
Function
Visual cortex receives axons of last order of neurons
(thalamic level) of visual pathway from lateral
geniculate body via optic radiation which is made up
of corticopetal fibers of retrolentiform part of internal
capsule.
Somatotopic representation with retina and visual
field
Cortex of primary visual area corresponds with same
half of retina (right or left) so therefore with opposite half
of visual field (left or right). For example, right visual
cortex corresponds to right (temporal) half of right
retina and right (nasal) half of left retina, so left half of
field of vision of both the eyes. Further, it is important
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
to note at this state that, in one side upper lip of visual
cortex corresponds to upper quadrant of retina, so lower
quadrant of field of vision and vice versa.
Fibers from peripheral part of retina is related to
more anterior part of both the lips of visual cortex.
Fibers from macular area of the retina (for central
vision) corresponds to posterior most part of visual
cortex which extends round the occipital pole on
superolateral surface of cerebral cortex.
n Effect of lesion: Occlusive disorder of posterior
cerebral artery supplying medial surface of occipital
lobe may cause lesion in primary visual area. If right
visual area is lesioned, it will cause loss of function
of right half of both retina, so loss of left half of
field of vision of both eyes. This defect is known as
homonymous hemianopia.
Macular vision will be spared as posterior end of
visual area concerned with macular vision is extended
on superolateral surface of cortex which receives
its blood supply through collateral circulation with
branches of middle cerebral artery.
Areas 18 and 19 of Brodmann (Secondary
Visual Area)
Location
Areas 18 and 19 are sequentially superimposed on
outer aspect of area 17 and these also extends on the
superolateral surface of cerebral hemisphere.
Function
This area receives afferent inputs from
1. Area 17
2. Other cortical areas
3. Thalamus.
Secondary visual area helps an individual to
recognize and appreciate the presently visualized
object in relation to past visual experience.
n Effect of lesion: In case of lesion of areas 18 and
19, though it is not practicable without lesion of area
17, the patient is unable to utilize his/her past visual
experience when looking for a present object.
Occipital Eye Field
Location
In human brain, it is located in secondary visual area
(areas 18 and 19).
Function
It produces conjugate deviation of both eyes to the
opposite side, obviously related to visual stimuli. It
162
is to be recalled, frontal eye field regulates voluntary
scanning of eyes which is independent of visual
stimuli.
FUNCTIONAL AREAS IN TEMPORAL LOBE
Primary Auditory Area (Areas 41and 42 of
Brodmann)
Location
It is located on superior surface of superior temporal
gyrus.
The area corresponds to inferior wall of lateral
sulcus.
The specific area is called transverse temporal
gyrus being two in number. Anterior one is called
Heschls gyrus.
Function
Primary auditory area is the cortical sensory center
for hearing. Projection fibers arising from medial
geniculate body pass through auditory radiation of
sublentiform part of internal capsule to end in primary
auditory cortex. Anterior of the two transverse
temporal gyrus (Heschls gyrus) is concerned for
reception of sound of low frequency and posterior one
is for sound of higher frequency.
n Effect of lesion: Unilateral lesion of one sided
auditory area, due to occlusive vascular disorder
affecting middle cerebral artery causes partial
deafness of both ears.
But greater loss of hearing may be noticed in
opposite ear as because medial geniculate body
receives majority of the fibers from contralateral
organ of Corti with lesser number of fibers from
ipsilateral side.
Secondary Auditory Area (Area 22 of Brod-
mann)
Location
This area, also called auditory association area, is
situated in posterior end of superior temporal gyrus,
posterior to primary auditory area.
Function
It receives inputs from primary auditory area and
thalamus. Here the inputs are coordinated for inter-
pretation of auditory impulse in relation to other
sensory information.
 Cerebrum White Matter
White matter of cerebrum are huge number of
myelinated nerve fibers of different diameter with
associated neuroglial cells. It forms a compact mass
situated in the central core of cerebrum deep to
cortex. In contrast to the term of cortical gray matter,
white matter is referred as medullary substance. The
compact bundle of fibers in white matter may be
restricted within cerebral hemisphere or may connect
areas or centers outside it.
CLASSIFICATION (FIG. 9.1)
Bundles of white matter are classified into following
three groups:
9
1. Association fibers
2. Commissural fibers
3. Projection fibers.
Fundamental comparison among three types:
1. Association fibers are the fiber bundles which
interconnect different areas of same cerebral
hemisphere. But these may be restricted in one
lobe or may extend from one lobe to another.
So, these fibers do not cross midline and do not
go to any subcortical centers.
2. Commissural fibers interconnect identical areas of
two cerebral hemispheres.
So these fibers cross the midline but do not
extend to any center below cerebral cortex.

Association fibers

Cerebral cortex
Commissural fibers

Projection fibers
Lateral ventricle of brain

Thalamus
Three fundamental
types of fibers of Lentiform nucleus
white matter of brain

Brainstem

Fig. 9.1 Fundamental types of fibers of white matter of brain

 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Short association
fibers
Cingulum
Uncinate fasciculus
Septum pellucidum
Fig. 9.2 Association fibers of white matter of cerebrum
3. Projection fibers, as they are so called, project from
one cerebral hemisphere to subcortical centers of
same side or opposite side.
So these fibers extend beyond cerebral cortex
and may or may not cross the midline.
Association Fibers (Fig. 9.2)
These kind of fibers may be shortest, just to connect
adjacent gyri, so may be very superficial being just
beneath the cortex to lie on the floor of the sulcus. It
may be intermediate in length. These are restricted
within a lobe of cerebral hemisphere, but cross the
floors of more than one sulci. Again, it may be longest
to extend from frontal pole to occipital pole.
Broadly, association fibers are classified into follo-
wing two groups.
Short association fibers
These are restricted to one of the lobes of cerebral
hemisphere. As already briefed, some of the fibers
cross floor of one sulcus to interconnect adjacent gyri.
In the group of short association fibers some are
longer to cross over more than one sulci and thereby
more than one gyrus. But these fibers are restricted to
one lobe of hemisphere.
Long association fibers
These fibers extend from one lobe to another in
the form of bundle. They are present in the form of
following names
164
Corpus callosum
Superior longitudinal
fasciculus
Cingulum
Inferior longitudinal
fasciculus
Fornix
Anterior commissure
1. Uncinate fasciculus
This is so called because, fiber bundles hook around
the depth of stem of lateral sulcus. Fibers of uncinate
fasciculus form an arc, that is why also termed as
arcuate fibers. Bundle of fibers connect motor speech
area (Brocas area) and orbital gyri of frontal lobe with
adjacent part of temporal cortex. The fibers fan out at
both ends with compact and constricted central part.
2. Cingulum
This is the association fiber bundle of limbic system
for which it is called limbic association bundle. Cingu-
lum is a long but curved bundle. It starts from cortex
of medial surface of frontal lobe (below rostrum of
corpus callosum), passes beneath cingulate gyrus and
then parahippocampal gyrus and spreads in adjoining
part of temporal lobe.
3. Superior longitudinal fasciculus
Considering the extent it is called frontooccipito-
temporal fasciculus and is the longest among long
association fibers. It starts from anterior part of
frontal lobe (frontal eye field) to area 18 and 19
of occipital lobe. Some of the fibers further curves
downwards and forwards behind insular cortex to
reach temporal lobe.
4. Frontooccipital fasciculus
This bundle of fibers is same as superior longitudinal
fasciculus. But it is at a deeper plane and separated
 CerebrumWhite Matter
by descending bundle of projection fibers known as it is cut in median sagittal plane, corpus callosum is
corona radiata. It starts from frontal lobe and extend found to be curved or bent on itself with concavity
upto occipital as well as temporal lobes. looking downwards, like the letter C.

5. Inferior longitudinal fasciculus Length

It starts from visual association area (area 18 and 19)
and extend forwards to spread out to be distributed to
the whole temporal lobe.
Commissural Fibers
Commissural fibers interconnect identical or similar
areas of two cerebral hemispheres. These fibers,
which are also known as interhemispheric fibers,
are present in the form of bundles. The bundles are
known as commissures.
Name of important commissures
1. Corpus callosum
2. Anterior commissure
3. Habenular commissure
4. Posterior commissure
5. Hippocampal commissure.
Corpus callosum (Figs 9.3 and 9.4)
Corpus callosum is the largest and most compact
bundle of commissural fibers. This thick bundle of
fibers crosses the midline across the bottom of median
longitudinal fissure of brain to interconnect almost all
the identical area of two cerebral hemispheres (neop-
alium). So, to separate two cerebral hemisphere, when
End to end length of corpus callosum is 10 cm.
Curvature
1. Dorsoventral curvature: With concavity facing
downwards.
2. Anterior (cephalic) curvature: Cephalic or ant-
erior end present one anteroposterior bend called
genu.
Surface
1. Dorsal convex surface
2. Ventral concave surface.
Dorsal convex surface is covered by a thin layer of
gray matter called induseum griseum. On each side of
midline, surface of this gray matter presents two fine
anteroposteriorly directed fibers, called medial and
lateral longitudinal striae.
Ventral concave surface, on either side of midline,
is mostly related to different parts of lateral ventricle
of brain.
Parts
From cephalic to caudal end, parts of corpus callosum
are the following
1. Rostrum 2. Genu
3. Body (trunk) 4. Splenium.

Falx cerebri

Body of corpus callosum

Inferior sagittal sinus

Splenium

Genu Inferior sagittal sinus

Transverse sinus (left)
Rostrum

Great cerebral vein of

Lamina terminalis Galen

Tela choroidea
Septum pellucidum Fornix Pineal body

Fig. 9.3 Median relations of corpus callosum

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Cingulate gyrus
Pericallosal artery
Genu
Callosomarginal
artery
Anterior cerebral
artery
Rostrum
Anterior horn of
lateral ventricle
Fig. 9.4 Paramedian relations of corpus callosum
l Rostrum : It is so called because, it is most rostral
part of corpus callosum. It is also thinnest among the
four part and directed backwards and downwards
as continued with a thin layer of gray matter called
lamina terminalis.
n Relation (Figs 9.3 and 9.4):
l Superiorly: In the midline, it gives attachment, to
septum pellucidum. On either side of midline, rostrum
forms floor of anterior horn of lateral ventricle.
l Inferior: On either side of midline rostrum of
corpus callosum is related to paraterminal gyrus.
l Fiber interconnecting: Fibers of rostrum inter-
connect cortical areas of orbital surface of two frontal
lobes.
l Genu: Genu is the bend at the anterior end of
corpus callosum with convexity directed forwards.
It is 4 cm behind frontal pole. It is continuous
below with rostrum and above with body of corpus
callosum.
n Important relations:
In the midline: Posterior concavity of genu gives
attachment to septum pellucidum.
LATERAL TO MIDLINE
Anterior: Genu is separated from anterior end
of cingulate gyrus by pericallosal sulcus where ante-
rior cerebral artery divides into pericallosal and callo-
somarginal branches.
166
Body of corpus callosum
Splenium
Posterior horn of lateral
ventricle
Inferior horn of lateral
ventricle
Body or central part of
lateral ventricle
Posteriorly: Genu forms anterior boundary of
ante-rior horn of lateral ventricle of brain.
l Fibers passing through: While the fibers of genu
cross the midline, they are horizontal or transverse.
But on either side the fibers from a Ushaped loop to
reach frontal lobe. This loop with fork-like appearance
is known as Forceps minor which interconnect identical
areas of both frontal lobes except orbital surface (Fig.
9.5).
l Body (Trunk): Body of corpus callosum is also
called trunk or central part. In the midline, in between
two hemisphere, it is placed at the bottom of median
longitudinal fissure (interhemispheric fissure).
n Important relations:
l In the midline: Superior surface is related to
lower free margin of falx cerebri which lodges inferior
sagittal sinus.
Inferior surface gives attachment to septum pellu-
cidum and posterosuperior end of body of fornix (Fig.
9.3).
l On either side of midline: Superior surface is
related to cingulate gyrus from which it is separated
by pericallosal sulcus lodging pericallosal branch of
anterior cerebral artery.
Inferior surface forms the roof of central part or
body of lateral ventricle of brain (Fig. 9.4).
l Fibers interconnecting (Fig. 9.6): Fibers pas-
sing through body of corpus callosum are better
understood in coronal section. Crossing midline
 CerebrumWhite Matter

Fibers of genu form forceps

minor

Fibers of body of corpus

callosum

Fibers of posterior part

of body and part of
splenium form tapetum
Posterior horn of lateral
ventricle
Fibers of splenium form
forceps major

Fig. 9.5 Fibers of corpus callosum

horizontally, fibers on either hemisphere fan out or n Important relation:

radiate. These fibers are known as Callosal radiation.
The fibers which curve upwards and laterally interc-
onnect two parietal lobe areas. It is called superior
callosal radiation. Again fibers passing downwards
and laterally to interconnect temporal lobe area form
inferior callosal radiation.
l Splenium: Splenium is the posterior end and
thickest part of corpus callosum.
It is 6 cm in front of occipital pole.
Superiorly splenium is related to inferior sagittal
sinus and falx cerebri.
Inferiorly, in the median plane it is related to tela
choroidea of third ventricle of brain and pineal body
(Fig. 9.3). On either side of midline, splenium is related
to pulvinar of thalamus and tectum of midbrain.
Posteriorly splenium is related to great cerebral
vein of Galen which joins with inferior sagittal sinus
to form straight sinus.

Fibers of body of corpus

Parietal lobe callosum crossing midline
at the bottom of median
longitudinal sulcus

Superior callosal
radiation

Temporal lobe Inferior callosal

radiation

Fig. 9.6 Fibers of body of corpus callosum forming callosal radiation (seen through coronal section of brain)
167
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Interconnecting fibers (Fig. 9.5): Transversely
running fibers of splenium, crossing midline form U
shaped loop with its concavity directed backwards
to connect occipital lobes of both sides. These fibers,
having fork-like appearance, form a curved bundle,
known as Forceps major.
Fibers of forceps major, while passing backwards
and medially along the upper part of medial wall of
posterior horn of lateral ventricle, form a bulge on the
wall called bulb of posterior horn.
Some of the fibers of splenium and posterior end
of trunk of corpus callosum posses different course
and destination. These fibers arch downward,
backwards and laterally along the roof and lateral
wall of posterior horn and lateral wall of inferior
horn of lateral ventricle to connect both sided parietal
and temporal lobes. This band of fibers is known as
tapetum of corpus callosum.
Clinical significance of corpus callosum:
It is already known that corpus callosum links or
interconnects identical areas of two cerebral hem-
isphere. It is called homotopic connection. But it
may link also heterogeneous areas of cerebral cortex.
These areas of two sides may be functionally similar
but anatomically different. This types of connection is
known as heterotopic connection.
Interhemispheric connection for all the identical
areas of both hemisphere does not functionally exist
Uncus
Hippocampus
Posterior bundle of anterior
commissure Anterior commissure
Fig. 9.7 Fibers of anterior commissure
168
classically through corpus callosum. Areas of midline
representation only are linked to contralateral hemis-
phere. For example, somatic areas representing trunks
or body are callosally linked, but areas representing
limb are not.
But it has also been seen, in case of congenital
absence (agenesis) or in case where corpus callosum
is bisected surgically, each of the cerebral hemisphere
becomes isolated from other. The conditions is called
split brain syndrome in which case patient reacts in
such way that he or she has two separate brains.
Anterior commissure (Figs 9.2 and 9.7)
Anterior commissure is a compact bundle of myelin-
ated nerve fibers crossing midline horizontally. It
crosses in front of anterior column of fornix being
embedded in a thin layer of gray matter called lamina
terminalis. In sagittal section, it is oval in outline
with longer vertical diameter measuring 1.5 mm.
n Division of fibers: On either side of midline
bundle of anterior commissure splits into anterior
and posterior divisions.
n Anterior limb: Fibers of anterior limb extend
anterolaterally toward frontal lobe and interconnect
following identical areas of both sides.
1. Olfactory bulb
2. Anterior olfactory nucleus
Anterior bundle of anterior
commissure
Olfactory bulb
Olfactory tubercle
Anterior perforated
substance

3. Anterior perforated substance
4. Olfactory tubercle.
n Posterior limb: Fibers of posterior limb are
directed posterolaterally towards temporal lobe to
interconnect
1. Parahippocampal gyrus with
2. Anteroinferior part of temporal lobe.
Commissure related pineal gland (body)
Pineal gland or pineal body is a small sessile stru-
cture which is attached through pineal stalk to back
of diencephalon.
Pineal stalk is divided into two laminae upper
(proximal) and lower (distal). Small angular area
between two stalks form pineal recess of third
ventricle of brain.
Both the laminae of pineal stalk are traversed
by transversely running fibers passing through the
midline from one side of the brain to other. These are
commissural fibers connecting identical areas of both
sides.
Fibers passing through upper or proximal lamina
of pineal stalk are called Habenular commissure.
CerebrumWhite Matter
Those of the lower or distal stalk form posterior
commissure (Fig. 9.8).
Habenular commissure (Figs 9.8 and 9.9)
Habenular commissure is a thin bundle of fibers
passing transversely through proximal lamina of
pineal stalk. These fibers primarily interconnect
neurons of Habenular nucleus of both side located in
Habenular trigone.
Habenular trigone is a small triangular area
bounded by following structures (Fig. 9.9).
Medially Pineal gland
Superolaterally Thalamus
Inferolaterally Superior colliculus
Habenular nucleus receives afferent from amyg-
daloid nucleus and hippocampus. Some of the fibers
from these two areas of one side interconnect with
identical areas of other side passing through Habenular
trigone (nuclei) and promixal lamina of pineal stalk.
Functions of Habenular nucleus and its connections
in human are not clearly known.
Fiber forming
Habenular commissure

Proximal lamina of pineal

stalk
Fibers forming posterior
commissure

Distal lamina of Pineal gland

pineal stalk A
Proximal lamina
Habenular commissure

Habenular commissure

Posterior commissure
Posterior commissure

Distal lamina

B Pineal gland

Fig. 9.8 Pineal gland showing two laminae of its stalk through which traverse two types of commissural fibers. A. Sagittal section of
pineal gland, B. Posterosuperior view of pineal gland
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Habenular commissure
passing through proximal
lamina of pineal stalk

Thalamus

Habenular trigone

Habenular nucleus
Pineal gland
Superior colliculus
Inferior colliculus

Fig. 9.9 Fibers of Habenular commissure connecting Habenular nucleus

Posterior commissure (Fig. 9.10)
Posterior commissure is a thin bundle of fibers which
cross the midline through distal lamina of pineal stalk.
It connects identical areas of both sides which are
as follows:
1. Superior colliculus
2. Pretectal nucleus.
Hippocampal commissure (Fig. 9.11)
(commissure of the fornix)
As per the name, hippocampal commissure is made
up bunch of fibers which interconnect hippocampal
formation of both sides. It is also called commissure of
the fornix because its fibers cross the midline following
the course of fibers of posterior column of fornix.
Proximal lamina of pineal
stalk
Fornix is a band of myelinated fibers which starts
as efferent pathway from hippocampus to mammillary
body of hypothalamus. These efferent fibers start as
posterior column of fornix from hippocampus and
curve round forwards and upwards where fibers
of posterior column of both side meet to form body
of fornix. Fibers of body of fornix again diverge
downwards and forwards as anterior column to end
in mammillary body of hypothalamus in same side.
So fibers of fornix extending from hippocampus (part
of cerebrum) to hypothalamus (part of diencephalons)
beyond cortex are considered as projection fibers.
But fibers of hippocampal commissure, starting
from hippocampus of one side pass along posterior
column of fornix upto posterior end of body. From this
level commissural fibers follow the path of posterior
column of fornix of other side to reach other sided
hippocampus (consult Figure 9.11).

Distal lamina of pineal Pineal gland

stalk transmitting fibers of
posterior commissure

Fibers of posterior commissure connect

nucleus of superior colliculus and pretectal
nucleus of both sides

Superior colliculus
Midbrain

Pretectal nucleus

Fig. 9.10 Fibers of posterior commissure

170

Posterior column
of fornix
Body of fornix
Anterior column
fornix
Mammillary
body
Hippocampus
Fig. 9.11 Fibers of hippocampal commissure
Projection Fibers
Projection fibers differ fundamentally from assoc-
iation and commissural fibers by the fact that,
existence of this kind of fibers are not limited within
cerebral hemisphere of forebrain. These fibers are
vertically disposed in the central nervous system.
These are the fibers by which cerebral cortex is
connected to many centers ranging from the level
just below the cortex which are commonly termed as
subcortical centers. It is clear therefore, projection
fibers connect cerebral cortex with subcortical
centers in both directions. So projection fibers are
fundamentally of following two types.
1. Corticofugal fibers: These are efferent outflow
from cerebral cortex to subcortical centers which
are at following level
l Corpus striatum: These are components of basal
ganglia which are submerged collection of gray
matter embedded in central core of white matter of
cerebrum. Fibers are called corticostriate fibers.
l Thalamus: Corticothalamic fibers
l Various centers in brainstem: These fibers either
project to some specific nuclei, e.g. corticorubral,
corticonigral, corticopontine. Again these fibers
project to motor nuclei of some cranial nerves which
are called corticobulbar or corticonuclear tract.
l Anterior horn cells of spinal cord: The projection
fibers are called Corticospinal tract.
2. Corticopetal fibers: These are afferent fibers
projecting into cerebral cortex from various cen-
CerebrumWhite Matter
Hippocampus
Fibers of hippocampal
commissure passing from
posterior column of fornix of one
side to that of other connecting
hippocampal gyrus of both side
ters. But it is important and interesting to note
that fibers from any subcortical centers do not
project directly to cerebral cortex. All incoming
(afferent) projection fibers initially terminate in
thalamus. After relay, from thalamus corticopetal
projection fibers reach cerebral cortex.
l Thalamic radiation: From the above description,
it is clear that cerebral cortex and thalamus are
connected by fibers of both way directions. These
fibers connecting thalamus with all the four lobes of
cerebrum are called thalamic radiations which are as
follows.
1. Anterior thalamic radiation: Connecting
frontal lobe.
2. Superior thalamic radiation: Connecting parietal
lobe.
3. Posterior thalamic radiation: Connecting
occipital lobe.
4. Inferior thalamic radiation: Connecting tem-
poral lobe.
Phylogenetic classification of projection fibers
1. Projection fibers of allocortex (archicortex
and paleocortex): The fibers starts as fimbria.
Fimbria starts as a thin layer of white matter which
covers ventricular surface of hippocampus. It is known
as alveus. From the alveus fibers starts as fimbria.
Fimbria of both sides increases in thickness and
arch upwards and forwards beyond hippocampus,
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
around posterior aspect of thalamus, below corpus
callosum to form posterior column of fornix. Fornix
ends through its anterior column in mammillary body
of hypothalamus (diencephalon).
Fornix has been discussed above in the column of
hippocampal commissure.
2. Projection fibers of neocortex: Projection
fibers related to neocortex connect all the four lobes of
cerebral hemisphere with various subcortical centers.
These fibers are directed bothways.
Fibers connecting different lobes of cerebral hemi-
sphere with thalamus in both direction are called
thalamic radiations.
All the fibers extending from wide area of cerebral
cortex converge downward towards central or inner
core of white matter.
Just beneath the cortex, the convergent fibers
present a radiating appearance in a fan-shaped
maner called corona radiata (Fig. 9.12).
In the deeper part of white matter, the projection
fibers of corona radiation find less space to pass through
due to presence of some masses of gray matter, e.g.
thalamus, lentiform nucleus, caudate nucleus, etc.
That is why the projection fibers are condensed and
compact. The vertically passing bundles of fibers are
compressed between thalamus and head of caudate
nucleus lying medially and lentiform nucleus (shaped
like biconvex lens) laterally.
As this compact band of white matter is present as
a capsule on internal (medial) side of lentiform (lens-
like) nucleus, it is called internal capsule.
INTERNAL CAPSULE (FIG. 9.13)
Internal capsule appears as a broad and compact
band of white matter in horizontal section of cerebral
Corticospinal and
corticonuclear fibers
Frontopontine fibers
Temporopontine fibers
Projection fibers passing
through crus cerebri of
midbrain
Fig. 9.12 Projection fibers forming corona radiata adjacent to cortex, then form compact subcortical component before they reach
midbrain to be mediolaterally directed
172
hemisphere. It presents a lateral concavity to come
in contact with and thus to accommodate medial
(internal) convex surface of lentiform nucleus which
presents the shape like that of a biconvex lens.
Parts of Internal Capsule
1. Anterior limb: Between lentiform nucleus late-
rally and head of caudata nucleus medially.
2. Posterior limb: Between lentiform nucleus late-
rally and thalamus medially.
3. Genu: The bend between anterior and posterior
limbs.
4. Retrolenticular (retrolentiform) part: The
part behind or beyond lentiform nucleus.
5. Sublenticular (sublentiform) part: The part
below lentiform nucleus.
Identity of Various Fibers Passing Through
Internal Capsule
1. Corticopontine fibers: These are efferent fibers
cerebral cortex which form part of corticoponto-
cerebellar pathway. Through these fibers cerebral
cortex influence opposite cerebellar hemisphere.
Fibers arise from different areas of all the four
lobes of cerebrum. So these are frontopontine,
parietopontine, occipitopontine and temporopo-
ntine fibers. These descending fibers relay in pon-
tine nuclei of same side in basilar part of pons.
Then pontocerebellar fibers cross the midline
and pass through middle cerebellar peduncle to
contral-ateral half of cerebellum.
Beyond corona radiata and internal capsule, while
passing through crus cerebri of midbrain, differant
Parietopontine fibers
Corona radiata
Occipitopontine fibers

Frontopontine fibers
Head of caudate nucleus
Genu
Corticonuclear fibers
Corticospinal fibers
Thalamus
Medial geniculate body
Lateral geniculate body
Fig. 9.13 Parts of internal capsule with its fiber components
corticopontine fibers are mediolaterally directed
as follows (Fig. 9.12):
1. Frontopontine = In medial 1/5th of crus cerebri
}
2. Parietopontine
3. Occipitopontine = In lateral 1/5th of crus cerebri
4. Temporopontine
2. Thalamic radiation: These are the fibers which
connect thalamus with four lobes of cerebral
hemisphere in both directions. Corticopetal fibers
of thalamic radiation, i.e. the fibers which extend
from different parts of thalamus to cerebral cortex,
are the axons of last order of neurons of various
sensory pathways to terminate in respective sen-
sory areas of cerebral cortex.
Thalamic radiations are
l Anterior thalamic radiation: It connects thalamus
with frontal lobe.
l Superior thalamic radiation: It connects thalamus
with parietal lobe. Corticopetal fibers of superior
thalamic radiation extending from ventropostero-
lateral nucleus of thalamus to postcentral gyrus (area
3,2,1) of parietal lobe carry somatic sensations from
opposite half of body.
l Posterior thalamic radiation: It connects metath-
alamus (lateral geniculate body) to occipital lobe of
cerebrum. Corticopetal fibers of this thalamic radi-
ation extends from lateral geniculate body to primary
visual area (area 17) of occipital lobe. These fibers
bundle is called optic radiation. So optic radiation
is the afferent component of posterior thalamic
radiation.
CerebrumWhite Matter
Anterior thalamic radiation
Corticofugal fibers
Lentiform nucleus
Corticorubral fibers
Auditory radiation
Sublentiform part
Posterior limb
Retrolentiform part
Optic radiation
l Inferior thalamic radiation: It connects metath-
alamus (medial geniculate body) with temporal lobe
of cerebral hemisphere. Corticopetal fibers of inferior
thalamic radiation extend from medial geniculate
body to transverse gyrus (area 41 and 42) on superior
surface of superior temporal gyrus, known as auditory
area. These fiber bundle is called auditory radiation.
It is clear therefore, auditory radiation is the
afferent component of inferior thalamic radiation.
3. Corticospinal fibers: These are the fibers of
motor (descending) tracts arising from motor area
(area 4) and premotor area (area 6) of frontal lobe
of cerebral hemisphere. These are axons of upper
motor neurons (UMN) projecting on contralateral
anterior horn cells of spinal cord known as lower
motor neurons (LMN). This bundle of fibers,
as passing through the pyramidal elevation of
medulla oblongata lower down, are termed as
pyramidal tract.
4. Corticobulbar (corticonuclear) fibers: These
are descending (efferent) fibers from motor area of
cerebral cortex to the all motor nuclei of cranial
nerves of contralateral side.
5. Corticorubal fibers: These fibers project from
cerebral cortex to red nucleus of midbrain.
Fibers Passing Through Different Parts of
Internal Capsule (Fig. 9.13)
l Anterior limb:
1. Frontopontine fibers
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
2. Anterior thalamic radiation
l Genu:
1. Corticobulbar (corticonuclear) fibers
2. Anterior part of superior thalamic radiation
l Posterior limb:
1. Parietopontine fibers
2. Superior thalamic radiation
3. Corticospinal fibers in the form of multiple,
compact, discrete bundles. Fibers for head-neck,
upper limb, trunk and lower limb are placed in
anteroposterior order.
4. Corticorubral fibers
l Retrolenticular (retrolentiform) part:
1. Occipitopontine fibers
2. Posterior thalamic radiation: Corticopetal comp-
onent of posterior thalamic radiation form optic
radiation.
l Sublenticular (sublentiform) part:
1. Temporopontine fibers
2. Inferior thalamic radiation Corticopetal comp-
onent of inferior thalamic radiation is auditory
radiation.
Blood Supply of Internal Capsule (Fig. 9.14)
Various types of vertically running projection fibers
(both efferent as well as afferent types) pass through
compact and condensed area of internal capsule. The
compact band of white matter of cerebral hemisphere
is supplied by multiple sources of arteries. So vascular
lesion in advanced age is very common.
Branches for internal
capsule
Recurrent artery of Heubner
Arteries supplying internal capsule are direct
branches of circle of Willis lodged in interpeduncular
cistern of subarachnoid space at the base of brain.
These branches are called central, nuclear or ganglionic
branches, because in addition to central white matter
core of cerebral hemisphere, they supply centrally
placed masses of gray matter like caudate nucleus and
lentiform nucleus which are known as basal ganglia.
These central branches are example of end arteries.
Arteries Supplying Different Component of
Internal Capsule
1. Anterior part of anterior limb:
a) Striate branches of anterior cerebral artery
b) Recurrent artery of Heubner: Branch of ante-
rior cerebral artery.
2. Posterior part of anterior limb, genu and
anterior two-third of posterior limb:
a) Striate branches of middle cerebral artery.
One of the lateral striate branches is very long.
which is very often subjected to be ruptured
following cerebrovascular lesion. This branch
is called Charcots artery of cerebral hemo-
rrhage.
b) Genu is also supplied by direct branch from
internal carotid artery.
3. Posterior one-third of posterior limb, retrol-
entiform and sublentiform parts: Branches
from anterior choroidal artery.
Parent arteries

Anterior communicating artery

Striate branch of anterior
cerebral artery Anterior cerebral artery

Striate branches of Middle cerebral artery

middle cerebral artery AL
Internal carotid artery
G

Direct branch from Posterior communicating artery

internal carotid artery
PL
Posterior cerebral artery

SL Basilar artery

Branches from anterior Anterior choroidal artery

choroidal artery RL

AL Anterior limb G Genu PL Posterior limb RL Retrolentiform part SL Sublentiform part

Fig. 9.14 Arteries supplying diferent parts of internal capsule

174

CLINICAL ANATOMY OF INTERNAL CAPSULE
In elderly persons, internal capsule is very frequently
lesioned in case of cerebrovascular accidents. Most
common causes are arterial hemorrhage following
atheromatous degeneration of any of the cerebral
arteries supplying internal capsule in a patient
suffering from hypertension. Because of high concen-
tration of descending as well as ascending fibers
passing through compact area of internal capsule,
even a small vascular lesion may lead to widespread
motor and sensory deficit on the contralateral half
of body. Pathological reason behind this widespread
lesion is not only ischemic injury to the neural tissue,
but also compression by blood clot and edema of the
neural tissue.
In many cases of cerebral hemorrhage, long
Charcots artery of cerebral hemorrhage, a lateral
striate branch of middle cerebral artery, is ruptured.
As this supplies posterior limb of internal capsule,
corticospinal tract fiber bundles and superior thalamic
radiation carrying somatic sensory fibers are dam-
aged. So effect will be contralateral spastic paralysis
(hemiplegia) and loss of all somatic sensation (hemi-
anesthesia).
CerebrumWhite Matter
In some cases of cerebrovascular lesion retrole-
ntiform as well as sublentiform parts are also damaged
along with posterior limb. In this case, in addition to
contralateral hemiplegia following sensory deficit will
be noted on contralateral side.
1. Hemianesthesia: Loss of somatic sensation of
opposite half of body due to effect on superior
thalamic radiation of posterior limb.
2. Hemianopia: Loss of opposite half of field of vision
due to effect on optic radiation of retrolentiform
part.
3. Hemihypoacusis: Impairment of hearing of
opposite ear due to effect on auditory radiation of
sublentiform part of internal capsule.
These three kinds of sensory defects together are
known as contralateral triad.
A branch from recurrent artery of Heubner may
be responsible to supply genu of internal capsule.
In such case, rupture of this branch cause lesion of
corticobulbar (corticonuclear) tract. Effect will be
supranuclear paralysis of face along with weakness
of muscles for swallowing and phonation. Lesion in
genu may also cause paralysis of muscles of head-
neck and upper limb due to involvement of anterior
fibers of corticospinal tract.
175
 Basal Ganglia
General Consideration
l Basal ganglia are subcortical masses of gray mat-
ter inside cerebral hemisphere.
l They are also known as basal nuclei.
l Basal ganglia or basal nuclei are embedded in
the central white core of cerebral hemisphere
(telencephalon) at the level of diencephalon.
l Though basal ganglia are concerned with control
of posture and voluntary movements, they do not
have any direct input or output connections with
spinal cord.
l Basal ganglia are the important components of
extrapyramidal system.
Principle of Functions
Grossly, it can be stated that basal ganglia is conc-
erned with execution of quality of movements
through maintenance of muscle tone and posture with
coordination of voluntary movements. But function
of basal ganglia is actually the result of integration
of neurocircuit connecting various centers of central
nervous system with it.
First, basal ganglia receive afferent informations
from motor as well as sensory areas of cerebral
cortex, thalamus, subthalamus, brainstem including
substantia nigra.
Informations are then integrated.
Then outflow from basal ganglia passes to cerebral
cortex and centers of brainstem for the following
directives.
1. For initiation of gross movements of voluntary
muscles of trunk and proximal joints of the
10
limbs as a function of extrapyramidal system
which reciprocates function of pyramidal system
concerned with skilled and precise movements.
2. Basal ganglia exert influence on the centers for
voluntary motor function through
a) Initiation of desired movement
b) Restriction or limitation of unwanted movement
c) Cessation of movement when needed.
3. As basal ganglia parallelly inhibit unwanted
move-ment. It means that these centers helps in
smoo-thening of voluntary movement.
4. Basal ganglia also influence stereotyped associated
voluntary movements, e.g. swinging of arms while
walking.
Components of Basal Ganglia
1. Caudate nucleus
2. Lentiform nucleus
3. Amygdaloid nucleus (body)
4. Claustrum.
Subthalamic nuclei, substantia nigra and red
nucleus are correlated and colisted with the comp-
onents of basal ganglia clinically only because all
these masses of gray matter are the centers for
extrapyramidal system.
Other Terminologies
Head end of coma-shaped caudate nucleus and
lentiform nucleus are separated by vertically runn-
ing fibers of anterior limb of internal capsule.
Anteroinferior aspects of both these nuclei are conn-
ected by a narrow band of gray matter. This band

Internal capsule
Caudate nucleus
Fig. 10.1 Connecting band of gray matter between caudate nucleus and lentiform nucleus present striated appearance as traversed by
fibers of internal capsule
of gray matter mass is traversed by some fibers of
anterior limb of internal capsule, so presenting a
striated appearance (Fig. 10.1). That is why caudate
nucleus and lentiform nucleus together are termed
corpus striatum.
Lentiform nucleus, biconvex in outline is divided
into a lateral and medial part by a thin lamina of wh-
ite matter called external medullary lamina. Lateral
part is termed putamen and medial part is known as
globus pallidus. Internal medullary lamina, another
thin lamina of white matter divides globus pallidus
into lateral (external) and medial (internal) parts. It
is the putamen of lentiform nucleus that is connected
to caudate nucleus by intermediate band of gray
matter (Fig. 10.1).
Caudate nucleus and putamen of lentiform nucleus
are jointly known as striatum. Globus pallidus is
simply termed as pallidum.
Internal capsule
Head of caudate nucleus
Lentiform nucleus
Amygdaloid body
Fig. 10.2 Caudate nucleus with structures adjacent to it
Basal Ganglia
Lentiform nucleus
Striated mass of gray matter
Difference between striatum and pallidum
Striatum (Caudate nucleus Pallidum
and Putamen) (Globus pallidus)
1. Phylogenetically newer part Phyltogenetically older part
(Neostriatum). (Paleostriatum).
2. Neurons are round or Neurons are polygonal.
spherical.
3. Darker in color as more Paler in color as less
vascular. vascular.
4. Receptive part of corpus Effector part of corpus
striatum- So receives inputs. striatum-So sends output.
Phylogenetic Classification of Basal Ganglia
Phylogenetically, basal ganglia are classified as
follows:
l Archistriatum: Amygdaloid nucleus and claustrum
l Paleostriatum: Globus pallidus
l Neostriatum: Caudate nucleus and putamen.
Body of caudate nucleus
Tail of caudate nucleus
Thalamus
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Stria terminalis
Anterior horn
Head of caudate nucleus
Anterior perforated substance
Hypothalamus
Amygdaloid body
Fig. 10.3 Caudate nucleus with related structures
Caudate nucleus (Figs 10.2 and 10.3)
Caudate nucleus is C-shaped or coma-shaped
mass of gray matter forming a component of corpus
striatum or striatum.
It presents curvature because it curves round
thalamus and its convex side fits with concavity of
cavity of lateral ventricle (Fig. 10.3).
Parts
1. Head: Proximal, expanded and rounded end.
2. Body: Intermediate and gradually tapering part.
3. Tail: Distal anterioinferior end which is connected
to rounded amygdaloid body (nucleus).
Head of caudate nucleus is demarcated from the body
by the landmark of interventricular foramen of Monro.
Head is joined below with putamen of lentiform
nucleus by a band of gray matter which is traversed
by fibers of internal capsule (Fig. 10.1).
Corpus callosum
Septum
pellucidum
Fig. 10.4 Head of caudate nucleus forming inferolateral boundary of anterior horn of lateral ventricle (coronal sectional view)
178
Body of lateral ventricle
Body of caudate nucleus
Posterior horn of lateral
ventricle
Tail of caudate nucleus
Inferior horn of lateral
ventricle
Thalamus
Head of caudate nucleus forms inferolateral boun-
dary of anterior horn of lateral ventricle (Fig. 10.4).
Body of caudate nucleus extends from head as
elongated and gradually tapering part till it curves
around posterior pole of thalamus to be continued as
tail.
It forms the floor of central part or trunk of lateral
ventricle lateral to superior surface of thalamus.
On the floor of central part of lateral ventricle from
lateral to medial are placed body of caudate nucleus,
stria terminalis, thalamostriate vein and superior
surface of thalamus (Fig. 10.5).
Tail of caudate nucleus is the long and narrow
continuation of body around posterior end of thalamus.
Following the curve of lateral ventricle, tail is related
to roof of inferior horn of the ventricle. It ends at its
anterior extremity being attached to amygdaloid body
(nucleus) (Fig. 10.3).
Cavity of anterior horn
of lateral ventricle
Rostrum of corpus callosum
Head of caudate nucleus
 Basal Ganglia

Body of caudate nucleus

Stria terminalis

Amygdaloid body
Thalamostriate vein

Thalamus Tail of caudate

nucleus

Fig. 10.5 Caudate nucleus viewed from above with related structures

Lentiform nucleus (Fig. 10.6)
It is so called because this mass of gray matter looks
like a biconvex lens in outline, as evident both in cross
section as well as in coronal section.
Medial surface of the nucleus presents more acute
cervature, whereas its lateral surface is uniformly
curved.
Inferiorly, lentiform nucleus merges with gray
matter of base of brain at the site of anterior perforated
substance.
Capsules of lentiform nucleus
Both the medial as well as lateral surfaces are covered
by capsules made up of band of white matter. Medial
surface is covered by thick compact internal capsule
and lateral surface is covered by thinner lamina of
white matter, called external capsule. Lateral surf-
ace, outside the capsule is related to lateral striate
branches of circle of Willis which pierce the capsule to
supply the nuclear mass.
Subdivisions of lentiform nucleus
Primarily, a thin lamina of white matter, called exter-
nal medullary lamina subdivides lentiform nucleus
into lateral part called putamen and medial part,
globus pallidus. Globus pallidus is again divided
into medial (internal) and lateral (external) parts
by another thin sheet white matter called internal
medullary lamina.
Relations of lentiform nucleus
n Medial: On medial side lentiform nucleus is sepa-
rated from head of caudate nucleus and thalamus by
compact band of fibers of internal capsule.

Internal capsule

Fornix
Caudate nucleus (head)
Internal ventricle
Putamen
Thalamus
Globus pallidus
Claustrum
Insula
Extreme capsule
External capsule

Fig. 10.6 Coronal section of brain to show lentiform nucleus with other components of basal ganglia and related structures
179
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Stria terminalis
Septal area
Ant. perforated substance
Amygdaloid body
Olfactory bulb
Olfactory tract
Olfactory stria
Fig. 10.7 Amygdaloid body and its connections
n Lateral: From medial to lateral, lateral surface of
lentiform nucleus is related to following structures.
1. External capsule
2. Claustrum
3. Extreme capsule
4. Insular cortex at the floor of stem of lateral sulcus.
n Inferior: Below, lentiform nucleus merges with
cortical area of base of brain forming anterior perfo-
rated substance.
Amygdaloid body (nucleus) (Fig. 10.7)
Identity and location
Amygdaloid body or amygdaloid nucleus is an almond-
shaped mass of gray matter attached to the tip of
tail of caudate nucleus. It is located deep to uncus of
temporal lobe and related to anterior most end of roof
of inferior horn of lateral ventricle (Fig. 10.3).
Connections
n Afferents: From olfactory bulb via olfactory tract
and from primary olfactory area.
n Efferent: Efferent fibers start from amygdaloid
nucleus in the form of a curved fibrous band which
runs around the curve of thalamus following reverse
course of, and parallel to curve of caudate nucleus. It
is called stria terminalis. Reaching close to anterior
commissure and anterior pole of thalamus, stria
terminalis ends in
i. Septal area
ii. Anterior hypothalamic nuclei
iii. Anterior perforated substance.
Functions
Developmentally, so anatomically amygdaloid body
is a component of archistriatum (basal ganglia).
180
Anterior
Hypothalamic nuclei
But functionally it is considered to be part of limbic
system.
Very simply, it can be stated that amygdaloid body
help to adjust emotion and behavior of an individual
according to the environmental situation. Amygdaloid
body is concerned with feeling and expression of
fear, rage and irritability. The nucleus functions for
limitation for interest for intake of food and sexual
activity.
In a patient suffering from highly aggressiveness,
bilateral destruction of amygdaloid body result in
1. Decreased aggressiveness with change in docile
attitude.
2. Decreased emotional instability and diminished
restlessness.
3. Increased interest for food.
4. Increased sexual activity.
Claustrum (Fig. 10.6)
Claustrum is a thin, curved and wavy sheet of gray
matter which is well demonstrated in cross section of
cerebrum.
It is situated lateral to lentiform nucleus from
which it is separated by external capsule.
Laterally claustrum is related to insular cortex,
but separated by extreme capsule.
Developmentally, claustrum is a component of
archistriatum.
Connections and functions of claustrum are not
known.
Connections of corpus striatum (Fig. 10.8)
Fundamentals of connections of corpus striatum are
to be understood first. Neostriatum (caudate nucleus
and putamen) receive inputs from various parts
of central nervous system. Informations are then
 Basal Ganglia

Motor and sensory areas of cerebral cortex

Glutamate

Thalamus Corpus striatum Globus pallidus Thalamus

GABA

Do- GABA, Substance p, Acetylcholine

pamine

Substantia nigra

Serotonin

Brainstem

Spinal cord

Fig. 10.8 Connections of corpus striatum

integrated. Next, directives are sent to palleostriatum Neurotransmitter is glutamate.

(globus pallidus) which sends output.
Afferent fibers (to neostriatum) (Fig. 10.8):
1. Corticostriate fibers: Fibers from each part of
motor as well as sensory areas of cerebral cortex
project to a specific part of caudate-putamen complex.
The fibers are mostly ipsilateral. Maximum number
of inputs are from motor and sensory cortex.
2. Thalamostriate fibers: These fibers originate
from intralaminar nuclei of thalamus.
3. Nigrostriate fibers: Neurons of substantia nigra
send axons which end in caudate nucleus and putamen
to release dopamine which is inhibitory in function.
4. Ascending fibers from brainstem and spinal
cord: From different centers of brainstem other
181
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
than substantia nigra, fibers ascend to neostriatum
to liberate serotonin which is also inhibitory in
function. Similar functional fibers also ascend
from spinal cord.
Interconnecting fibers (Striopallidal fibers)
(Fig. 10.8): These fibers pass from neostriatum (ca-
udate nucleus and putamen) to pallidum (globus
pallidus).
Neurotransmitter released by these fibers are
Gamma-aminobutyric acid (GABA). Some of the
fibers from caudate nucleus putamen complex pass
back to substantia nigra. Neurotransmitters released
from these fibers are GABA or acetylcholine.
Efferent fibers (Pallidofugal fibers) Fig. 10.8:
After the informations (inputs) from different centers
of central nervous system are received and integrated
in corpus striatum (caudate nucleus and putamen),
these are channelled to globus pallidus. Globus pal-
lidus then influences activities of motor areas of
cerebral cortex and other motor centers in brainstem.
Globus pallidus influence directly to brainstem
centers. But cerebral cortex, so also spinal cord are
influenced indirectly through thalamus. So direct
pallidofugal fibers are to
1. Thalamus
2. Subthalamus
3. Brainstem tegmental centers.
These pallidofugal fiber are as follows
n Ansa lenticularis (Fig. 10.9A): These pallidofugal
fibers loop around posterior limb of internal capsule
to reach ventroanterior and ventrolateral nuclei of
thalamus.

Caudate nucleus
Putamen

Globus pallidus

Fasciculus lenticularis

Posterior limb of internal capsule

Thalamus
Ansa lenticularis
A

Thalamus
Internal capsule

Subthalamic nucleus Subthalamic fasciculus

Globus pallidus
Putamen

Putamen

Globus pallidus

Pallidotegmental fibers

Tegmentum of midbrain

Figs 10.9A to C Some of the pallidofugal fibers. A. Ansa lenticularis and fasciculus lenticularis (Pallidothalamic fibers), B. Subthalamic
fasciculus, C. Pallidotegmental fibers
182

n Fasciculus lenticularis (Fig. 10.9A): These
fibers also reach the same nuclei of thalamus, but
traversing through posterior limb of internal capsule.
n Subthalamic fasciculus (Fig. 10.9B): These
pallidofugal fibers connect subthalamic nucleus in
both directions. Subthalamic nucleus is a small mass
of gray matter which presents biconvex appearance
in coronal section. It is located caudal to thalamus
and inferomedial to globus pallidus from which it is
separated by fibers of internal capsule. Subthalamic
fasciculus connect globus pallidus with subthalamic
nucleus in both directions. The fibers of the fasciculus
traverse internal capsule.
n Pallidotegmental fibers (Fig. 10.9C): These
fibers descend from globus pallidus to motor centers
situated in tegmentum of brainstem.
CLINICAL ANATOMY
Disorder of function of basal ganglia results from
lesion in basal ganglia. Lesion of basal ganglia may
be vascular in orgin or due to genetic disorder, less
commonly may be infective or degenerative.
Lesion of basal ganglia is clinically characterized
by two general types of disorders.
n Hyperkinetic disorder: Showing excessive
abnormal involuntary movements as seen in chorea,
athetosis and ballism (ballismus).
n Hypokinetic disorder: Presenting slow and
sluggish abnormal involuntary movements.
n Parkinson disease is characterized of course, by
both types of disorders.
CHOREA
The patient of chorea presents nonrepetitive irre-
gular, quick and jerky movements.
Swift and sudden movements of head and limbs are
good examples which exhibits typical dancing gait.
Two different forms of choreiform disease are as
follows.
Huntington Disease (Huntington Chorea)
It is an autosomal dominant inherited disease due to
single gene defect on chromosome 4. Onset of disease
is in adult life. Prognosis is bad as death occurs by 15
20 years after onset. Males and females are equally
affected.
At the onset muscles of limbs and face are affected.
This results in choreiform movements with twitching
of face characterized by facial grimacing. Later on
more muscles are affected. So patient ultimately be-
comes confined and swallowing and speaking become
difficult.
Basal Ganglia
Sydenham Chorea
This disorder is infective in origin. Children suffering
from rheumatic fever due to streptococcal infection
are affected. Streptococcal antigen attacks the neurons
of basal ganglia. The disease is characterized by
rapid involuntary and irregular movements of limb,
trunk and face which is characterized by choreiform
movements. However, prognosis of the disease is good
as patient gets a full recovery.
BALLISMUS
It is the disorder caused due to vascular lesion of
subthalamic nucleus.
Subthalamic nucleus functions for integration
of smooth movements of different parts of body.
Ballismus due to lesion in subthalamic nucleus is
characterized by small strokes of sudden outburst
of violent involuntary movements affecting trunk,
girdle and proximal part of limb of opposite half of
body. Usually both upper as well as lower limbs of
contralateral side are affected, for which disorder is
known as hemiballismus. If restricted to one limb, it
is called monoballismus.
ATHETOSIS
This is a degenerative disease of globus pallidus.
Degeneration of neurons of globus pallidus leads
to breakdown of neurocircuit, globus pallidus
thalamuscerebral cortex. The disorder is charac-
terized by slow, sinuous writhing movements of distal
part of limbs affecting muscles of fingers and toes.
PARKINSON DISEASE
Parkinson disease is also known as Parkinsonism or
paralysis agitans.
It is a progressive degenerative disease of unknown
cause.
The disease starts between the age of 45 years to
55 years. It is the result of degeneration of neurons
of substantia nigra and to a lesser extent, those of
globus pallidus, putamen and caudate nucleus.
Substantia nigra contains melanin pigment
containing neurons. These neurons release dopamine
through their axons (nigrostriate fibers) to corpus
striatum. Dopamine exerts inhibitory effect on striatal
neurons. So, reduction of dopamine due to lesion of
neurons of substantia nigra causes loss of inhibitory
effect on function of neurons of corpus striatum.
Clinically it is characterized by Release phenomenon.
Patient of Parkinson disease presents following
clinical manifestations.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
1. Tremor: This is repetitive alternating, involun-
tary movement of agonists and antagonists of
limbs. This movement is observed in resting cond-
ition of patient and disappears when he or she
performs a voluntary movement. That is why it
is called static tremor or resting tremor. It is
to be remembered here that, patient of cerebellar
disease present intention tremor which is observed
when the patient intends to perform a movement.
2. Hypokinesia: Parkinson disease is characterized
by combination of both hyperkinetic and hypok-
inetic disorder. Tremor is a manifestation of
hyperkinetic disorder. In Parkinson disease feat-
ures of hypokinesia are also observed. Akinesia
is lack of initiation of movement. Bradykinesia
is slowness in performance of movement. Face is
found to be expressionless. Voice is slurred and its
modulation is absent. While walking, swinging of
arm is absent.
3. Rigidity: Rigidity of muscles is elicited by pas-
sive movement of a joint, when a resistance is
felt. Unlike rigidity in pyramidal tract lesion, in
184
Parkinson disease rigidity is present in opposing
muscle groups to an equal extent. Again nature
of rigidity varies depending upon presence or
absence of tremor. If tremor is present, uniform
and sustained resistance during passive move-
ment of limb joint is overcome by a series of
jerky movement. Resistance and jerky movement
occurring alternately is like movement of cogwheel
of a watch. That is why it is called Cog-wheel
rigidity. In absence of tremor, uniform and
sustained resistance during passive movement
shows plastic rigidity on lead-pipe rigidity.
4. Postural disorder: Patient of Parkinson disease
presents a stooping (forward bend) posture with
knee and elbow joints flexed partially which are
due to rigidity of muscles of trunk and limbs
respectively.
5. Disorder in gait: Patient walks slowly in short
steps and may run to maintain balance and may
be unable to stop when starts walking which is
due to loss of limitation of voluntary movement.
The typical style of walking is called shuffling gait.
 Lateral Ventricle of Brain
Lateral ventricle of brain is the cavity of telencep-
halon. So it is the cavity of ventricular system present
in cerebral hemisphere.
Lateral ventricles are two in number, right and
left, present inside the respective cerebral hemisp-
here.
Lateral ventricle presents C-shaped curvature
with a short variable posterior prolongation (Fig. 11.1).
The concavity of the ventricle curves round thalamus
and caudate nucleus. Central parts of the ventricles
of both sides are just paramedian in position where
they are separated by a midline septum called septum
pellucidum.
Parts of Lateral Ventricle (Fig. 11.2)
Lateral ventricle presents four parts. Each of the four
parts of the ventricle coincides with the position of
four lobes of cerebral hemisphere.
Interventricular foramen
of Monro
Third ventricle
Cerebral aqueduct of Sylvius
Fourth ventricle
Central canal
Fig. 11.1 Two lateral ventricles in superior view with other parts of ventricular system
11
1. Anterior horn in frontal lobe
2. Central part of body in parietal lobe
3. Posterior horn in occipital lobe
4. Inferior horn in temporal lobe.
Out of three horns, inferior horn is largest. Poste-
rior horn is not only smallest, it is also variable and
very often asymmetrical in two sides.
Ventricular System (Fig. 11.3)
Ventricles of brain are developmentally derived
from cavity of neural tube. Ventricles are four fluid-
filled cavities located inside different parts of brain.
They are intercommunicating with each other and
other parts of cavity of central nervous system. The
ventricles are therefore lined with ependyma and
contain cerebrospinal fluid. Ventricles are four in
number.
Anterior horn
Central part
Lateral ventricle
Inferior horn
Posterior horn
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Anterior horn Central part or body

FL PL

OL

TL

Inferior horn Posterior horn

Fig. 11.2 Parts of lateral ventricle in relation to four lobes of cerebral hemisphere

Anterior horn of lateral Body of lateral ventricle

ventricle

Interventricular foramen
of Monro Posterior horn of lateral
ventricle

Third ventricle

Inferior horn of lateral

ventricle
Aqueduct of midbrain

Fourth ventricle

Central canal of lower half

of medulla oblongata

Central canal of upper end

of spinal cord

Fig. 11.3 Lateral ventricle inrelation to complete ventricular system

1. Lateral ventricle: Two in number, right and left,
present on either side of midline. They are cavities
of telencephalon (cerebral hemisphere).
2. Third ventricle: Narrow, single midline cavity
of diencephalon, situated between the thalamus
of two sides. Superiorly, on either side of midline
it communicates with lateral ventricle through
interventricular foramen of Monro.
186
3. Fourth ventricle: It is the cavity of rhombenc-
ephalon (hindbrain) located between cerebellum
behind, and pons and medulla oblongata in front.
Cavity of fourth ventricle communicates with third
ventricle above through aqueduct of midbrain (of
Sylvius), and with narrow central canal of spinal
cord through central canal of lower-half of medulla
oblongata below. Lower part of ependymal roof of

fourth ventricle presents foramen of Magendie in
the midline, and foramen of Luschka on either side,
through which ventricular cavity communicates
with subarachnoid space. Choroid plexus of ventr-
icles liberate cerebrospinal fluid which freely
circulates in subarachnoid space through foramen
of Magendie and foramen of Luschka. Constant
secretion of cerebrospinal fluid is balanced by its
constant absorption by arachnoid granulations
projecting in intracranial venous sinus from
arachnoid mater.
Different Parts of Lateral Ventricle
Anterior horn
It is the anterior most part of lateral ventricle proje-
cting into frontal lobe. Its anterior end is blind and
posteriorly it becomes continuous with central part or
body of lateral ventricle at the level of interventricular
foramen of Monro.
Genu of
Corpus callosum
Anterior horn of lateral
ventricle
Rastrum of
Corpus callosum
Interventricular
foramen of Monro
Fig. 11.4A Lateral ventricle is sagittal section. Anterior horn is bounded by body, genu and rostrum of corpus callosum superiorly,
anteriorly and inferiorly respectively
Septum pellucidum
Cavity of anterior horn of lateral
ventricle
Fig. 11.4B Boundaries of anterior horn of lateral ventricle on coronal section
Lateral Ventricle of Brain
Boundaries
n Anteriorly: Anterior horn is limited by posterior
surface of genu of corpus callosum (Fig. 11.4A).
n Posteriorly: Anterior horn is continuous with
central part of lateral ventricle (Fig. 11.4A).
n Superiorly: Roof is formed by inferior surface of
anterior part of body of corpus callosum (Fig. 11.4B).
n Inferiorly: Floor of anterior horn is formed
medially by superior surface of rostrum of corpus
callosum and laterally by head of caudate nucleus
(Fig. 11.4B).
n Medially: Septum pellucidum intervens anterior
horn of both sides.
Central Part or Body
Central part or body of lateral ventricle coincides
with the position of central core of parietal lobe below
central part (trunk) or body of corpus callosum.
n Extent: From the landmark of interventricular
foramen of Monro to the level of splenium of corpus
callosum.
Body of
Corpus callosum
Posterior horn of
lateral ventricle
Inferior horn of lateral ventricle
Body of corpus callosum
Head of caudate nucleus
Rostrum of corpus callosum
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Communications: Central part of lateral vent-
ricle communicates with all the three horns of lateral
ventricle.
n Anteriorly: With anterior horn infront of interve-
ntricular foramen of Monro.
n Posteriorly: Beyond (posterior to) splenium of
corpus callosum, central part of body communicates
with posterior horn.
n Inferiorly: Below splenium, central part commu-
nicates anterioinferiorly with inferior horn.
Besides, it has alread been learnt that junction
of anterior horn and body of lateral ventricle
communicates with third ventricle through foramen
of Monro.
Boundaries (Fig. 11.5)
Central part or body of lateral ventricle is triangular
on coronal section having following walls.
Medial wall is formed by a thin bilaminar membrane
which is vertically suspended in midsagittal plane from
undersurface of corpus callosum. It is called septum
pellucidum. Lower margin of septum pellucidum is
attached to superior aspect of body of fornix.
Floor is formed by the following structures from
lateral to medial direction.
1. Body of caudal nucleus
2. Stria terminalis
3. Thalamostriate vein
4. Superior surface of thalamus which is covered by
fringe of choroid plexus.
Superolateral wall is arched downwards and late-
rally forming roof as well as lateral wall. It is formed
by mediolateral concavity of undersurface of body of
corpus callosum.
Coronal section through body of
corpus callosum
Septum pellucidum
Fornix
Fissure between thalamus and
fornix for invagination of tela
choroidea
Cavity of third ventricle
Fig. 11.5 Boundaries of central part or body of lateral ventricle
188
Choroid fissure is a curved slit seen from medial side
of cerebral hemisphere. It is between inferior aspect of
body of fornix and superior surface of thalamus.
n Tela choroidea: A thin layer of ependyma
projects through the choroid fissure over the superior
surface of thalamus to carry a fringe-like fine network
of blood vessels to form choroid plexus. Tela choroidea
carrying the network of choroid plexus invaginating
ependyma through choroid fissure is common for the
lateral ventricles and third ventricle (Fig. 11.6).
Posterior horn (Fig. 11.7)
Posterior horn is a small backward prolongation
from body of lateral ventricle to the occipital lobe of
cerebral hemisphere.
It can be considered as backward continuation
of central part of body beyond splenium of corpus
callosum.
Variations
1. Posterior horn may be absent in any side.
2. If present in both sides, it may be asymmetrical in
size.
Boundaries (Fig. 11.7)
Posterior horn project backwards bisecting the fibers
of splenium and posterior end of body of corpus
callosum. That is why it is smallest among three
horns and its walls are minimum. The walls are
inferomedial and superolateral.
Inferomedial wall is also considered as medial
wall. This wall presents two bulges towards the
cavity. Upper bulge is called bulb of posterior horn
which is raised by the fibers of forceps major running
Cavity of central part or
body of lateral ventricle
Body of caudate nucleus
Stria terminalis
Thalamostriate vein
Thalamus
Hypothalamus

Tela choroidea for
lateral ventricle
Choroid plexus of
third ventricle
Fig. 11.6 Common invagination of tela choroidea for lateral as well as third ventricles
Forceps major
Calcarine sulcus
Fig. 11.7 Boundaries of posterior horn of lateral ventricle
backwards from splenium of corpus callosum. Lower
elevation is caused due to invagination of calcarine
sulcus which produces indentation in the inferomedial
wall of posterior horn called calcar avis. That is why
calcarine sulcus is an example of complete sulcus.
Superolaterally, posterior horn is bounded by
posteriorly running fibers of body of corpus callosum.
It is called tapetum which separates ventricular wall
from optic radiation.
Inferior horn
Inferior horn of lateral ventricle is the largest among
three horns.
It projects into the temporal lobe curving down-
wards and forwards around posterior end of thalamus
from the junction of body and posterior horn.
Triangular area of junction of body, posterior horn
and inferior horn is known as collateral trigone which
is widest area of the ventricular cavity.
Inferior horn roughly corresponds to the level of
superior temporal sulcus.
Lateral Ventricle of Brain
Choroid plexus of lateral
ventricle
Optic radiation
Tapetum
Bulb of posterior horn
Calcar avis
Boundaries (Fig. 11.8)
In coronal section, inferior horn looks like a concavo-
convex transverse slit presenting a roof and floor.
Roof
Roof is convex in outline. Its medial part is rel-
ated to stria terminalis and tail of caudate nucleus
mediolaterally positioned. Lateral part of roof is form-
ed by tapetum of corpus callosum which are the fibers
arching backwards from splenium and posterior end of
body. Anterior end of roof is also related to amygdaloid
body attached to the tail of caudate nucleus.
Outside tapetum, fibers of optic radiation are
superimposed.
Floor
Lateral part of floor presents an elevation called
collateral eminence which is the indentation caused
by bottom of collateral sulcus, which is an example of
complete sulcus of cerebral cortex.
Medial part of floor is formed by hippocampus which
is a mass of gray matter. Anterior end of hippocampus
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Tela choroidea
Alveus
Fimbria
Hippocampus
Dentate gyrus
Parahippocampal
gyrus
Fig. 11.8 Boundaries of inferior horn of lateral ventricle
is expanded and slightly furrowed at its anterior end
which is called pes hippocampus. Ventricular surface
of hippocampus is covered by a thin layer of white
matter called alveus. Alveus is formed by axons of the
neurons present in hippocampus. The axons converge
on the medial side of hippocampus to form a band of
white matter called fimbria. Fiber bundle of fimbria is
continuous posteriorly as posterior column of fornix.
Choroid fissure
Choroid fissure of the inferior horn is a slit on medial
side in the interval between stria terminalis of roof
and fimbria of the floor. Choroid plexus of lateral
ventricle turns round posterior end of thalamus to
invaginate ependyma through choroid fissure of
inferior horn from medial side.
CLINICAL ANATOMY
Ventricular system so also subarachnoid space contain
normally an optimum quantity of cereb-rospinal fluid
due to balance maintained between its secretion
by choroid plexus of ventricles and absorption by
arachnoid granulations in subarachnoid space.
In pathological conditions there may be overacc-
umulation of cerebrospinal fluid which is known as
hydrocephalus. Hydrocephalus is associated with
raised intracranial pressure.
Varieties of Hydrocephalus
1. Noncommunicating hydrocephalus: In this
case, blockage in flow of cerebrospinal fluid may
be at any point between its formation at choroid
plexus and its exit from ventricular system through
the foramina at the roof of fourth ventricle.
190
Stria terminalis
Tail of caudate nucleus
Tapetum
Collateral eminence
Collateral sulcus
2. Communicating hydrocephalus: In this var-
iety, there is no blockage anywhere between site
of formation and exit of cerebrospinal fluid from
ventricular system to subarachnoid space. So it
is the effect of either overproduction or impaired
absorption of fluid.
Causes of Hydrocephalus
1. Abnormal increase in formation of cerebrospinal
fluid is a rare condition which occurs in case of
tumor of choroid plexus.
2. Blockage in circulation of cerebrospinal
fluid Obstruction may be at different level
leading to different types of manifestations.
a) Tumor adjacent to interventricular for-
amen of Monro: It will cause unilateral obst-
ruction of lateral ventricle of one side leading to
its dilatation. It will ultimately cause atrophy
of surrounding neural tissue.
b) Obstruction anywhere beyond interven-
tricular foramen, e.g. in third ventricle,
cerebral aqueduct or foramen of Magendie and
foramen of Luschka will cause symmetrical
distension of both lateral ventricles along with
distension of third ventricle.
Obstruction of foramen of Magendie and
foramen of Luschka may occur due to expanding
tumor or inflammatory exudate, e.g. in case of
meningitis.
3. Impaired absorption of cerebrospinal fluid
through arachnoid granulations may be due
to following causes.
a) Inflammatory exudate

b) Pressure or thrombosis of venous sinuses
c) Obstruction of internal jugular vein.
In these cases distension of lateral ventricles with
other ventricles is secondary to overaccumulation of
cerebrospinal fluid in subarachnoid space.
Radiological Investigation of Lateral Ventricle
Size, shape and situation of lateral ventricle are
assessed by radiological investigations for its
a) Distension as a result of obstruction in
ventricular system or subarachnoid space
b) Distortion
c) Displacement (shifting).
These types of abnormality in outline of lateral
ventricle may be due to
Lateral Ventricle of Brain
i. Expanding tumor
ii. Intracerebral hemorrhage which may be ext-
radural, subdural or intracerebral.
Lesion in one side will cause deviation of brain
with lateral ventricle to the opposite side which
neurologically termed as midline shifting.
Assessment of these types of pathology of lateral
ventricle and also different areas of brain in different
levels are done by two easy and safe radiological
investigations which are known as
i. Computed tomography scanning (CT Scan)
ii. Magnetic resonance imaging (MRI).
Pneumoventriculography is another radiological
investigation in which case straight X-ray of cranium
is taken after injecting oxygen or air inside cavity of
lateral ventricle which will replace cerebrospinal fluid.
191
 Diencephalon
Diencephalon is the central midline portion of fore-
brain (prosencephalon).
Superolaterally it is continuous with telencephalon
on either side which forms cerebral hemispheres.
Inferiorly, it merges with midbrain component of
brainstem.
Main mass of diencephalon (the thalamus) is
divided into two identical halves which are separated
by a narrow midline cleft which is the cavity of
diencephalon called third ventricle of brain.
Diencephalon is primarily divided into dorsal
diencephalon and ventral diencephalon by a narrow
sulcus called hypothalamic sulcus which extends
from interventricular foramen of Monro to upper end
of aqueduct of Sylvius (Fig. 12.1).
12
Parts of diencephalon: These are five in number.
n Dorsal diencephalon (above hypothalamic sulcus)
1. The thalamus (dorsal thalamus)
2. Metathalamus
3. Epithalamus.
n Ventral diencephalon (below hypothalamic sulcus)
4. Subthalamus
5. Hypothalamus.
The thalamus is the main mass of diencephalon.
Metathalamus is made up of lateral and medial
geniculate bodies.
Epithalamus is the pineal gland connected to
posterior pole of thalamus by proximal and distal
laminae of pineal stalk. Unlike other components of

Corpus callosum Interthalamic adhesion

Septum pellucidum Metathalamus

Thalamus Epithalamus (pineal gland)

Hypothalamus
Subthalamus
Hypothalamic sulcus

Part of hypothalamus in floor

of third ventricle
Cerebellum
Pons
Fourth ventricle

Medulla oblongata

Fig. 12.1 Diencephalon in midsagittal section with structures around it


Cavity of lateral
ventricle
Cavity of third
ventricle
Fig. 12.2 Diencephalon in coronal section
diencephalon it is not bilateral structure, but single
midline component.
Subthalamus is posterior part of ventral dience-
phalon which is continuous with brainstem below. It
contains subthalamic nucleus (Fig. 12.2).
Hypothalamus is anterior part of ventral dienceph-
alon which is divided into upper and lower part. Upper
part forms lowermost portion of lateral wall of third
ventricle. Lower part forms floor of third ventricle, so
from outer aspect it forms base of brain (Figs 12.1 and
12.2).
THALAMUS
l Thalamus is the largest component of diencephalon.
l It is an egg-shaped ovoid mass of gray matter, one
on either side of midline.
l A narrow midline cleft between thalami of two
sides is third ventricle of brain.
l Gray mass of thalamus forming different nuclei
forms the cell stations for all contralateral sensory
pathways of body except the olfactory pathway.
l Two thalami are interconnected by a compact
band of white matter crossing midline. It is called
interthalamic adhesion.
Diencephalon
Interthalamic adhesion
Thalamus
Subthalamic
nucleus
Subthalamus
Hypothalamus
l It is the thalamus component of dorsal dience-
phalon, which merges with the two components of
ventral diencephalon as follows (Fig. 12.1).
i. In anterior plane: Merges with hypothalamus.
ii. In posterior plane: Merges with subthalamus.
l Ovoid mass of thalamus is anteroposteriorly elon-
gated with following dimensions.
Anteroposterior measurement 3.5 cm
Transverse measurement 1.5 cm
l Longer anteroposterior axis is directed forwards
and medially.
Features of Thalamus
Poles
Anterior pole is narrower and more close to the midline.
It forms posterior boundary of interventricular fora-
men of Monro.
Posterior pole is broader. It is known as Pulvinar.
Pulvinars of both side are separated by a narrow
interval which lodges pineal gland. Pulvinar is the
part of thalamus which overhangs lateral geniculate
body of metathalamus (Fig. 12.3).
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Superior surface covered
by a thin lamina of white
matter (stratum zonale)

Anterior pole

Posterior pole (pulvinar)

Lateral surface covered by
a thin layer of white matter
(external medullary lamina)

Lateral geniculate body

Fig. 12.3 Lateral view of left thalamus

Surfaces Subdivisions of Thalamus

1. Superior surface: It forms the floor of central
part or body of lateral ventricle along with thala-
mostriate vein, stria terminalis and body of cau-
date nucleus which are mediolaterally placed (Fig.
12.2). Superior surface of thalamus is covered by
thin layer of white matter called stratum zonale
(Fig. 12.3).
2. Medial surface: It forms lateral boundary of
third ventricle. Medial surfaces of both thalami
are connected by interthalamic adhesion (Fig.
12.2).
3. Lateral surface: It is immediately covered by
a thin lamina of white matter called external
medullary lamina (Fig. 12.3). Beyond this, lateral
surface is related to thick compact fibrous band of
posterior limb of internal capsule.
Superior and medial surfaces are covered by
ependyma lining the cavity of lateral ventricle and
third ventricle respectively (Fig. 12.2).
Thalamus is grossly subdivided by a vertical Y sha-
ped lamina of white matter, called internal medullary
lamina. Three parts of thalamus demarcated from
each other by the lamina are, (Fig. 12.4)
1. Anterior part
2. Medial part
3. Lateral part.
White Matter of Thalamus
Thalamus is a condensed mass of gray matter with
minimum amount of white matter as following.
1. Stratum zonale: It is a thin lamina of white
matter covering superior surface.
2. External medullary lamina: It is a thin lamina
of white matter covering lateral surface.
3. Internal medullary lamina: It is a Y shaped
vertical lamina inside thalamus dividing it into
anterior, medial and lateral part.
Anterior part

Medial part

Internal medullary
lamina
Lateral part

Lateral geniculate body Pulvinar

Fig. 12.4 Internal medullary lamina dividing thalamus into anterior, medial and lateral parts
194

4. Interthalamic adhesion: It is a very narrow
but compact bundle of white matter, round on
cross section, connecting medial surface of both
thalami. Though the band crosses the midline to
link two thalami, but fibers truly do not cross the
midline. Fibers, though may cross midline, but
return back to the same sided thalamic nuclei.
So fibers of interthalamic adhesion are not true
commissure (Figs 12.1 and 12.2).
Nuclei of Thalamus
1. Larger nuclei: Larger nuclei of thalamus are
subdivided into three groups which lie in
a) Anterior part
b) Medial part
c) Lateral part.
2. Smaller nuclei: These nuclei are related to surf-
ace or white matter lamina of thalamus. These are
smaller collection of nerve cells as following
a) Intralaminar nuclei
b) Midline nuclei or paraventricular nuclei
c) Reticular nuclei.
Nuclei related to anterior and medial parts of thal-
amus constitute paleothalamus and those of lateral
part are considered as neothalamus.
Anterior part (Fig. 12.5)
This part contains anterior thalamic nuclei. These
nuclei is concerned with.
1. Function which is associated with that of limbic
system.
Diencephalon
2. Emotional tone.
3. Mechanism of recent memory.
Medial part (Fig. 12.5)
Medial part of thalamus contains many smaller
nuclei and a large medial dorsal or dorsomedial
nucleus. The dorsomedial nucleus is made up of
anteromedial magnocellular and posterolateral par-
vocellular parts.
Medial part of thalamus is concerned with
integration of large number of sensory informations
(somatic as well as visceral) and correlation with
emotional feelings.
Lateral part (Fig. 12.5)
Nuclei of lateral part are divided into a dorsal tier and
a ventral tier.
Dorsal tier nuclei are (from anterior to posterior)
1. Lateral dorsal nucleus
2. Lateral posterior nucleus
3. Pulvinar.
Ventral tier nuclei are following from before back-
wards.
1. Ventral anterior nucleus: It influences activities
of motor system.
2. Ventral lateral nucleus: This nucleus also infl-
uences motor activities.
3. Ventral posterior nucleus: It is divided into
ventroposteromedial and ventroposterolateral nu-
clei. These nuclei receive various sensory inputs
(somatic as well as visceral) and convey these to
sensory areas of cerebral cortex.
Anterior thalamic nucleus
(anterior zone)

Dorsal medial nucleus (medial

}
zone)

Ventral anterior Lateral dorsal

nucleus nucleus

Ventral Lateral posterior

Dorsal tier of
Ventral lateral nucleus
lateral zone
tier of nucleus
lateral Ventroposterolateral
zone nucleus Pulvinar

Medial geniculate body

Ventroposteromedial
nucleus Lateral geniculate body

Fig. 12.5 Nuclei of different zones of thalamus

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Internal medullary
lamina
Fig. 12.6 Smaller nuclei of thalamus
Other Nuclei of Thalamus (Fig. 12.6)
Intralaminar nuclei
These are small collections of neurons which are pres-
ent in internal medullary lamina.
These nuclei influence level of consciousness and
alertness of an individual.
Midline nuclei (paraventricular nuclei)
These group of neurons are situated in the lateral
wall of third ventricle beneath ependyma and some
are also scattered in interthalamic adhesion.
Function of these nuclei are not clearly known.
Reticular nucleus
This is a thin layer of nerve cells which are interposed
between external medullary lamina and posterior limb
of internal capsule. It means that this thin lamina of
nucleus is situated on lateral surface of thalamus.
Through this nucleus, cerebral cortex regulates
thalamic activity.
GENICULATE BODIES: Lateral and medial
geniculate bodies are together known as metathala-
mus. These two small round elevations are overhung
by pulvinar and nowadays are considered as comp-
onents of thalamus. Lateral and medial geniculate
bodies are diencephalic level relay stations of visual
end cochlear pathways respectively.
Connections of Thalamus (Fig. 12.7)
Connections of thalamus is better understood and
remembered if Figure no. 12.7 is consulted along with
study of under-mentioned text.
Anterior part
Name of nucleus Afferent Efferent
Anterior thalamic Mammillary 1. Cingulate gyrus
nuclei body 2. Hypothalamus
196
Ependyma on
medial surface
Midline (paraventricular)
nuclei
Intralaminar nuclei
Reticular nuclei on
lateral surface
Medial part
Name of nucleus Afferent Efferent
Dorsomedial nucleus Amygdaloid body 1. Prefrontal cortex
2. Hypothalamus
Lateral part
Dorsal tier
Name of nucleus Afferent Efferent
Lateral dorsal Medial nucleus Cingulate gyrus
nucleus of thalamus
Lateral posterior Other thalamic Superior parietal
nucleus nuclei lobule (Area 5)
Pulvinar Other thalamic Inferior parietal
nuclei lobule (Area 7)
Ventral tier
Name of nucleus Afferent Efferent
Ventral anterior 1. Globus pallidus Premotor cortex
nucleus 2. Substantia (Area 6)
nigra
Ventral lateral 1. Globus pallidus Motor and premotor
nucleus 2. Substantia nigra cortex (Area 4 and
3. Dentate nucleus 6)
4. Red nucleus
Ventroposterolateral 1. Spinal lemniscus Postcentral gyrus
nucleus 2. Medial lemniscus (Area 3, 1, 2)
Ventroposteromedial 1. Trigeminal Postcentral gyrus
nucleus lemniscus (Area 3, 1, 2)
2. Solitariothalamic
tract
Metathalamus
Name of nucleus Afferent Efferent
Lateral geniculate Optic tract of Primary visual
body visual pathway cortex Area 17
Medial geniculate Lateral lemniscus Auditory cortex
body and inferior colliculus (Area 41 and 42)
 Diencephalon
Prefrontal cortex and
hypothalamus

Cingulate gyrus Amygdaloid body

Superior parietal lobule (area 5)
Hypothalamus
Other thalamic nuclei

Mammillary body AN Inferior parietal

lobule (area 7)
VA
LD DM
Globus pallidus
LP
substantia nigra VL Lateral lemniscus
VPL PUL inferior colliculus
Premotor cortex
(area 6) Auditory cortex
(area 41, 42)
Globus pallidus, substantia nigra, VPM
dentate nucleus and red nucleus
Optic tract

Premotor and motor areas Primary visual

(area 6 and area 4) cortex (area 17)
Trigeminal
Postcentral gyrus lemniscus, solitario-
Spinal lemniscus, medial (area 3, 1, 2) thalamic tract
lemniscus

Fig. 12.7 Connections of thalamic nuclei

n Connection of laminar nuclei 3. Probably olfactory sensation is indirectly related

n Intralaminar nuclei to thalamus. Possibly olfactory sensation from
Afferent: amygdaloid nucleus and hippocampus is integrated
1. Reticular formation in lower level in mammillary body along with
2. Spinal lemniscus taste sensation. Finally information passes to the
3. Trigeminal lemniscus thalamus through mammillothalamic tract.
Efferent: Via other thalamic nuclei to 4. For perception of moderate degree of pain and
1. Cerebral cortex temperature sensation, ventroposterior nuclei of
2. Corpus striatum thalamus are highest center.
n Midline (Paraventricular) nuclei 5. It is known that, final order of neurons for all
Afferent: Reticular formation kinds of sensory inputs passes from thalamus
Efferent: Not clearly known to sensory cortex. But for any kind of crude
n Reticular nucleus sensations, thalamus itself can appreciate it.
Afferent: But for interpretation of sensations based in past
1. Reticular formation experience, functional integrity of thalamocortical
2. Cerebral cortex connection is required. It can be understood by an
Efferent: example. If sensory cortex is destroyed, one can
Other thalamus nuclei. appreciate presence of a hot object in hand, but
appreciation of approximate temperature, shape
Functions of Thalamus and weight of the object will be impaired.
6. Ventral anterior and ventral lateral nuclei of
1. In connection with functions of thalamus the first thalamus receive inputs from globus pallidus,
and foremost point is to note that, thalamus is made substantia nigra and cerebellar dentate nucleus.
up of a complex collection of nerve cells which are These nuclei discharge outflow to motor and
centrally placed in brain and are interconnected premotor areas of cerebral cortex. So this thalamic
with various motor and sensory centers. circuit regulate voluntary movement with harmony
2. Thalamus is the central sensory cell station where in right direction and to a right extent. So lesion of
all kinds of sensory pathways (except olfactory these thalamic nuclei will cause various kinds of
pathway) relay on their way to concerned sensory abnormal involuntary movements.
areas of cerebral cortex for perception and inte- 7. Dorsomedial nucleus of thalamus connects hypo-
gration. thalamus and prefrontal cortex of frontal lobe.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
This pathway is concerned with maintenance of
personality and subjective feeling (mood), and
emotion of an individual.
8. Anterior nucleus of thalamus is concerned with
mental attention and memory of recent events.
9. Reticular laminar nuclei between external medu-
llary lamina and posterior limb of internal capsule
are required for alertness and wakefulness of an
individual.
CLINICAL ANATOMY
Thalamus is centrally placed important relay station
and center for integration of various types of inputs to
central nervous system. So disease of this gray matter
mass will produce profound effect.
Cause of thalamic lesion is mostly vascular as a
result of thrombosis or hemorrhage of posteromedial
sets of ganglionic or central branches of circle of
Willis. The artery is named as thalamogeniculate
branch. Sometimes thalamic lesion may be neoplastic
or degenerative in origin.
Clinical manifestations of thalamic lesion is funda-
mentally based on two principles:
1. Effect of lesion will depend upon loss of function of
different nuclei of thalamus.
2. As the thalamus is centrally placed and closely
approximated to many other important areas
or centers of brain, associated lesion of adjacent
structures may overshadow the effect of thalamic
lesion. Example is lesion of internal capsule,
corpus striatum or midbrain.
Some Important Effects of Thalamic Lesion
1. Sensory impairment: Once ventroposteromedial
and ventroposterolateral nuclei of thalamus
are affected, it will present grossly noticeable
sensory impairment. Ventroposteromedial nucleus
receives exteroceptive as well as proprioceptive
sensations from opposite half of face through
trigeminal lemniscus and taste sensation through
solitariothalamic tract. So these sensations will
be impaired. Again lesion of ventroposterolateral
nucleus, which receives spinal lemniscus and
medial lemniscus, will cause loss of exteroceptive
sensation including pain, temperature, touch (inclu-
ding discriminative touch) and pressure sensation,
proprioceptive sensations from muscles and joints,
sense of vibration of opposite half of body.
2. Motor dysfunction:
l Abnormal involuntary movement: These chore-
iform movements or athetosis with ataxia are
due to lesion of ventral anterior and ventral
lateral nuclei which link a neurocircuit of
198
globus pallidus, substantia nigra, dentate
nucleus with cerebral cortex. Ataxia is due to
loss of appreciation of movements of muscles
and joints.
l Thalamic hand: Contralateral hand is held
in an abnormal position. Forearm is pronated
with flexed wrist and metacarpophalangeal
joint and extended interphalangeal joint. This
deformity is due to altered tone in different
groups of muscle.
3. Altered higher function: Lesion of anterior
nucleus will cause loss of alertness or attentiveness
and loss of recent memory.
Medial dorsal nucleus is concerned with mainten-
ance of mood and emotional balance of an individual.
It is, of course, related to nature of sensory input as
well as the past experience gathered. Lesion of this
nucleus will cause alteration of mood which ranges
from a simple sense of well being or euphoria to
mental depression.
Thalamic Syndrome
Features of thalamic syndromes is absolutely different
from clinical manifestations of thalamic lesion which
has been described above. Findings of thalamic
syndrome appear during the stage of recovery of a
patient getting thalamic infarct. In this case, sensory
perception threshold for touch, pain, temperature
is lowered. It means, stimulation of lower intensity
gives rise to higher feelings. For example, a simple pin
prick on body surface will give the feeling of burning
sensation. Light touch on body surface may even give
rise to feeling of excruciating pain. Similar effect is
observed in relation to special sensory inputs. For
example, a melodious musical sound may be heard by
the patient very loud and disagreeable.
METATHALAMUS
Metathalamus is the component of dorsal dien-
cephalon. These are two oval elevations lateralo-
medially placed and connected to posterior aspect of
thalamus, underneath the projected posterior pole
called pulvinar. These are called medial and lateral
geniculate bodies. They are so named because they are
bend on themselves giving a geniculate appearance.
Both the geniculate bodies are grouped together
under metathalamus. But, because of their functional
relationship they are nowadays incorporated in dorsal
thalamus.
Medial Geniculate Body
This oval body is placed underneath pulvinar of
thalamus lateral to superior colliculus. Inferior coll-

iculus is connected to medial geniculate body by a
band known as inferior brachium. Medial geniculate
body is the diencephalic relay station of cochlear
pathway for hearing. So afferent fibers reach this
nuclear mass coming from below and efferent fibers
go upto the auditory cortex.
n Afferent: These are narrow compact ascending
fiber bundle called lateral lemniscus which are
axons of nerve cells from superior olivary nucleus
and nucleus of trapezoid body in lower end of pons.
Some of the fibers pass to medial geniculate body
after relaying in inferior colliculus. Beyond inferior
colliculus, fibers enter medial geniculate body through
inferior brachium.
n Efferent: Efferent fibers are axons of nerve cells
in medial geniculate body. These fibers form auditory
radiation. These form sublentiform part of internal
capsule to end in auditory cortex which is present
in the form of transverse gyri on upper surface of
superior temporal gyrus (Area 41 and 42).
Lateral Geniculate Body
This is positioned also underneath pulvinar of thal-
amus and lateral to medial geniculate body and
smaller in size. It is connected to superior colliculus
Right optic tract
Right lateral geniculate
body
Fig. 12.8 Layers 1, 4 and 6 of right lateral geniculate body receive fibers from right half of opposite retina and layers 2, 3, 5 receive
fibers from same half (right half) of same retina
Diencephalon
of midbrain by superior brachium. Lateral geniculate
body is the diencephalic relay station of visual path-
way. Lateral geniculate body of one side receives
visual information of ipsilateral half (right or left) of
both retina, so form contralateral half of field of vision
of both eyes.
n Afferent: Neurons of lateral geniculate body are
arranged in six layers which are numbered one to six
from ventral to dorsal aspects. Afferent fibers reach
lateral geniculate body via optic tract. The axons of
multipolar ganglionic neurons of retina leave eyeball
through optic nerve, optic chiasma and then through
optic tract to relay in lateral geniculate body. Lateral
geniculate body receives almost all the fibers of optic
tract except some, which go to pretectal nucleus for light
reflex. It is known that lateral geniculate body of one
side receive fibers from same half (right or left) of both
retina. Laminae 1, 4 and 6 of lateral geniculate body
receive fibers of retina of opposite side and laminae 2, 3
and 5 receive fibers of retina of same side (Fig. 12.8).
n Efferent: Efferent fibers from all the layers of
lateral geniculate body form geniculocalcarine tract.
It is also known as optic radiation which is the
thalamocortical (corticopetal) component of posterior
thalamic radiation. These fibers pass through
retrolentiform part of internal capsule.
Right half of right retina
Right half of left retina
Fibers from same half (right)
of contralateral retina end in
layers 1, 4 and 6 of LGB
(Red)
Fibers from same half (right)
of ipsilateral retina end in
layers 2, 3 and 5 of LGB
(Blue)
6
5
4
3
2
1
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EPITHALAMUS
Epithalamus is the part of dorsal diencephalon
which is posterosuperior to the thalamus. In this
connection, it is to be noted that metathalamus
is posteroinferior to the thalamus. Epithalamus
is a composite structure which lies in relation to
posterior part of roof and adjacent part of posterior
walls of third ventricle.
Composition of Epithalamus:
1. Pineal gland.
2. Paraventricular nuclei (anterior and posterior).
These are quite different from paraventricular
nucleus of hypothalamus.
3. Habenular nuclei: Medial and lateral, with Habe-
nular commissure.
4. Stria medullaris thalami.
5. Posterior commissure.
Pineal gland (Fig. 12.9)
Pineal gland is also known as epiphysis cerebri. Itis
a small, reddish gray midline sessile organ placed
posterosuperior to the main thalamic mass.
Evolution
In some classes of fishes and amphibian, this structure
used to represent dorsal third eye. In higher animals
and in the past in case of human, this organ was
considered as vestigial organ. That is why it is used
to be termed more commonly as pineal body.
Tela choroidea
Pineal recess
Fig. 12.9 Pineal gland with structures around it
200
Recent identity
Nowadays this is more popularly termed as pineal gland
as it is very highly evolved endocrine gland exerting
influence in activities of so many endocrine glands of
body including hypophysis cerebri (pituitary gland).
Special characteristics
Following are very special characteristics of pineal
gland.
1. Pineal gland, an endocrine gland, though present
in the brain, does not contain nerve cells, but
contains neuroglia (astrocytes) and modified
neurons.
2. The gland receives some nerve fibers called nervus
conarii, which are postganglionic sympathetic fib-
ers coming from superior cervical ganglion.
3. After two decades of life, pineal gland may show
some age changes characterized by deposition of
calcium salts. Calcification will show tiny opaque
shadow in radiological imaging. This is called
Brainsand.
Gross anatomy
Pineal gland is a small, reddish gray, sessile, conical
organ, lying posterosuperior to main thalamic mass
and it is lodged in a small depression between two
superior colliculi. Above it is related to splenium of
corpus callosum. Anteroposteriorly it measure 8 mm
with the base directed forwards. Base of the gland is
pedunculated. Peduncle of pineal gland (pineal stalk)
is split up to form proximal (superior) and distal
(inferior) laminae. In between two laminae, a small
Splenium of corpus callosum
Habenular commissure
Pineal gland
Posterior commissure
Superior colliculus

conical outpouching of third ventricle of brain forms its
pineal recess. Both the laminae of pineal stalk present
transversely running fibers forming commissures.
Fibers passing through upper lamina form Habenular
commissure and fibers through lower lamina form
posterior commissure. Some fibers invading the gland
are called aberrant commissure which of course, do not
terminate in cells of pineal gland.
Reader is suggested to consult the chapter of
white matter of Brain for further details about the
commissures.
Important relations (Fig. 12.9)
Superiorly pineal gland is related to splenium of
corpus callosum. Tela choroidea of third ventricle of
brain invaginates between splenium and the gland.
Inferiorly pineal gland is related to tectum of mid-
brain.
Pineal gland is covered by an envelope of pia mater
derived from inferior layer of tela choroidea which is
ultimately continuous over tectum.
Anteriorly, base of pineal gland presents the
peduncle (pineal stalk). In between two laminae of the
stalk is the pineal recess of third ventricle of brain.
Structure
Pineal gland is classically known as neuroendocrine
gland. Pia mater from inferior layer of tela choroidea
of third ventricle forms an envelope of the gland.
From this pial capsule, number of septae enter inside
the gland to divide it into number of lobules. The
septae also carry blood vessels and thin unmyelinated
sympathetic nerve fibers arising from superior cer-
vical ganglion.
Blood vessels
The gland is richly supplied by arteries which are
branches of medial division of posterior choroidal
branch of posterior cerebral arteries. Capillaries
end in numerous pineal veins which finally come
out to drain into internal cerebral vein and/or great
cerebral vein of Galen.
Cell structure
Pineal gland contain two kinds of cells which are
pinealocytes and neuroglia.
1. Pinealocytes: These are parenchymal cells of
the gland. These are not nerve cells but may be
considered as modified neurons. Pinealocytes
present inside the lobule in the form of clusters on
cords which are endocrine cells. Multiple processes
(two or more) extend from the cell body. These
processes end in bulbous expansions which are
packed with rough endoplasmic reticulum, mito-
chondria and dense core vesicles. The terminal
expansions are approximated to fenestrated capil-
Diencephalon
laries or ependymal lining. Dense core vesicles
of bulbous expansions of pinealocytes release the
hormone melatonin. Melatonin and its precursor
serotonin are synthesized from tryptophan.
The released hormone melatonin is transported
through bloodstream and also alternative medium
of cerebrospinal fluid passing through capillaries
or ependyma of pineal recess respectively.
2. Neuroglia: These are astrocytes, interstitial in
position and posses supportive function. Cells in
the laminae of pineal stalk are mostly neuroglial
cells.
Noncellular element
1. Pineal gland does not contain nerve cells. But it
contain fine unmyelinated fibers which are the
axons arising from superior cervical ganglion.
These are called nervus conarii. These sympathetic
nerve fibers reach the gland along the course of
blood vessels.
2. After two decades of life, inorganic salt, e.g. calcium
phosphate and calcium carbonate may be deposited
inside the gland. Through radiological imaging,
these particles are evidenced as radioopaque dots.
This is known as corpus arenacea or brain sand.
Functions
Number of indoleamine and polypeptide hormones,
including melatonin are secreted by pinealocytes.
These hormones exert widespread regulatory effect
on many endocrine glands of body, e.g.
1. Both adenohypophysis and neurohypophysis
2. Islets of pancreas
3. Parathyroid gland
4. Adrenal cortex as well as medulla
5. Gonads.
Effects on all these endocrine glands are inhibitory.
Inhibitory effect on pituitary gland is either direct or it
may be indirect through inhibitory effect on hormone
releasing factors liberated by hypothalamus.
n Melatonin on reproductive system: Melatonin
has got inhibitory effect on gonadotrophins. During
prepubertal life, inhibitory effect of melatonin on
gonadotrophic hormones exerts a temporary hault on
development of reproductive system and maturity of
reproductive activity until optimum period is being
reached.
n Pineal gland acting as a biological clock:
Secretion of indoleamine hormones including mela-
tonin and enzymes responsible for synthesis of these
hormones show variation in blood concentration in
day and night. The level of concentration of hormones
increases in darkness and falls during day time. The
reduced concentration of day time is due to inhibition
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of secretion as a result of activity of sympathetic
fibers in pineal gland. As the hormonal concentration
show a circadian rhythm, it is told that pineal gland
acting as biological clock through which physiological
activities of life is regulated.
CLINICAL ANATOMY
Selective lesion of pineal gland is rare. Lesion, if
occurs, will lead to release of inhibitory effect of pineal
gland hormone on other endocrine glands. Release or
withdrawal of inhibitory influence on gonads, will
cause loss of normal inhibition on sexual activity.
Calcification of pineal gland with advancement
of age is found in more than 50% of normal adult
persons. Radiological investigation will show its
shadow in midsagittal plane 5 cm above the shadow
of external auditory meatus. Deviation of shadow
of calcified pineal gland from midline is important
diagnostic point in case of any space occupying lesion
of brain which may be hemorrhagic, hydrocephalic or
neoplastic in origin.
PARAVENTRICULAR NUCLEI OF EPITHALAMUS
These are different from paraventricular nuclei
of thalamus. But both the groups are very close to
each other beneath the ependyma of third ventricle.
Paraventricular nuclei of epithalamus are situated
deep to ependyma dorsal part of third ventricle.
Connections of Paraventricular Nuclei
n Afferent:
1. Hypothalamus
2. Hippocampal formation
3. Locus coeruleus.
n Efferent:
1. Amygdaloid body
2. Hippocampal formation.
HABENULAR NUCLEUS AND HABENULAR COMMI-
SSURE (CONSULT FIGURES OF COMMISSURE IN
CHAPTER OF WHITE MATTER OF BRAIN)
n Habenular nucleus: These are collection of
neurons forming an important component of epith-
alamus. Groups of neurons forming Habenular
nucleus is placed beneath a triangular area called
Habenular trigone. The triangle is bounded by
Pineal gland medial
Posterior end of thalamus superolaterally
Superior colliculus inferolaterally.
Connections of Habenular Nucleus
n Afferent: Habenular nucleus forming part of
limbic system, is connected to several area through
afferent fibers which are as follows
202
1. Hypothalamus
2. Propyriform cortex
3. Septal nuclei
4. Basal nucleus of Meynert.
Afferent fibers from above mentioned areas pass to
Habenular nucleus through stria medullaris thalami.
Stria medullaris thalami is a well-defined band
of white matter being considered as an important
constituent of epithalamus. It extends from anterior
pole of thalamus, along the line of demarcation
between superior and medial surfaces of thalamus to
reach habenular nucleus.
Other afferents are
5. Noradrenergic and serotoninergic fibers from brai-
nstem.
6. Substantia nigra
7. Globus pallidus.
n Efferent:
1. To pineal gland through habenulopineal tract.
2. To interpeduncular nucleus and reticular form-
ation through habenulopeduncular tract or fascic-
ulus retroflexus.
Habenular Commissure
These are commissural fibers connecting Habenular
nucleus of both sides. The fibers pass through prox-
imal (upper) lamina of pineal stalk.
Functions of habenular nucleus
1. Habenular nucleus, being part of limbic system, is
considered as cell station in olfactory and visceral
pathways.
2. Habenular nucleus influences other neuronal
groups which influence various endocrine and
visceral functions.
3. It is also thought that habenular nucleus, if not
directly but indirectly, possesses influence on
sleep and temperature regulation.
Posterior Commissure (Consult Figure
of Commissure in Chapter of White Matter
of Brain)
Posterior commissure is one of the components of
epithalamus. But, as it is named commissure, it is
composed of fibers only. These commissural fibers
pass across the midline through distal (lower) lamina
of peduncle of pineal gland.
The areas of both sides connected by fibers of
posterior commissure are
1. Medial longitudinal fasciculus
2. Pretectal nucleus
3. Superior colliculi
4. Interstitial nucleus of Cajal.

SUBTHALAMUS
Subthalamus is the posterior smaller part of ventral
diencephalons (Fig. 12.1).
n Position and relation: Subthalamus is posterior
to hypothalamus. This narrow part of diencephalon is
compressed between thalamus and midbrain. Above
it is demarcated from thalamus (dorsal thalamus) by
posteroinferior part of hypothalamic sulcus. Below it
merges with tegmentum of midbrain.
n Subthalamic nucleus: This is a small biconvex
mass of gray matter present in subthalamus (Fig.
12.10). In coronal section of brain, subthalamic
nucleus is superomedially related to thalamus from
which it is separated by another smaller biconvex mass
of gray matter called Zona incerta. Inferolaterally
subthalamic nucleus is related to lentiform nucleus
from which it is separated by descending fibers of
internal capsule.
n Connections: Subthalamic nucleus is connected
to globus pallidus in bothway direction. Other fibers
related to subthalamic nucleus are pallidothalamic
fibers. Fibers of ansa lenticularis are posteroinferior
to the nucleus while passing around posterior limb of
internal capsule. Anterosuperior to the nucleus pass
the fibers of lenticular fasciculus.
Other Components of Subthalamus
Apart from subthalamic nucleus and related fiber
bundles mentioned above, it is considered that
cranial end of red nucleus and substantia nigra are
also incorporated in subthalamus.
Function of Subthalamus
Though subthalamus is anatomically a component
of diencephalons, but functionally it is related to
basal ganglia. Apart from its connection with globus
Zona incerta
Thalamus
Subthalamic nucleus
Internal capsule
Fig. 12.10 Subthalamic nucleus with gray and white matters around it
Diencephalon
pallidus, it is believed that it has connections with red
nucleus and substantia nigra. Through this circuit,
subthalamic nucleus also controls muscular activity.
The neurons of subthalamic nucleus is glutaminergic
and excitatory in nature.
HYPOTHALAMUS
General Consideration (Fig. 12.11)
Hypothalamus is lower and anterior part of dien-
cephalon.
It is the anterior part of ventral diencephalon,
posteriorly merging with subthalamus.
Hypothalamic sulcus, extending from intervent-
ricular foramen of Monro to upper end of aqueduct
of Sylvius demarcates hypothalamus from dorsal
diencephalon above it.
Hypothalamus being very essential for life, is
centrally placed in limbic system below thalamus and
overhung by both cerebral hemispheres.
Hypothalamus forms the lower part of lateral wall
and also the floor of third ventricle of brain which is a
central midline cleft.
Part of hypothalamus forming floor of third vent-
ricle of brain forms the components of interped-
uncular fossa of base of brain when seen from below.
Anteroposteriorly these structures are 1. Optic
chiasma 2. Tuber cinereum with infundibulum
of pituitary gland (not the gland itself) and
3. Mammillary body.
l How small is hypothalamus:
1. Hypothalamus is 10 gm in weight.
2. It constitutes only 0.3% of total body mass.
l How much important hypothalamus is functionally:
Hypothalamus is very essential for life because
almost all the functions of body are controlled by it
either directly or indirectly.
Lenticular fasciculus
Lentiform nucleus
Bothway connection of subthalamic
nucleus with globus pallidus (Subthalamic
Ansa lenticularis fasciculus)
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Thalamus
Hypothalamus
Preoptic area
Optic chiasma
Tuber cinereum with
infundibulum
Fig. 12.11 Hypothalamus in sagittal plane with surrounding structures
Broadly, functions of hypothalamus can be stated as
1. It controls activities of autonomic nervous system.
Being the supreme center for regulation of auto-
nomic nervous system, hypothalamus had been
referred by Sherington as head-ganglion of auton-
omic nervous system.
2. It controls functions of endocrine system.
Thus controlling both autonomic nervous system
and endocrine system, hypothalamus maintains
body homeostasis.
3. Hypothalamus plays an important role in emotional
activities through its influence on limbic system.
Relations of Hypothalamus
In coronal section, hypothalamus can be simulated
with the capital letter U. Intermediate part of U
form the floor and, both the limbs form lower part of
lateral wall of third ventricle.
So relations of four aspects of hypothalamus are
following (Fig. 12.12)
l Superiorly: Thalamus, demarcated by hypothal-
amic sulcus.
l Inferiorly: It is free and form components of
interpeduncular fossa of base of the brain. It forms
the floor of third ventricle.
l Medially: Cavity of third ventricle of brain (lower
part).
l Laterally: Internal capsule of brain.
Anteroposterior extent
Anteriorly, hypothalamus merges with an area known
as preoptic area which extends from optic chiasma to
204
Hypothalamus sulcus
Epithalamus
Subthalamus
Mammillary body
lamina terminalis. Anatomically preoptic area is a
part of telencephalon. But functionally it is considered
as anteriormost part of hypothalamus containing one
of its nuclei called preoptic nucleus.
Posteriorly, hypothalamus merges with subthala-
mus which becomes continuous below with tegmentum
of midbrain.
Fundamental Subdivision of Hypothalamus
Mediolateral subdivision (Fig. 12.13)
Anterior column of fornix ends in mammillary body.
Mammillothalamic tract extends from mammillary
body to anterior nucleus of thalamus. These two bands
of fibers divide hypothalamus primarily into medial
and lateral zones. Subependymal surface (medial
surface) of medial zone presents a thin strip which
is differentiated from main part of medial zone. This
thin medialmost lamina of hypothalamus possesses
its own identity as paraventricular zone.
So, from lateral to medial, hypothalamus is
ultimately divided into following three zones.
1. Lateral zone
}
2. Intermediate zone No. 2 and No. 3 zone
3. Paraventricular together actually
or subependymal zone forms medial zone
(also called medial zone)
Anteroposterior subdivision (Fig. 12.11)
1. Preoptic region: It is the part of brain
behind lamina terminalis, extending inferiorly
 Diencephalon
Thalamus Cavity of third ventricle

Hypothalamus sulcus
Fibers of internal
capsule related lateral
Hypothalamus forming to hypothalamus
lower part of lateral wall
of third ventricle

Hypothalamus forming Hypothalamus forming

floor of third ventricle base of brain

Fig. 12.12 Hypothalamus on coronal section

upto optic chiasma. Anatomically it is part of 2. Supraoptic region: It is the part of hypothalamus
telencephalon. But for functional reason it has above optic chiasma.
been incorporated into hypothalamus of dience- 3. Tuberal region: It is the part adjoining tuber
phalon. cinereum and infundibulum of pituitary gland.

Body of fornix

Thalamus

Anterior column of fornix

Lateral zone

Posterior column
of fornix
Intermediate
zone

Mammillothalamic tract

Mammillary body

Paraventricular or subependymal
zone of hypothalamus

Fig. 12.13 Mediolateral subdivision of hypothalamus

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
4. Mammillary region: It is the part where mam-
millary body is situated.

Nuclei of Hypothalamus
1. Hypothalamus is composed of small nerve cells
which are arranged in groups called hypothalamic
nuclei. Preoptic nucleus
2. Many of these nuclei are not clearly demarcated Supraoptic nucleus
from each other. Even some may show overlapping.
3. A group of neurons, known as preoptic area,
situated between lamina terminalis and optic
chiasma, is anatomically part of telencephalon.
But from functional point of view, the area forming Tuberoinfundibular nucleus
a nucleus, preoptic nucleus is incorporated in Mammillary nucleus
hypothalamus (diencephalon).
4. Various nuclei of hypothalamus are divided Fig. 12.15 Nuclei of hypothalamus bisected for both lateral and
into three zones already stated. These zones are intermediate zone
lateral, intermediate and paraventricular or
subependymal. The last group is also known as Nuclei common for lateral and intermediate zones
medial zone. (Fig. 12.15)
5. Some of the nuclei are bisected, thereby falling
in two adjacent zones. These are preoptic, supr- 1. Preoptic nucleus
aoptic and tuberal nuclei. 2. Supraoptic nucleus
6. Nuclei which are anatomically classified, are 3. Tuberoinfundibular nucleus
not often grouped physiologically. It means that 4. Mammillary nucleus.
nuclei of two different anatomical zones may be
physiologically identical in function. Intermediate zone (Fig. 12.16)
7. For more academic interest, very often, nuclei
are classified in a complex manner. But simplest, 1. Anterior nucleus
conventional and mediolateral subdivision of nu- 2. Ventromedial nucleus
clei of hypothalamus is mentioned below. 3. Dorsomedial nucleus
4. Posterior nucleus.
Nuclei of lateral zone (Fig. 12.14)
n Lateral nucleus: This nucleus is made up of large
sized and loosely packed neurons which occupies whole
anteroposterior extent of lateral zone. Lateral nuclear
zone is also associated with abundance of fibers.

Anterior Dorsomedial
nucleus nucleus

Posterior
Ventromedial
nucleus
nucleus

Lateral nucleus

Fig. 12.16 Nuclei of intermediate zone of hypothalamus

Paraventricular or subependymal zone (Fig. 12.17)

It is a thin strip-like zone just beneath the epen-
dyma of lateral wall third ventricle at the level
Fig. 12.14 Nucleus of lateral zone of hypothalamus of hypothalamus. The nucleus is known as para-
206

Paraventricular
nucleus
Fig. 12.17 Paraventricular nucleus of hypothalamus
ventricular nucleus. This nucleus is medialmost in
position among all hypothalamic nuclei.
Connections of Hypothalamus
Hypothalamus situated at the center of limbic system
present connections with various areas of brain.
Afferent connections
1. Somatic afferent: Exteroceptive sensations, e.g.
touch/pressure and pain/temperature sensations
are carried via ventral and lateral spinothalamic
tracts respectively. To pass through the brainstem,
before reaching their primary destination to thala-
mus, the tracts present compact bundle known
as spinal lemniscus. Similarly, medial lemniscus
is another compact bundle destined to thalamus
while passing through brainstem. This carries
proprioceptive sensations from muscles and joints,
sense of vibration and discriminative touch. Before
terminating in thalamus, these lemnisci send
collaterals to hypothalamus.
2. Special visceral afferent: These are the afferent
fibers from the gustatory pathway. Axons of nucleus
tractus solitarius ascend to ventroposteromedial
nucleus of thalamus as solitariothalamic tract.
Collaterals from this tract reach hypothalamus.
3. General visceral afferent: General sensations
from viscera, sense of stretch, compression or
distension and pain sensation due to lack of oxygen
following ischemia, primarily reach the autonomic
center of brain (dorsal nucleus of vagus) and spinal
cord (T1 L2 and S2 S4 segments). But finally
afferent fiber from these centers ascend through
reticular formation to reach hypothalamus which
is considered as headganglion of autonomic
nervous system.
Diencephalon
4. Visual afferent: Afferent fibers from visual path-
way pass from opticchiasma to supraoptic nucleus
of hypothalamus via retinohypothalamic tract.
5. Olfactory afferent: Fibers from olfactory path-
way pass to hypothalamus as medial forebrain
bundle.
6. Auditory afferent: This connection has not
been clearly established. But it has been proved
experimentally that sound stimulating cochlear
pathway stimulates activity of hypothalamus.
7. Descending cortical afferent: These are cortico-
hypothalamic fibers descending from frontal lobe
of cerebral cortex directly to hypothalamus.
8. Hippocampal afferent: Fibers from hippoca-
mpus pass along the curved course of fornix to
reach mammillary body. It is considered by many
neurologists that hypothalamus is the main output
path of limbic system.
9. Afferent from amygdaloid body: These are
the fibers of stria terminalis which extend from
amygdaloid body around the curve of thalamus to
reach hypothalamus.
10. Afferent from thalamus: These are fibers
reaching hypothalamus from dorsomedial, anter-
ior and midline nuclei of thalamus.
11. Afferent from midbrain: These are the fibers
from tegmentum of midbrain.
Efferent connections
1. Descending efferent (to autonomic centers
of brainstem and spinal cord): These fibers
descend via brainstem reticular formation.
a) Termination in brainstem: These fibers end
in following parasympathetic cranial nerve
nuclei.
i. Edinger Westphal nucleus (IIIrd)
ii. Superior salivatory nucleus (VIIth )
iii. Interior salivatory nucleus (IXth)
iv. Dorsal nucleus of vagus (Xth).
b) Termination in spinal cord:
i. Sympathetic: Fibers from posterior part of hyp-
othalamus pass to sympathetic neurons in
lateral gray horns of 1st thoracic to 1st/2nd
lumbar segments of spinal cord.
ii. Parasympathetic: Fibers from anterior half of
hypothalamus pass to parasympathetic neu-
rons of intermediate area of 2nd, 3rd and 4th
sacral segments of spinal cord.
2. Efferent to thalamus (mammillothalamic
tract): These fibers pass from hypothalamic nuc-
leus of mammillary region to anterior nucleus of
thalamus.
3. Efferents to hypophysis cerebri (pituitary gland):
a) Efferent to neurohypophysis (posterior
pituitary) (Fig. 12.18): Axons of supra-
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Supraoptic nucleus
Adenohypophysis (anterior
pituitary)
Fig. 12.18 Efferent connection of hypothalamic nuclei with neurohypophysis to form hypothalamohypophyseal tract
optic and paraventricular nuclei of hypo-
thalamus extend upto posterior pituitary
(neurohypophysis). These fiber bundles are
known as hypothalamohypophyseal tract.
Neurons of supraoptic and paraventricular
nuclei possessing secretory functions liber-
ate hormones vasopressin and oxytocin res-
pectively. These hormones released from
neurons of hypothalamus are transported
though the axoplasm of the hypothalamo
hypophyseal tract to neurohypophysis (poste-
rior pituitary). Finally the hormones circ-
ulate in the general bloodstream through the
venules of posterior pituitary.
Sinusoids in
adenohypophysis
Hypophyseal vein
Adenohypophysis
Fig. 12.19 Efferent connection from tuberal nucleus of hypothalamus for adenohypophysis
208
Paraventricular nucleus
Mammillary body
Hypothalamohypophyseal tract
Venules
Neurohypophysis
Venules (posterior pituitary)
Vasopressin (antidiuretic hormones) is vaso-
constrictor in nature and causes reabsorption
of water from distal convoluted tubules and
collecting tubules of kidney. Oxytocin stim-
ulates contraction of uterine musculature and
myoepithelial cells of alveoli of mammary gland.
b) Efferent for adenohypophysis (anterior
pituitary) (Fig. 12.19): Neurons of tuberal
nucleus of hypothalamus send axons to infu-
ndibulum of pituitary gland. These axon bun-
dles are known as tuberoinfundibular tract
which transports two hormones liberated by
neurons of tuberal nucleus. The hormones
are named as hormone releasing factors and
Tuberal nucleus
Tuberoinfundibular tract
(superior) Hypophyseal artery
Capillaries
Neurohypophysis

hormone release inhibiting factors. These sub-
stances reach through tuberoinfundibular
tract to infundibulum of pituitary gland from
hypothalamus. Through hypophyseal portal
system capillaries at both ends the hormone
releasing factors and hormone release inhi-
biting factors reach the adenohypophysis (ant-
erior pituitary) to produce influence on the
endocrine cells.
Specific functions of two hormones:
1. Hormone releasing factors: These stimulate
release of following hormones from the concerned
cells of adenohypophysis.
a) Growth hormones (GH)
b) Adrenocorticotrophic hormone (ACTH)
c) Thyroid stimulating hormones (TSH)
d) Follicle stimulating hormones (FSH)
e) Luteinizing hormones (LH).
2. Hormone release inhibiting factors: These inh-
ibit release of following hormones from concerned
cells of adenohypophysis.
a) Melanocyte stimulating hormones (MSH)
b) Lactogenic hormones (Prolactin).
Functions of Hypothalamus
Hypothalamus exerts its influence on almost every
function of body. Only the important and better
studied functions are discussed below.
Autonomic control
Hypothalamus is primarily considered as higher
autonomic center to have a control on lower autonomic
center for both parasympathetic and sympathetic
system present is brainstem and spinal cord.
Beside this, hypothalamus is also considered as
a center for integration of both autonomic nervous
system and endocrine system, thus maintaining body
homeostasis.
Parasympathetic and sympathetic components of
autonomic nervous system are controlled by anterior
and posterior parts of hypothalamus respectively. It is
also proved experimentally. Electrical stimulation of
anterior and preoptic nuclei of hypothalamus leads to
increased parasympathetic activities, e.g. lowering of
blood pressure, decreased heart rate, hyperperistalsis,
contraction of bladder wall, increased salivation and
gastric juice and constriction of pupil.
Stimulation of posterior and lateral nuclei cau-
ses hyperactivity of sympathetic system which is
manifested by rise of blood pressure, increased heart
rate, diminished intestinal peristalsis and dilatation
of pupil.
Diencephalon
Neurosecretion
Supraoptic and paraventricular nuclei of hypotha-
lamus are concerned with liberation of vasopressin
and oxytocin respectively. Vasopressin basically
being selective vasoconstrictor in nature, causes rea-
bsorption of water from distal convoluted tubules
and collecting tubules of kidney. Oxytocin increases
contractility of uterine musculature and myoepithelial
cells in the alveolar wall of mammary gland.
Endocrine control
Tuberoinfundibular nucleus of hypothalamus libe-
rates two hormones called hormone releasing factor
and hormone release inhibiting factor. Initially these
hormones reach infundibulum of pituitary gland via
tuberoinfundibular tract. But finally through the
vascular portal system of pituitary gland hormones
reach adenohypophysis (anterior pituitary) to exert
regulations on different endocrine cells liberating
respective hormones. Hormones releasing factor
stimulates release of growth hormones, adrenoc-
orticotrophic hormone, thyroid stimulating hormone,
follicle stimulating hormone and luteinizing hormone.
Hormone release inhibiting factor inhibits release
of melanocyte stimulating hormone and lactogenic
hormone (prolactin).
Control of body temperature
Normal body temperature is maintained due to
balance of function of anterior and posterior part of
hypothalamus. Anterior part is concerned for heat
loss by cutaneous vasodilation and sweating which
result in lowering of body temperature. Posterior part
of hypothalamus, if activated, causes vasoconstriction
of skin and inhibition of sweating with no heat loss.
Skeletal muscle is also responsible for production of
heat which results in shivering.
Control of food and water intake
n Food intake: Intake of food by an individual is
regulated by two centers of hypothalamus called
Hunger center and satiety center. Hunger center is
present in lateral part of hypothalamus, whereas
medial part lodges satiety center. Stimulation of
lateral part results in increase in food intake. Lesion
of this area will lead to anorexia and subsequent loss
of body weight. Stimulation of medial part of hypot-
halamus containing satiety center inhibits intake
of food. Obviously lesion in this area will results in
uncontrolled voracious appetite which finally causes
excessive obesity.
209
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Water intake: Some area of lateral zone of
hypothalamus is known as thirst center. Stimulation
of this area makes an individual thirsty with severe
urge to drink water. Again, supraoptic nucleus,
through its influence on liberation of vasopressin
(antidiuretic hormone), maintains optimum osmol-
arity of blood, thus maintains water balance of body.
Regulation of emotion and behavior
Hypothalamus is considered as principal outlet for
action of limbic system for emotion and behavior of
an individual through prefrontal cortex. Rage and
passivity are two opposite poles of emotion and
behavior. These are again dependent upon effect
of surrounding environment. Hypothalamus acts
as an integrator for various informations received
from different areas of nervous system and leads to
manifestations of emotion.
Lateral nuclei of hypothalamus are considered as
the center for rage and ventromedial nucleus is the
center for passivity. Tuberal nucleus by synthesis of
hormone releasing factors exert influence on secretion
of gonadotrophins, thus has an effect indirectly on
sexual behavior.
Relation of circadian rhythm
Hypothalamus acts as biological clock through regu-
lation of circadian rhythm. Along with thalamus,
limbic system and reticular activating system, hypot-
halamus regulates cycle of sleeping and waking.
Supraoptic nucleus, which receives afferent impulse
from retina through optic chiasma, plays an important
role in the biological rhythm of sleeping and waking.
Circadian rhythm controlled by hypothalamus,
also includes body temperature, adrenocortical activ-
ity, eosinophil count and renal excretion.
CLINICAL ANATOMY
Although hypothalamus is a very tiny area of central
nervous system, its immense clinical importance
should never be ignored. Because, hardly there is
a tissue of body which is not under the influence of
hypothalamus. Hypothalamus is the principal outlet
of limbic system which influences three important
aspects of daily life, which are autonomic function,
endocrine function and emotional activities.
Lesion of hypothalamus may be due to direct reason
like vascular and inflammatory, or indirect pressure
effect, e.g. neoplasm or internal hydrocephalus adja-
cent to it.
Important clinical manifestations of hypothalamic
syndrome are following:
210
Obesity and Wasting
These are two opposite indirect manifestations of
lesion of satiety and hunger center of hypothalamus.
Medial zone contain the satiety center and the hunger
center is present in lateral zone. Usually severe
obesity is the common manifestation of hypothalamic
lesion which is associated with genital hypoplasia.
Wasting is rare in occurrence.
Hyperthermia and Hypothermia
These manifestations are the result of imbalance in
normal body temperature regulation due to lesion
in hypothalamus. Hyperthermia is commoner than
hypothermia. It may result following head injury
or neurosurgical operation in the area adjacent to
hypothalamus. Patient of hyperthermia is otherwise
normal, because patient is not suffering from head-
ache or malaise which are the effect of pyrexia
following any infection.
Diabetes Insipidus
This clinical condition is characterized by passage
of large volume of urine with low specific gravity.
As a result patient remains severely thirsty and
frequently drinks large quantity of water. This effect
is due to lesion of supraoptic nucleus of hypothalamus
or hypothalamohypophyseal tract with impairment
of secretion of vasopressin or antidiuretic hormone
(ADH).
Sexual Disorder
Craniopharyngioma is a congenital tumor arising from
remnants of Rathkes pouch. In children, its pressure
effect on hypothalamus may show sign of sexual
retardation along with other clinical manifestation of
hypothalamic lesion. After puberty, the patient suff-
ers from impotence or menstrual disorder.
Sleep Disorder
Patient suffers from disorder of circadian rhythm of
sleep and wakefulness. Typically patient may suffer
from insomnia or frequent short period sleep during
the hours of waking.
Emotion Disorder
In patient of hypothalamic lesion, various kinds
of emotional outbursts are observed. It may be
unexplained weeping or laughter. Patient may show
uncontrollable rage. Sometimes there may be features
of mental depression.
 Third Ventricle of Brain
Identity
Third ventricle of brain is a narrow midline cavity of
diencephalon.
Morphologically, it is central midline part of cavity
of forebrain vesicle. Two lateral extensions are lateral
ventricle.
Third ventricle is slit-like cleft between two tha-
lami. It is limited below by hypothalamus forming
base of the brain.
Communications (Fig. 13.1)
1. Proximal: On either side of midline, third vent-
ricle communicates anterolaterally with lateral
ventricle through a narrow slit, called interve-
ntricular foramen of Monro which is bounded
anteriorly by anterior end of anterior column of
fornix and transversely running fibers of anterior
commissure, and posteriorly by anterior pole of
thalamus.
Interventricular foramen is directed forwards, up-
wards and laterally.
2. Distal: Third ventricular cavity communicates
distally in the midline. It is posteroinferior in dire-
ction where the cavity is continuous with narrow
passage of cerebral aqueduct of Sylvius passing
through midbrain. Aqueduct distally leads to cav-
ity of fourth ventricle of brain.
Boundaries (Figs 13.1 and 13.2)
It has already been mentioned that third ventricle
is a narrow midline cleft between medial surfaces of
13
two thalami and upper part of hypothalamus. So, its
four walls, anterior, posterior, superior and inferior,
are narrow. Both the lateral walls are wider which
are clearly demonstrated in midsagittal section of
brain.
Lateral Wall
Larger upper part of lateral wall is formed by me-
dial surface of thalamus. Lower part is formed by
hypothalamus below hypothalamic sulcus. Surfaces
of thalamus and hypothalamus forming lateral wall
are lined by ventricular ependyma.
Important features of lateral wall
1. Stria medullaris thalami (Fig. 13.2)
It is a subependymal thin band of white matter that
extends anteroposteriorly along the line of dem-
arcation between medial surface and superior surface
of thalamus, thus indicating upper extent of lateral
wall of third ventricle. Stria medullaris thalami
extends from anterior pole of thalamus to Habenular
nucleus.
2. Hypothalamic sulcus (Figs 13.1 and 13.2)
It is a narrow and shallow sulcus which extends from
interventricular foramen of Monro to upper end of
cerebral aqueduct of Sylvius. The sulcus demarcates
medial surfaces of thalamus and hypothalamus.
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Interthalamic adhesion Fornix
Anterior column of
fornix
Interventricular
foramen of Monro
Anterior commissure
Tela choroidea

Suprapineal recess

Hypothalamic sulcus Pineal recess

Lamina
terminalis Optic recess Cerebral aqueduct of Sylvius
Infundibular recess
Optic chiasma

Infundibulum of pituitary gland

Mammillary body
Fourth ventricle of brain

Fig. 13.1 Third ventricle of brain viewed in midsagittal diagram with its boundaries, recesses and communications

3. Interthalamic adhesion (Figs 13.1 and 13.2)
It is a short, narrow and compact band crossing the
midline which connects very closely apposed medial
surfaces of both thalami. It is round on cross-section
visible on medial surface of thalamus. It is made up of
both white as well as gray matter.
n White matter: These fibers arising from thalamic
nuclei of one side cross the midline. But these are not
true commissural fibers, as instead of reaching nuclei
of opposite thalamus, they return back to the same
side (Fig. 13.2).
n Gray matter: Interthalamic adhesion also contain
some scattered neurons which are considered to be
detached cells of paraventricular or midline nuclei of
thalamus.
Tela choroidea

Choroid plexus

Stria medullaris thalami Ependymal roof of third

ventricle

Interthalamic adhesion
Thalamus

Hypothalamic sulcus

Cavity of third ventricle Hypothalamus

Fig. 13.2 Third ventricle of brain on coronal section

212
 Third Ventricle of Brain

Fornix

Tela choroidea
Corpus callosum

Cavity of lateral ventricle

Head of caudate nucleus Choroid plexus

Stria terminalis
Ependymal roof of third
Thalamostriate vein ventricle
Cavity of third ventricle
Thalamus

Hypothalamus

Fig. 13.3 Tela choroidea in relation to roof of third ventricle

Anterior Wall (Fig. 13.1)
It is formed by following structures from above down-
wards.
l Anterior column of fornix.
l Anterior commissure: Its fibers cross transve-
rsely in front of lower end of anterior column of fornix.
l Lamina terminalis: A thin layer of gray matter
extending from lower end of rostrum of corpus
callosum to optic chiasma.
Posterior Wall (Fig. 13.1)
It is shorter than anterior wall and formed by
l Pineal gland
l Two laminae of pineal stalk called Habenular
commissure proximal posterior commissure
distal.
Floor (Fig. 13.1)
From before backwards structures forming the floor
are
l Optic chiasma
l Tuber cinereum with infundibulum of pituitary
gland (not the gland itself)
l Mammillary bodies which is bilateral
l Posterior perforated substance
l Tegmentum of midbrain.
Roof
This wall is lined only by ependyma which extends
from upper border of medial surface of one thalamus
along the length of stria medullaris thalami to that
of other.
Roof is therefore narrow having the breadth
between two thalami and anteroposteriorly extends
from the level of interventricular foramen to superior
lamina of pineal stalk forming Habenular commissure.
Recesses of Third Ventricle (Fig. 13.1)
Recesses are mostly small angular pockets of cavity
of the ventricle in relation to the structures forming
its boundary.
The recesses are following:
n Optic recess: It is an angular pocket of the cavity
above optic chiasma which lies on the anterior end of
the floor. The recess is at the junction of anterior wall
and floor of the ventricle.
n Infundibular recess: This recess is comparatively
deeper which is tubular in shape with pointed lower
end. It extends through tuber cinereum into the stalk
(infundibulum) of pituitary gland.
n Pineal recess: It is a small angular recess on the
posterosuperior aspect of the cavity which is bounded
by superior and inferior stalks of pineal gland.
n Suprapineal recess: It is wider and blunt recess
which is obviously above pineal gland but below tela
choroidea which is below splenium of corpus callosum.
Besides these four well-defined recesses, another
triangular recess is found in relation to the anterior
wall. It is between two diverging anterior column
of fornix, in front of interventricular foramen and
behind anterior commissure. It is called anterior
recess of third ventricle.
213
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Anterior apical end of
tela choroidea at the
level of interventricular
foramen of Monro
Posterior basal end of
tela choroidea between
splenium and pineal gland
Fig. 13.4 Tela choroidea taken out from roof of third ventricle
TELA CHOROIDEA AND CHOROID PLEXUS (FIGS
13.3 AND 13.4)
Splenium of corpus callosum and fornix lie above the
ependymal roof of third ventricle but do not form the
boundary of roof. Through the gap between splenium
and pineal gland, pia mater, invaginates forward over
the ependyma of roof. As the pial fold invaginates
forwards, it extends from the level of splenium and
pineal gland upto anterior blind end at the level of
interventricular foramen. This pial reflexion presents
two characteristics:
1. It is double layered, one layer is reflected back as
second layer from anterior end.
2. It is triangular in outline. Posterior basal end lies
in the interval between splenium and pineal gland.
Anterior apical end extends upto interventricular
foramen (Fig. 13.4).
This is known as tela choroidea.
n Choroid plexus: Tuft of finer blood vessels
which are anterioposteriorly linear and fringe-like
invaginates between two layers of tela choroidea from
behind forwards. The choroid plexus contains four
anteroposterior running components parallel to each
other. Central two belong to third ventricle. Outer
two form choroid plexus of lateral ventricle which
protrude outwards through the slit between fornix
and thalamus (Figs 13.3 and 13.4).
CLINICAL ANATOMY
In normal individual, third ventricle of brain is a
narrow midline cleft of ventricular system. But its
cavity is dilated in case of hydrocephalus which is a
214
Superior layer of tela
choroidea
Choroid plexus of third
ventricle
Inferior layer of tela
choroidea
clinical condition characterized by overaccumulation
of cerebrospinal fluid in its cavity. Normally a balance
is maintained between secretion of cerebrospinal fluid
by choroid plexus of ventricles and its absorption by
arachnoid granulations. Hydrocephalus may develop
due to any of following causes
1. Oversecretion of cerebrospinal fluid.
2. Impaired abosorption of cerebrospinal fluid.
3. Obstruction in ventricular system anywhere upto
communication with subarachnoid space through
foramen of Magendie and foramen of Luschka.
Dilatation of third ventricle in a case of hydrocephalus
will occur if the obstruction is distal to interventricular
foramen of Monro. This obstruction occurs due to any
expanding tumor close to wall of the ventricle. Cranio-
pharyngioma is a common supratentorial congenital
tumor in children. It is the benign neoplasm arising
from remnants of Rathkes pouch.
Dilatation of third ventricle in a patient of hydro-
cephalus secondarily may cause pressure effect on
structures of the floor the ventricle.
The manifestations commonly observed are
1. Bitemporal hemianopia: That is loss temporal
field of vision of both eyes due to pressure effect on
decussating nasal fibers of optic chiasma.
2. Hypothalamic syndrome: It is characterized by
obesity, diabetes insipidus, hyperthermia or hypo-
thermia, disorder in sexual activity, emotional
and sleep disturbances.
The site of obstruction and nature of dilatation
can be detected through radiological investigation
like ventriculography, Computed Tomography
Scanning (CT Scan) and Magnetic Resonance
Imaging (MRI).
 Meninges of Brain and
Cerebrospinal Fluid
Brain, being the part of central nervous system is
made up of very delicate and sensitive tissue. It needs
adequate protection. For this, brain is primarily
encased within the cranium. In addition, following
are two additional factors which help to keep brain in
safe and secured position.
1. Brain is covered by three membranes called men-
inges, of different thickness, transparency and
stretchibility. From outside inwards these are
l Dura mater: Its most characteristic feature is
its toughness.
l Arachnoid mater: It is transparent and elastic.
l Pia mater: It is thinnest, most delicate, inti-
mately related to surface upto bottoms of fossa,
sulci and fissures.
2. Space beneath arachnoid mater, called subarachn-
oid space is filled up with thin watery cerebrospinal
fluid which acts as a cushion around brain.
Spinal meninges has been described in the chapter
of spinal cord.
DURA MATER
Dura mater of brain, as it is inside the cranium, is
called cranial dura. It is made up of two layers, outer
endosteal and inner meningeal layer.
n Endosteal layer: This layer of cranial dura
is nothing but periosteum lining inner surface of
cranium which is also called endosteum. Through
the sutures of cranial bones, endosteal layer of dura
14
(endosteum) is fused with the periosteum outside
cranium.
n Meningeal layer: It is the true meninx (sing.) or
covering of brain. It is a dense, opaque fibrous mem-
brane which possesses maximum protective power.
It is to be noted here that, spinal cord is covered by
single meningeal layer with which meningeal layer of
cranial dura is continuous through foramen magnum.
Endosteal layer of cranial dura ends being attached
at the margin of foramen magnum.
Normally, endosteal and meningeal layers are
firmly adherent to each other except
1. In some sites where meningeal layer is infolded to
form some dural septae.
2. In some areas two layers of dura are separated to
lodge intracranial venous sinuses.
Any trauma, leading to head injury may lead to
formation of blood clot (hematoma) outside dura
(extradural hematoma). It will then separate men-
ingeal layer from endosteal layer.
Dura mater is discussed below on following two
fundamental headings
l Dural folds or septae.
l Intracranial venous sinuses between two layers of
dura.
Folds of Dura Mater
These are formed when meningeal layer gets separated
from endosteal layer to invaginate in the gaps (sulci
or fissures) between adjacent parts of brain.
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Superior sagittal sinus

Falx cerebri
Inferior sagittal sinus

Right transverse sinus

Crista galli giving

attachment to anterior Straight sinus
end of falx cerebri
Left transverse sinus

Falx cerebelli Tentorium cerebelli

Fig. 14.1 Folds of dura mater

Important dural septae or fold are n Ends: Anterior apical end is attached to crista
1. Falx cerebri galli of ethomoid and adjacent part of internal crest of
2. Tentorium cerebelli frontal bone.
3. Falx cerebelli Posterior basal end is anteroposteriorly running
4. Diaphragma sellae. straight border which is attached to midline of supe-
rior surface of tentorium cerebelli.
n Borders: Superior border is convex and attached
Falx cerebri (Figs 14.1 and 14.2)
to margins of a narrow linear sulcus on the inner
It is a sickle-shaped fold of dura mater which extends surface of median sagittal sutures connecting two
anteroposteriorly, through midsagittal plane and dips parietal bones.
in median longitudinal fissure of brain between two Inferior border is concave and comparatively
cerebral hemispheres. sharper free border which comes in relation to ante-
Endosteal layer of dura
Superior sagittal sinus

Meningeal layer of dura Falx cerebri

Inferior sagittal sinus

Supratentorial compartment

Tentorium cerebelli

Transverse sinus
Infratentorial compartment

Foramen magnum

Meningeal layer of cranial

dura continues as spinal dura

Fig. 14.2 Dural folds on coronal section of cranium are found to form compartments
216

roposteriorly convex superior surface of corpus
callosum.
Venous sinuses related
It is already known that intracranial venous sinuses
lies between endosteal and meningeal layers of dura
mater. Venous sinuses related to falx cerebri are
followings
1. Superior sagittal sinus: Runs from before
backwards along upper convex border of the falx.
2. Inferior sagittal sinus: It runs also anteropo-
steriorly, but along the lower free concave margin
of falx cerebri.
3. Straight sinus: It is anteroposteriorly straight in
direction, present along the line of attachment of
falx cerebri and tentorium cerebelli in the median
plane.
Tentorium cerebelli (Figs 14.1 and 14.2)
It is a double fold of dura mater which invaginates
horizontally forwards through the gap between the
occipital lobes of cerebrum and cerebellum (Fig. 14.3).
Tentorium cerebelli is so called because from
midline it slopes on either side downwards and late-
rally to adjust the slopes from raised superior vermis
to superior surface of cerebellar hemispheres on
either side (Fig. 14.2).
Surface
Superior surface is related to inferior surface of
occipital lobe of cerebrum.
Inferior surface is related to superior surface of
cerebellum.
Cerebellum
Fig. 14.3 Horizontal shelf of tentorium cerebelli separating occipital lobe of cerebrum from cerebellum
Meninges of Brain and Cerebrospinal Fluid
Margins
1. Posterior margin: It is actually peripheral, conv-
ex and fixed margin which is attached on either
side of midline and from behind forwards to
l Two lips of transverse sulcus of occipital bone.
l Superior border of petrous part of temporal
bone.
Anterior end of this margin is attached to posterior
clinoid process of sphenoid bone.
2. Anterior margin: It is the inner central free
margin of the dural fold. Free margin of both sides
together forms a concavity which is called tentorial
notch. In front of this notch passes brainstem from
supratentorial compartment to infratentorial com-
partment of cranial cavity to pass through foramen
magnum.
Anterior end of free margin is attached to anterior
clinoid process of sphenoid bone.
Venous sinuses related
Anterior part of peripheral margin attached to sup-
erior margin of petrous part temporal bone is related
to superior petrosal sinus.
Posterior part of peripheral margin related to tran-
sverse sulcus of occipital bone is related to transverse
sinus.
Function of tentorium cerebelli
Horizontal shelf of tentorium cerebelli holds on it
the occipital lobes of cerebrum in supratentorial
Endosteal layer of dura
Occipital lobe
Meningeal layer of dura
horizontally reflected forwards to
form tentorium cerebelli
217
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
compartment and prevents its pressure unduely to
be applied on cerebellum in the infratentorial com-
partment.
Falx cerebelli (Fig. 14.1)
It is a small, crescentic fold of dura mater which extends
along the midline vertical plane forwards between two
cerebellar hemisphere bellow tentorium cerebelli.
Margins
Superior margin is anteroposteriorly straight. It runs
along midline being attached on the undersurface of
tentorium cerebelli.
Posterior margin is convex and attached to internal
occipital crest. This margin lodges occipital sinus.
Anterior margin is concave and free. It invaginates
through the gap between posteroinferior aspect of
two cerebellar hemispheres. Occipital sinus is lodged
between right and left layers of this dura fold (Fig.
14.1).
Diaphragma sellae (Fig. 14.4)
It is a small, round and horizontal fold of dura mater
whose peripheral margin is attached to the outline of
hypophyseal fossa (sella turcica) of superior surface of
body of sphenoid on middle cranial fossa. It presents a
central circular aperture through which infundibulum
(stalk) of pituitary gland passes upwards to be atta-
ched to the base of brain.
Arterial Supply of Dura Mater
Dura mater is supplied meningeal branches of so
many arteries. These meningeal branches are divided
into following three sets.
1. Anterior: For anterior cranial fossa.
2. Middle: For middle cranial fossa.
3. Posterior: For posterior cranial fossa.
Anterior meningeal branches
These branches arise from
1. Anterior and posterior ethmoidal arteries.
Optic chiasma
Infundibulum of pituitary gland
Fig. 14.4 Diaphragma sellae related to pituitary gland at the base of brain
218
2. Internal carotid artery.
3. A branch from middle meningeal artery.
Middle meningeal branches
1. Middle meningeal artery: It is a branch from
maxillary artery. It is the largest of the meningeal
arteries. Entering through foramen spinosum it
lies deep to pterion. This landmark of the artery
is clinically important for neurosurgeons. Here it
divides into anterior frontal and posterior parietal
branches. Some of the branches may ascend upto
vertex and anastomose with the corresponding
branches of other side.
2. Accessory meningeal artery: It is also branch
of maxillary artery and it enters cranium through
foramen ovale.
3. A branch from ascending pharyngeal artery
enters through foramen lacerum.
Posterior meningeal branches
1. Meningeal branch of occipital artery. It may
be two. One enters through jugular foramen and
another through mastoid foramen.
2. Multiple meningeal branches of vertebral
artery.
Apart from very fine branches from all of the above
meningeal arteries distributed to dura mater,
branches are also distributed to periosteum (end-
osteum), bone and bone marrow.
Nerve Supply of Dura Mater
Sensory nerves for cranial dura mater are also divided
like arteries into three sets for anterior, middle and
posterior cranial fossae. These are as following:
Anterior cranial fossa
1. Anterior ethmoidal nerve.
2. Posterior ethmoidal nerve.
Mammillary body
Diaphragma sellae
Pituitary gland

3. Meningeal branch of maxillary nerve (Nervus
meningeus medius).
4. Recurrent meningeal branch of mandibular nerve
(Nervus spinosus).
Middle cranial fossa
1. Nervus meningeus medius.
2. Nervus spinosus: Which also carries sympathetic
fibers from middle meningeal plexus.
Nervus spinosus divides into anterior and post-
erior divisions which follow the course of anterior
and posterior divisions of middle meningeal artery.
3. A recurrent tentorial branch from ophthalmic
nerve which supplies tentorium cerebelli.
Posterior cranial fossa
1. Ascending meningeal branches from upper three
cervical nerves. They enter through foramen
magnum.
2. Recurrent meningeal branch of hypoglossal nerve.
It is actually made up of fibers of first cervical
nerve and reenters cranium through hypoglossal
canal.
3. Meningeal branch may arise from vagus nerve at
the site of its superior ganglion.
In addition, meningeal branches are also given
from facial nerve and glossopharyngeal nerve.
It is important to notice at this stage that arachnoid
mater and pia mater do not receive any sensory nerve.
These are restricted to dura mater only. Sympathetic
fibers from cervical sympathetic trunk are vasomotor
in nature.
Venous Sinuses of Dura Mater
These are intracranial venous channels between
endosteal and meningeal layer of cranial dura mater.
These are formed due to separation of two layers or
invagination of meningeal layer from endosteal layer
of dura mater.
Characteristics of venous sinuses
1. These are thin-walled with absence of muscle
fibers in their wall.
2. They are devoid of valves, so blood can flow in both
directions.
3. Walls are formed by dura mater with inner
endothelial lining.
4. The venous sinuses communicate with the veins
outside cranium through emissary veins which
adjust intracranial venous pressure.
5. Venous sinuses receive venous blood from brain,
meninges, bones of the cranium.
Meninges of Brain and Cerebrospinal Fluid
6. Circulated cerebrospinal fluid also finally drains
into venous sinuses.
7. Blood from all venous sinuses finally drains
through internal jugular vein.
Names of dural venous sinuses
Unpaired Paired
1. Superior sagittal sinus 1. Cavernous sinus
2. Inferior sagittal sinus 2. Superior petrosal sinus
3. Straight sinus 3. Inferior petrosal sinus
4. Occipital sinus 4. Transverse sinus
5. Anterior intercavernous sinus 5. Sigmoid sinus
6. Posterior intercavernous sinus 6. Petrosquamous sinus
7. Basilar venous plexus 7. Middle meningeal sinus
8. Sphenoparietal sinus
Some important venous sinuses (Fig. 14.5)
Superior sagittal sinus
It is anteroposteriorly directed along the superior
convex margin of falx cerebri. Narrower anterior
end communicate with nasal veins through foramen
cecum. Posteriorly at the level of internal occipital
protuberance it usually turns to the right to become
continuous with right transverse sinus. Cerebrospinal
fluid is absorbed through arachnoid villi projecting to
the wall of this sinus.
Inferior sagittal sinus
It also runs anteroposteriorly along the lower concave
free margin of falx cerebri.
It joins with great cerebral vein of Galen to form
straight sinus.
Straight sinus
It is so called because of its straight anteroposterior
midline direction along the line of attachment of falx
cerebri and tentorium cerebelli.
It is formed by union of inferior sagittal sinus and
great cerebral vein. Its posterior end turns to the left
to become continuous with left transverse sinus.
Occipital sinus
It is small in size and runs downwards and forwards
along the posterior, attached, convex margin of falx
cerebelli.
It starts from confluence of sinus which is mee-
ting point of following venous sinuses at the level of
internal occipital protuberance.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Inferior sagittal sinus
Anterior intercavernous
sinus
Left sphenoparietal sinus
Left cavernous sinus
Left superior petrosal sinus
Left inferior petrosal sinus
Fig. 14.5 Important dural venous sinuses
1. Superior sagittal sinus
2. Straight sinus
3. Two transverse sinuses.
Occipital sinus ends in internal vertebral venous
plexus beyond posterior margin of foramen magnum.
Cavernous sinus
This is a paired venous sinus present in middle cranial
fossa in relation to lateral surface of body of sphenoid.
It extends from apex of petrous part of temporal
bone to superior orbital fissure.
Lateral wall of the sinus is related to oculomotor,
trochlear, ophthalmic and maxillary nerves from
above downwards. Medially it is related to pituitary
gland in hypophyseal fossa. Inferomedial to the sinus
lie internal carotid artery and abducent nerve.
Cavernous sinus has many important tributaries
and communications. It communicates through emis-
sary veins at base of skull with pterygoid venous
plexus which is clinically important.
For detailed study of this sinus, reader is advised
to consult Textbook of Gross Anatomy.
Transverse sinus
This paired sinus is lodged in the transverse sulcus on
either side of internal occipital protuberance, at the
posterior part of peripheral fixed margin of tentorium
cerebelli.
Right transverse sinus is formed usually as a
continuation of posterior end of superior sagittal sinus
and posterior end of straight sinus usually continues
as left transverse sinus.
220
Superior sagittal sinus
Right transverse sinus
Confluence of sinus
Straight sinus
Great cerebral vein of Galen
Left transverse sinus
Sigmoid sinus
Internal jugular vein
Both transverse sinuses are continuous, at its
lateral end, as sigmoid sinus on inner aspect mastoid
part of temporal bone.
Sigmoid sinus
It is so called because of its sinuous or S-shaped
appearance. It is lodged on a deep groove on inner
aspect of mastoid part of temporal bone. Sigmoid sinus
on either side starts as a continuation of transverse
sinus and continues as upper end (superior bulb) of
internal jugular vein just beyond the level of jugular
foramen.
Superior petrosal sinus
Superior petrosal sinus is also bilateral sinus. It is
situated along the superior border of petrous part of
temporal bone at the anterior part of peripheral fixed
border of tentorium cerebelli.
It extends from posterior end of cavernous sinus
to lateral end of transverse sinus at its junction with
sigmoid sinus.
Blood is drained in anteroposterior direction from
cavernous sinus towards transverse sinus.
Inferior petrosal sinus
This paired sinus extends from before backwards
along the groove between inferior border of petrous
part of temporal bone and clivus of sphenoid bone. It
drains blood from cavernous sinus to bulb of internal
jugular vein passing through anterior compartment
of jugular foramen.

Sphenoparietal sinus
It is a bilateral narrow and small venous sinus running
along posterior border of lesser wing of sphenoid to
drain into cavernous sinus.
ARACHNOID MATER
Arachnoid mater is a thin, delicate, impermeable
transparent membrane which wraps over brain (as
well as spinal cord). It is placed in the plane between
dura mater outside and pia mater inside.
Arachnoid mater invests the surface of brain and
does not dips into any depression, fossa, sulcus or
fissure on the surface of brain except in following two
sites.
1. Inside the median longitudinal fissure of cerebrum,
arachnoid mater is taken inside by the meningeal
dura to the bottom of fissure through the formation
of falx cerebri.
2. Inside the stem of lateral sulcus of brain, arachnoid
mater is pushed by posterior free margin of lesser
wing of sphenoid.
Investing the brain arachnoid mater is continuous
below foramen magnum to cover spinal cord and ends
along with spinal dura at the level of lower border of
body of second sacral vertebra.
Spaces Related to Arachnoid Mater
Arachnoid mater is closely related to dura mater from
which it is separated by a thin potential space called
subdural space which contains a thin layer of fluid.
Beneath arachnoid a noticeable space is there
between it and pia mater called subarachnoid space.
The subarachnoid space is much wider in some sites.
Contents of Subarachnoid Space
Subarachnoid space contains following
1. Cerebrospinal fluid which, after being secreted
by choroid plexus of ventricle and circulated in
ventricular system, is transported into subara-
chnoid space, through apertures of roof of fourth
ventricle.
2. Blood vessels of brain before they enter inside
or come out of brain substance.
3. Cranial nerves after they exit out of the brain
and before come out through foramen of skull.
4. A fine network of reticular fibers traversing sub-
arachnoid space binds arachnoid with pia mater.
Surface lining
Both superficial and deep surfaces of arachnoid mater
are covered by a layer of mesothelial cells which are
Meninges of Brain and Cerebrospinal Fluid
lubricated by fluid of subdural and subarachnoid
space.
Prolongations of Arachnoid Mater
1. Along the nerves: When cranial nerve arise from
surface of brain, so also spinal nerve arising from
spinal cord, they take a sleeve of meningeal dura as
well as arachnoid mater. Dura stops at the margin
of foramina through which the nerves come out.
But arachnoid continues for a short distance over
the perineural sheath.
2. Along the blood vessels: When arteries from
subarachnoid space penetrate brain substance,
they take prolongation of arachnoid along with pia
to form perivascular sheath.
Processes of Arachnoid (Fig. 14.6)
1. Arachnoid villi: These are multiple, short
finger-like prolongations of arachnoid mater
which invaginate the wall of intracranial venous
sinuses. These villi perforate the dural wall of
venous sinus while pushing through it and come
in contact with endothelial wall of the sinus. The
specialized mesothelial cells of the arachnoid villi
is concerned with transport of cerebrospinal fluid
from subarachnoid space to venous sinus.
Maximum number of arachnoid villi are found
in relation to wall of superior sagittal sinus.
2. Arachnoid granulations: These are nothing but
modified forms of arachnoid villi. With adva-
ncement of age, arachnoid villi are enlarged in
size, becomes pedunculated and clumped together
to form arachnoid granulations whose function is
same, i.e. as absorption of cerebrospinal fluid from
subarachnoid space into venous blood.
Prominent arachnoid granulations, in old age,
produce impressions in the form of multiple pits on
the inner surface of bones of vault of skull adjacent
to the sulcus for superior sagittal sinus.
Subarachnoid Space
It is the space beneath arachnoid mater, so between
it and pia mater. Subarachnoid space of brain is
continuous with that around spinal cord through
foramen magnum.
Contents
1. Cerebrospinal fluid: Which flows freely around
the surface of brain.
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Outer periosteum Emissary vein

Bone of
cranial vault Superior sagittal
sinus

Endosteal layer
of dura

Meningeal layer
of dura

Arachnoid villi

Arachnoid mater

Fig. 14.6 Arachnoid villi invaginating dura and endothelial wall of dural venous sinus

2. Blood vessels: Main arteries and veins supplying Communication

or draining brain lie in the plane of subarachnoid
space.
3. Cranial nerves: After exit from brain, cranial
nerves initially lie in the subarachnoid space
before they leave cranium through corresponding
foramina.
4. Subarachnoid space is traversed by fine net-
work of reticular fibers binding arachnoid and
pia together. This fibrous network looks like a
spider web. That is why arachnoid is no named,
as it means spider-web.
The network of fibers with cerebrospinal fluid
in subarachnoid space appears like a water-filled
sponge acting as a cushion around brain having
significant protective function.
Subarachnoid space communicates with ventricular
system through foramen of Magendie and foramen
of Luschka on the lower ependymal roof of fourth
ventricle.
Prolongations of subarachnoid space
1. Along cranial nerve, for a short distance outside
cranium beyond foramina of cranial bones forming
perineural space.
2. Along blood vessels, inside brain forming periv-
ascular space.
Subarachnoid Cisterns (Fig. 14.7)
As arachnoid mater straightway sweeps over the
surface of the brain, in some areas, where brain

Cisterna ambiens (cistern

of great cerebral vein)

Interpeduncular cistern

Cisterna pontis Fourth ventricle of brain

Cerebellomedullary cistern

Fig. 14.7 Subarachnoid cisterns

222

surface presents a marked depression, fossa or not-
ch, subarachnoid space is found to be much more
spacious. These roomy areas of subarachnoid space
are known as subarachnoid cisterns. These cisterns
are filled with adequate quantity of cerebrospinal
fluid. Some cistern again contains many of the arteries
which gives secondary branches to brain.
Some important cisterns
1. Cerebellomedullary cistern (cisterna magna)
It is the largest cistern present in the angle between
dorsal surface of medulla oblongata and anteroinferior
aspect of cerebellum. It is the area of subarachnoid
space which directly communicates with cavity of
fourth ventricle through the foramina at its roof.
Inferiorly it is continuous with spinal subarachnoid
space.
2. Interpeduncular cistern
It is the cistern formed due to sweep of arachnoid
mater over interpeduncular fossa. As this prominent
cistern is situated on base of brain, it is also called
cisterna basalis. This cistern is important because,
1. It lodges arterial circle of Willis.
2. It is related to important structures of interpe-
duncular fossa, e.g. optic chiasma, infundibulum
with pituitary gland, mammillary bodies.
3. Pontine cistern (cisterna pontis)
It is another prominent cistern in front of basilar part
of pons.
It lodges basilar artery with its many important
branches.
This cistern is continuous
Above With interpeduncular cistern.
Below With spinal subarachnoid space.
Posteriorly With cerebellomedullary cistern.
4. Cistern of lateral sulcus
It is also called Sylvian cistern. This cistern is actually
situated in front of stem of lateral sulcus, between
temporal pole and frontal lobe of cerebral hemisphere.
It contains middle cerebral artery.
5. Cistern of great cerebral vein
This cistern is also known as cisterna ambiens. It is
situated between splenium of corpus callosum and
superior surface of cerebellum. It contains great
cerebral vein of Galen and pineal gland.
PIA MATER
Pia mater is thinnest and innermost covering of brain.
It is transparent and vascular membrane.
Meninges of Brain and Cerebrospinal Fluid
Its surface is lined by a layer of mesothelial cells.
Pia mater is closely related to the surface of brain
everywhere.
It lines the walls and also the bottom of all sulci
of brain. However in cerebellum, it is not that much
intimate to all the fissure. It lines mainly the larger
cerebellar fissure. Blood vessels while penetrating
through the surface of brain, take a sleeve of pia mater
(along with arachnoid) inside the brain. It forms there
the perivascular sheath. Space underneath is called
perivascular space.
CLINICAL ANATOMY
Functional Importance of the Meninges
Tough membrane of dura mater encasing the brain
has got the vital protective role. Apart from this, dural
folds, mainly falx cerebri and tentorium cerebelli limit
excessive movements of brain within the skull.
Arachnoid mater binds the subarachnoid space
containing cerebrospinal fluid and meshwork of deli-
cate fibers which together act as a cushion around
brain.
Pia mater is the vascular membrane which acts as a
media for penetration of blood vessels inside the brain.
Disharmony Between Excessive Movement of
Brain and Skull with Meninges
In an individual subjected to head injury with a moving
head, momentum of brain strikes it against skull and
also dural folds. It may cause tear of fragile cortical
veins draining into dural venous sinus. Consequence
may be subdural or subarachnoid hemorrhage.
Intracranial Hemorrhages Related to Dura
Epidural Hemorrhage Resulting Extradural
Hematoma
Epidural hemorrhage results from injury to men-
ingeal artery or vein. The most common blood vessel
affected is the anterior (frontal) division of middle
meningeal artery. A minor degree of head injury may
lead to fracture of anteroinferior part of parietal bone
or squamous part of temporal bone. As a result of
hematoma, meningeal layer of dura will be stripped
off from inner surface of skull. Intracranial pressure
will be raised and enlarging hematoma exerts
pressure over motor area of precentral gyrus.
Subdural Hemorrhage
Subdural hemorrhage result in case of injury to supe-
rior cerebral vein at its site of drainage in superior
sagittal sinus.
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It is interesting to note here the differential
findings in Computed Tomography Scan (CT Scan) in
epidural and subdural hematoma. In case of epidural
hemorrhage, meningeal layer of dura is stripped
up from endosteal layer visualizing a biconvex lens
shaped hyperdense area. In patient with subdural
hematoma, blood accumulates in extensive potential
space between meningeal dura and arachnoid mater
producing a long crescentic hyperdense area.
Meningeal Headache
Dura mater is mainly supplied by different branches of
trigeminal nerve and ascending meningeal branches
of upper three cervical nerves.
Headache related to supratentorial part of dura,
supplied by branches of trigeminal nerve, is refe-
rred to forehead. Whereas, headache related to infra-
tentorial part of dura supplied by branches of upper
three cervical nerves, is referred to occipital region.
In case of meningitis, or inflammation of meninges,
headache is experienced over the entire head and
back of the neck.
In this connection, it is to be noted here that
arachnoid mater and pia mater do not have any
sensory nerve fibers. Sensory nerves are only rest-
ricted to dura mater.
Meningioma
Meningiomas are one of the types of intracranial
tumors which arise from arachnoid villi which are
most commonly related to superior sagittal sinus.
Thrombosis of Dural Venous Sinus
Superior sagittal sinus receives communications from
veins of scalp through emissary veins and from veins of
nose. So infection from this areas may spread through
venous communication to superior sagittal sinus.
Complication may lead to venous sinus thrombosis.
Cavernous sinus communicates with veins drain-
ing dangerous area of face through emissary veins at
base of skull, pterygoid venous plexus and deep facial
veins. Neglected infection of this area of face may
cause spread of infection in cavernous sinus with a
serious complication like cavernous sinus thrombosis.
Sigmoid sinus is separated from mastoid air cells
by a thin plate of bone on the floor of sigmoid sulcus of
mastoid part of temporal bone. Mastoiditis, resulting
from middle ear infection (otitis media) may lead to
spread of infection to sigmoid sinus following erosion
of thin plate of bone. Infection may lead to thrombosis
of sigmoid sinus.
224
Pulsating Exophthalmos
Cavernous sinus is related to internal carotid artery
on its inferomedial aspect. Violent head injury may
cause fracture of middle cranial fossa with rupture of
internal carotid artery at this site. A communication
is established between cavernous sinus and internal
carotid artery. So arterial blood is pushed in caver-
nous sinus engorging communicating veins. Eyeball
becomes engorged and protrudes forwards (exoph-
thalmos). The protruded eye is found to be pulsatile
synchronizing with every systole so also pulse. That
is why the clinical condition is called pulsating
exophthalmos.
CEREBROSPINAL FLUID
Cerebrospinal fluid is a modified tissue fluid which
is present in ventricular system of central nervous
system and whole of subarachnoid space around brain
and spinal cord.
Cerebrospinal fluid is constantly synthesized by
choroid plexus of ventricle. After being circulated, it
is also constantly absorbed through arachnoid villi
of subarachnoid space. While circulated, in between
secretion and absorption, its volume and pressure are
also kept constant in normal individual. Its volume
is 150 ml and pressure ranges between 60150 mm of
water.
Physical Property
l Cerebrospinal fluid is a clear, colorless fluid being
slightly alkaline in nature.
l Its specific gravity is 10051008.
l It contains inorganic salts in similar concentration
as blood plasma.
l Chloride content is half the amount as compared
to blood plasma.
l It contains traces of protein.
l Microscopic study shows only a few lymphocytes
(up to 3 cells per cubic millimeter).
Formation
Cerebrospinal fluid (CSF) is synthesized at the rate of
200 ml per hour or 5000 ml per day.
CSF is formed by choroid plexus of all the three
ventricles. 8090% is formed by choroid plexus of
lateral ventricle. Remaining is by that of third and
fourth ventricles.
A very small quantity of the fluid is formed by
capillaries related to the surface of brain and spinal
cord.

Secretion of cerebrospinal fluid is an active
process and it creates a small pressure gradient. It
is important to realize that synthesis of cerebrospinal
fluid is not pressure regulated as it occurs in case of
blood pressure.
Cerebrospinal fluid acts as a medium for transport
of metabolites from nervous tissue to blood. Lower
concentration of potassium, calcium, magnesium,
bicarbonate and glucose than in blood plasma explains
active transport.
Circulation
8090% of cerebrospinal fluid is secreted by choroid
plexus of lateral ventricle. Remaining smaller amount
is synthesized from choroid plexus of third and fourth
ventricle and from smaller blood vessels of brain
surface.
Circulation of cerebrospinal fluid is a continuous
process like its synthesis. From lateral ventricle the
fluid passes to third ventricle through interventricular
foramen of Monro. From third ventricle CSF enters
fourth ventricle through cerebral aqueduct of Sylvius.
Following two factors facilitate this circulation.
1. Arterial pulsation of choroid plexus.
2. Movement of cilia of the ependymal cells lining
ventricles.
Fluid is then squeezed slowly through fora-
men of Magendie and two lateral foramina of
Luschka of ependymal roof of fourth ventricle to
cerebellomedullary cistern of subarachnoid space.
Then it passes to pontine cistern from where it
ascends through tentorial notch to reach inferior
surface of cerebrum.
Then pulsations of cerebral arteries help to
propel the fluid upwards along superolateral surface
of cerebral hemisphere. It is from this stage some
amount of cerebrospinal fluid descends through
subarachnoid space of spinal cord and further lower
down around cauda equina upto the level of second
sacral vertebra.
At the bottom of spinal subarachnoid space, cereb-
rospinal fluid flow depends upon following factors
1. Pulsation of spinal arteries
2. Movements of spinal column
3. Respiration
4. Coughing
5. Change of posture of body.
Absorption
Principal sites of absorption of cerebrospinal fluid are
the arachnoid villi. These are finger-like projections
from the arachnoid mater lining which project into
Meninges of Brain and Cerebrospinal Fluid
the dural venous sinuses. Mainly they project into
the wall of superior sagittal sinus. Clusters of villi
grouped together form elevations which are known as
arachnoid granulations.
Structurally, arachnoid villi is a diverticulum from
the arachnoid mater which pierces dura mater to
invaginate the wall of venous sinus. The diverticulum
is covered by a thin cellular layer which are the
mesothelium of arachnoid, being capped on its outer
surface by endothelium of venous sinus.
The arachnoid granulations increase in number
and size with advancement of age. Sometimes these
become calcified in old age.
Other way of absorption
Small quantity of cerebrospinal fluid is absorbed thro-
ugh following alternate routes.
1. Directly through some veins in subarachnoid
space.
2. Through perineural lymph vessels following cranial
and spinal nerves.
Regulation of absorption
When the pressure of cerebrospinal fluid rises more
than venous pressure in venous sinuses, absorption of
cerebrospinal fluid is facilitated. Electron microscopic
studies show that tips of arachnoid villi presents
minute tubules connecting venous sinus and are lined
with endothelium. Flow of cerebrospinal fluid into
venous sinus is regulated by rise of venous pressure.
When the pressure inside the venous sinus rises more
than cerebrospinal fluid pressure, tubules at the tips
of arachnoid villi are closed and thus reflux of blood
back into the subarachnoid space is prevented. So
arachnoid villi act as one-way valve.
Blood cerebrospinal fluid barrier (Fig. 14.8)
It is a partition or demarcation which form barrier
between blood and ventricular cerebrospinal fluid
existing in relation to choroid plexus.
Structure
It is the structure of a villus of a choroid plexus. It is
the wall of villus of choroid plexus which separates
lumen of capillary from cavity of ventricle. It is made
up of following elements.
1. Very thin lining of endothelial cells of capillaries
which do not show true fenestration. The fene-
stration areas are bridged by thin diaphragm.
2. A continuous layer of basement membrane outside
capillary endothelial lining.
3. Some scattered flattened pale cells.
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Tight junction
Pale cell
Fig. 14.8 BloodCerebrospinal fluid barrier
4. A continuous basement membrane of choroidal
epithelial cells.
5. Layer of choroid epithelial cells. The adjacent epit-
helial cells are joined by tight junctions. These
tight junctions acts as barrier.
Water, gases and lipid-soluble substances are able
to pass through the barrier from blood to cerebrospinal
fluid. Macromolecules like protein are unable to pass
through.
Functional significance
n BloodCerebrospinal fluid barrier is an important
semipermeable membrane which prevents entry of
many potentially harmful substances into the brain
and spinal cord. But it permits entry of gases and
nutrients inside the nervous tissue.
Functions of cerebrospinal fluid
1. Cerebrospinal fluid circulated as a thin film of fluid
act as support and protective factor in addition to
the meninges.
2. Along with meshwork of fibers extending from
arachnoid to pia mater, cerebrospinal fluid acts as
a cushion around the brain like a sponge soaked
with water.
3. Cerebrospinal fluid is partly concerned with nour-
ishment of central nervous system tissue.
4. Cerebrospinal fluid, as comes in direct relation
with central nervous system, helps to drain meta-
bolites.
5. As brain floats on surrounding cerebrospinal
fluid encased by arachnoid as well as tough dura,
weight of the brain is felt lighter.
6. As cerebrospinal fluid comes in close contact
with blood at the site of venous sinuses, pressure
gradient helps for absorption of cerebrospinal fluid
to a variable extent as per situation.
226
Choroidal epithelial cells
Epithelial basement
membrane
Endothelial basement
membrane
Endothelial cell
CLINICAL ANATOMY
Effect of Increased Cerebrospinal Fluid
Pressure
In normal healthy individual, cerebrospinal fluid
pressure is 60150 mm of water. If the pressure rises
due to any reason, it will lead to some effect also
beyond subarachnoid space of brain. For example
subarachnoid space continues beneath arachnoid
around optic nerve upto its attachment at posterior
pole of retina. Pressure of cerebrospinal fluid will
exert pressure at optic disk which will compress thin-
walled retinal vein producing congestion with swelling
(edema) of optic disk. It is known as papilledema.
Obstruction in Flow of Cerebrospinal Fluid at
Subarachnoid Space
Normal cerebrospinal fluid pressure is 60150 mm of
water. If pressure is applied on internal jugular vein
at neck, pressure of intracranial venous sinus rises
which will retard the flow of cerebrospinal fluid to
venous sinuses with consequent rise in CSF pressure.
In normal healthy individual this rise of pressure is
observed with the help of manometer placed through
spinal tap (lumbar puncture). In case of obstruction
in spinal subarachnoid space by tumors of meninges
or spinal cord, this rise of cerebrospinal fluid press-
ure fails to be observed. It is known as positive
Queckenstedt sign.
In case of blockage of flow of cerebrospinal fluid
anywhere in subarachnoid space of spinal cord, fluid
below the level of obstruction, collected by lumbar
puncture, exhibits following characteristics.
1. As the amount of protein is increased remarkably,
fluid drained out coagulate quickly.

2. Fluid looks yellowish in color (Xanthochromia)
due to presence of altered blood pigment.
This condition is known as Froins syndrome.
Hydrocephalus
Hydrocephalus is a clinical condition which is cha-
racterized by abnormal increase in quantity of cere-
brospinal fluid inside cranium. Hydrocephalus with
raised intracranial pressure may be due to one of the
following causes.
1. Abnormal increase in formation of the fluid.
2. Obstruction anywhere in the pathway of circulation
of fluid.
3. Impaired absorption through arachnoid villi into
venous sinus.
If the hydrocephalus develops due to oversecretion
and/or reduced absorption, with no blockage, it is called
communicating hydrocephalus where subar-
achnoid space along with ventricular system is
dilated because of patency of foramina at the roof of
fourth ventricle. But if there is obstruction anywhere
between intraventricular foramen of Monro and,
foramen of Magendie and foramina of Luschka at
fourth ventricular roof, hydrocephalus is characterized
by dilatation of ventricular system only. It is called
noncommunicating hydrocephalus.
Excessive formation of cerebrospinal fluid is very
rare which occurs in tumors arising from choroid
plexus.
Impaired absorption of the fluid from arachnoid
villi leading to hydrocephalus may be due to any of
following reasons.
1. Inflammatory exudate related to arachnoid villi.
2. Venous sinus thrombosis.
Meninges of Brain and Cerebrospinal Fluid
3. Increased pressure of venous sinus, when it exc-
eeds the pressure of cerebrospinal fluid.
4. Compression of internal jugular vein.
Study of Cerebrospinal Fluid in Different
Diseases
Physical, chemical with biochemical, microbiological
and histological (pathological) examinations are done
for the purpose of detection of so many neurological
diseases.
The fluid is withdrawn from spinal subarachnoid
space through the process of a clinical investigation
called lumbar puncture (spinal tap) which has been
described in the chapter of spinal cord.
Increased pressure of cerebrospinal fluid occurs in
case of meningitis, or in case cerebral edema, cerebral
tumors, or formation intracranial hematoma or
abscess.
Gross appearance of normal cerebrospinal fluid
is colorless, clear and watery. Turbid or cloudy
appearance indicates presence of polymorphonuclear
leukocytes or excess of proteins. Leukocyte count
increases in meningitis and encephalitis. In case of
tuberculous meningitis and poliomyelitis, protein
content is increased because of increased vascular
permeability.
Normal cerebrospinal fluid does not contain red
blood cells. Gross appearance of blood is due to fault in
lumbar puncture when vertebral veins are punctured by
spinal tap needle. Cerebrospinal fluid may be uniformly
stained with blood in subarachnoid hemorrhage.
However, after some hours of subarachnoid hem-
orrhage, yellowish coloration (xanthochromia) will be
observed due to presence of oxyhemoglobin.
227
 Blood Supply of Brain and Spinal Cord
Brain and spinal cord, constituting central nervous
system, have high metabolic demand as these are
made up of very sensitive and delicate nervous tissue.
This demand is fulfilled by aerobic combustion of
glucose. For this, there is very much necessity of adeq-
uate and continuous supply of glucose and oxygen
which are transported through bloodstream.
It is interesting to note that, though central
nervous system (brain and spinal cord) constitutes
only 2% of body weight, it receives 17% of cardiac
output and utilizes 20% of total oxygen utilized by
body.
Central nervous system tissue is very much sensi-
tive and highly vulnerable to injury due to lack of blood
supply, so lack of oxygen (hypoxia). Experimental
studies as well as clinical observation established
that, in case of arrest of blood supply to the brain for
10 seconds, there occurs loss of consciousness and if
it continues for 10 minutes for even a tiny area of the
tissue, it leads to irreversible damage.
BLOOD SUPPLY OF BRAIN
Arteries of Brain
Brain is richly supplied by arteries. Brain is encased
inside cranial cavity and covered by meninges.
Source of the arteries are from outside the cranium
so these arteries will have to enter the cranium.
Entering the cranium the arteries and their main
branches pierce dura mater and then arachnoid mater
and are initially placed in subarachnoid space.
15
Final sets of branches penetrate brain tissue in
the form of two groups which are
1. Superficial (cortical): Which have two characte-
ristics.
a) They supply superficial cortical part of brain.
b) They form anastomosis on the surface of the
brain which will help in collateral circulation.
2. Deep (central, ganglionic or nuclear): Which
have two characteristics
a) They supply deeper part of brain, e.g. white
matter (fiber bundles) and deep-seated mass
of gray matter like basal nuclei.
b) These branches are end arteries which do not
have any anastomosis before capillary level.
l Sources of arteries: Sources of arteries to the
brain are from two bilateral arterial systems which
are
1. Vertebrobasilar arterial system.
2. Carotid arterial system.
Vertebrobasilar arterial system
This arterial system is formed by two vertebral
arteries. Vertebral artery originates at scelenoverte-
bral triangle of root of neck. But it is the fourth part of
vertebral artery which becomes intracranial entering
through foramen magnum to supply brain (with
spinal cord).
Fourth part of vertebral artery pierces dura mater
and then arachnoid mater inside the cranium. Arteries
of both sides run upwards, forwards and medially
over anterolateral aspect of medulla oblongata and
converge towards midline. Uniting with each other
in midline at pontomedullary junction both vertebral

Basilar artery
Vertebral artery
Fig. 15.1 Branches of vertebral artery
arteries from basilar artery. Basilar artery runs
upwards along basilar sulcus of pons. At the upper
end of basilar sulcus basilar artery bifurcates into
posterior cerebral arteries (Figs 15.1 and 15.2).
So, branches from vertebrobasilar system are
divided into two groups
1. Branches from vertebral artery.
2. Branches from basilar artery.
Branches from vertebral artery (Fig. 15.1)
These are five sets of branches
1. Medullary arteries: These are minute, multiple
and medial branches of vertebral artery. These
short branches pierce medulla oblongata. These
are called paramedian branches by clinician.
2. Meningeal arteries: These are also minute and
multiple but lateral set of branches. The branches
supply dura mater and bone of posterior cranial
fossa.
3. Anterior spinal artery: This is single and midline
artery which is formed by union of one contributory
branches of each of the vertebral arteries. Each of
the branches runs downwards and medially, and
adjoin with each other in the midline to descend
vertically along the anterior median fissure of
spinal cord. Anterior spinal artery though single,
supplies anterior two-thirds of spinal cord.
4. Posterior spinal artery: This is bilateral branch
which arises from lateral side of vertebral artery.
Posterior spinal artery also descends vertically,
but along posterolateral sulcus of spinal cord
which coincides with the line of attachment of
posterior root of spinal nerves.
Blood Supply of Brain and Spinal Cord
Posterior inferior
cerebellar artery
Meningeal arteries
Medullary arteries
Anterior spinal artery
Posterior spinal artery
Though posterior spinal arteries are two in number,
they supply posterior one-third of spinal cord.
Distribution of both anterior as well as
posterior spinal arteries are discussed in details in
connection with blood supply of spinal cord.
5. Posterior inferior cerebellar artery: It is the
largest branch of intracranial part of vertebral
artery and presents an irregular course from
side of medulla at the level of olive towards
cerebellum. This artery is so named because it is
posterior in position among two inferior cerebellar
arteries (Fig. 15.3). The artery runs backwards
winding round medulla to supply inferior aspect
of cerebellum, both vermis as well as hemisphere.
It also gives branches to posterolateral aspect of
medulla oblongata.
n Branches for choroid plexus: Choroid plexus
of fourth ventricle is formed by branches of posterior
inferior cerebellar artery.
Branches of basilar artery (Fig. 15.2)
Basilar artery is formed by union of two vertebral
arteries in the midline of pontomedullary junction.
The artery runs upwards along basilar sulcus of
pons and at its upper end it bifurcates into right and
left posterior cerebral arteries.
Branches of basilar artery are of five groups like
those of vertebral artery.
1. Pontine arteries: These are short, narrow and
multiple branches, being paramedian in position.
Just after origin, these branches penetrates
through basilar part of pons.
2. Labyrinthine artery: It is so called because
it supplies labyrinth of internal ear. It is a long
229
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Basilar artery
Vertebral artery
Fig. 15.2 Branches from basilar artery
narrow branch which accompanies facial and
vestibulocochlear nerves to enter through internal
acoustic meatus and supplies internal ear.
3. Anterior inferior cerebellar artery (Figs
15.2 and 15.3): It is so named because it is the
anterior of the two inferior cerebellar arteries.
It may be recalled that posterior one arises from
vertebral artery. This branch of basilar artery
passes backwards and laterally to supply anterior
part of inferior aspect of cerebellum. It also gives
short branches to posterolateral part of medulla
oblongata and pons.
Sometimes labyrinthine artery arises from ante-
rior inferior cerebellar artery.
Posterior cerebellar artery
Basilar artery
Vertebral artery
Fig. 15.3 Three cerebellar arteries arising from vertebrobasilar system
230
Posterior cerebellar artery
Superior cerebellar artery
Pontine arteries
Labyrinthine artery
Anterior inferior cerebellar artery
4. Superior cerebellar artery: It arises from
terminal part of basilar artery close to its bifur-
cation. Initially it curves around cerebral peduncle
and finally reaches superior aspect of cerebellum
(Fig. 15.3). It is the artery to supply mainly sup-
erior aspect of cerebellum (vermis as well as
hemispheres), but branches are also distributed to
pons, pineal gland and superior medullary velum.
5. Posterior cerebral artery: These are two term-
inal branches (right and left) of basilar artery
arising at upper end of basilar sulcus. The artery
runs upwards, backwards and laterally winding
round cerebral peduncle to approach posterior part
Superior cerebellar artery
Anterior inferior cerebellar
artery
Posterior inferior
cerebellar artery

of medial surface of cerebral hemisphere. It is the
artery mainly to supply cerebral hemisphere as it
is named Cerebral. Its distribution in detail will
be discussed later, but at this stage it is to be noted
that it gives following three types of branches.
a) Cortical branches: These supply parts of tem-
poral and occipital cortex.
b) Central branches: These branches penetrates
deep into the substance of brain as end arteries
to supply midbrain, pineal gland, thalamus
and lentiform nucleus.
c) Choroidal branches: It takes part in formation
of choroid plexus of inferior horn of lateral
ventricle.
Vertebrobasilar system of arteries approaching brain
from behind supplies
1. Hindbrain: Pons, medulla oblongata and cere-
bellum
2. Midbrain
3. Posterior part of:
a) Diencephalon: Geniculate bodies, pineal gland
and posterior part of thalamus.
b) Telencephalon: Smaller posterior part of cere-
bral hemisphere.
Carotid arterial system
Carotid arterial system is formed by intracranial
portion of internal carotid artery and its branches.
Internal carotid artery enters cranial cavity
through carotid canal at the base of skull. Entering
inside cranium it first lies in middle cranial fossa
where it follows the following course.
Optic nerve
Optic chiasma
Optic tract
Posterior cerebral artery
Basilar artery
Fig. 15.4 Branches of carotid arterial system for brain, viewed from inferior aspect (base) of the brain
Blood Supply of Brain and Spinal Cord
The artery runs forwards along carotid sulcus
in relation to inferomedial wall of cavernous sinus.
Medial to anterior clinoid process it turns upwards.
Here it pierces dura mater and then arachnoid mater
to reach the plane of subarachnoid space. Internal
carotid artery finally turns upwards and backwards
lateral to optic chiasma below anterior perforated
substance where it divides into its two terminal
branches Anterior and middle cerebral arteries.
Branches from intracranial carotid arterial system
(Fig. 15.4)
Same as vertebral artery and basilar artery of vert-
ebrobasilar systemFive branches arise from carotid
system.
1. Ophthalmic artery: It arises from internal caro-
tid artery when it emerges from cavernous sinus
to pass upwards medial to anterior clinoid process.
Ophthalmic artery arises inside cranium but it
is destined to orbital cavity. It leaves cranium
through optic canal being inferolateral to optic
nerve. In the orbit it supplies eyeball and other
related structures.
2. Posterior communicating artery: It is a narrow
branch which arises from the site of bifurcation
of internal carotid artery. It runs backwards and
communicates with posterior cerebral artery. On
either side posterior communicating artery plays
an important role to establish communication
between carotid system and vertebrobasilar
system.
3. Anterior choroidal artery: It is a long narrow
branch arising from internal carotid artery, close
Anterior cerebral artery
Anterior communicating artery
Ophthalmic artery
Middle cerebral artery
Internal carotid artery
Anterior choroidal artery
Posterior communicating artery
communicates with posterior cerebral
artery of vertebrobasilar system
231
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
to its bifurcation into two cerebral arteries. It runs
backwards along the direction of optic tract and
enters through the choroid fissure of inferior horn
of lateral ventricle. It takes part in formation of
choroid plexus and also gives branches to impor-
tant structures like crus cerebri, optic tract,
lateral geniculate body and internal capsule.
4. Anterior cerebral artery: It is the narrower
terminal branch of internal carotid artery.
It runs forwards and medially above optic nerve.
Then it reaches median longitudinal fissure of
brain.
Here it is joined to the anterior cerebral artery
of opposite side by anterior communicating artery
which may be double or absent in some cases.
Finally anterior cerebral artery approaches the
medial surface of cerebral hemisphere where it
divides into two terminal branches called peric-
allosal artery and callosomarginal artery.
Anterior cerebral artery itself gives rise to two
sets of branches called cortical and central (nuclear
or ganglionic) branches.
5. Middle cerebral artery: It is the larger terminal
branch of internal carotid artery and looks to be
the continuation of parent arterial trunk after
anterior cerebral branch is given out. It is also the
largest branch of internal carotid artery. Middle
cerebral artery, after its origin at the base of brain
near anterior perforated substance, runs upwards
backwards and laterally to reach stem of lateral
sulcus of cerebrum.
Like posterior and anterior cerebral arteries,
middle cerebral artery also gives out following two
sets of branches.
a) Central branches: These branches arise from
middle cerebral artery while it is in base of
brain near anterior perforated substance.
Fig. 15.5 Circle of Willis to establish communication between vertebrobasilar system and carotid system
232
b)
Cortical branches: These branches arise while
the parent trunk approaches superolateral
surface of cerebral hemisphere.
Communication Between Vertebrobasilar and
Carotid Arterial Systems (Fig. 15.5)
It has already been noticed that at the base of the
brain arteries of vertebrobasilar system approach
from behind and those of carotid system proceed
from the front. But a communication is established
among branches of two systems of both sides. This
arterial communication is called circle of Willis
or circulus arteriosus (Fig. 15.5). This arterial
circle is situated on interpeduncular fossa of base of
the brain in the plane of interpeduncular cistern of
subarachnoid space.
Though it is called arterial circle of Willis, it is
not circular but polygonal (hexagonal) in outline.
Arteries forming the circle of Willis are
1. Anterior communicating artery
2. Anterior cerebral artery
3. Internal carotid artery, continued as middle cere-
bral artery
4. Posterior communicating artery
5. Posterior cerebral artery
6. Basilar artery.
VARIATIONS OF CIRCLE OF WILLIS
1. Commonest variation is in relation to anterior
communicating artery. Very often it may be dou-
ble. Sometimes it is absent.
2. Incomplete circle: Posterior communicating artery
of one side or even of both sides may be absent
making the arterial circle incomplete.
1. Anterior communicating artery
2. Anterior cerebral artery
3. Internal carotid artery continued
as middle cerebral artery
4. Posterior communicating artery
5. Posterior cerebral artery
6. Basilar artery

Functional Significance of Circle of Willis
Parent arteries which contribute to formation of circle
of Willis are divided in following four units.
1. Right internal carotid artery
2. Left internal carotid artery
3. Right vertebral artery
4. Left vertebral artery.
In normal healthy individual, because of uniformity
of arterial pressure in four units, blood from one unit
is not at all mixed up with blood of other unit, neither
side to side, nor anteroposteriorly. It is important as
well as interesting to note that, even in basilar artery
blood from two vertebral arteries are not admixtured.
So, it is very clear that in normal person, anatomical
anastomosis of circle of Willis is not physiologically
active. But in pathological condition, if any one of
the arteries forming the arterial circle is blocked,
collateral circulation is established. So depending
on the site and nature of occlusion, blood from one
arterial unit may flow to any part of brain.
Branches of Circle of Willis (Fig. 15.6)
It has already been learnt that, brain receives two
sets of branches from arteries of both vertebrobasilar
and carotid system. These are cortical and central.
Branches from circle of Willis are all central.
These are also called nuclear or ganglionic branches
which are example of end arteries.
Branches are divided into following four groups.
1. AnteromedialMedian
2. AnterolateralRight and left
3. PosteromedialMedian
4. PosterolateralRight and left.
Anteromedial branches
These branches arise from anterior communicating
and anterior cerebral arteries. One of the branches
Anterior cerebral artery
Recurrent artery of Heubner
Middle cerebral artery
Internal carotid artery
Posterior communicating artery
Posterior cerebral artery
Basilar artery
Fig. 15.6 Central branches of circle of Willis
Blood Supply of Brain and Spinal Cord
arise from anterior cerebral artery which presents a
recurrent course. This is called recurrent artery of
Heubner. Anteromedial set of branches supply
l Anterior half of anterior limb of internal capsule
l Putamen
l Head of caudate nucleus.
Anterolateral branches
These are called striate arteries which arise from site
of origin of middle cerebral artery.
These branches penetrate through anterior perfo-
rated substance and are divided into two groups
called lateral and medial striate arteries.
Lateral striate arteries ascend along lateral
surface of lentiform nucleus. These arteries supply
l Posterior half of anterior limb and anterior two-
thirds of posterior limb of internal capsule
l Lentiform nucleus
l Caudate nucleus
l Thalamus.
One of the lateral striate arteries supplying
posterior limb of internal capsule presents a long
course. It is called Charcots artery of cerebral
hemorrhage. Because of its length, it is more prone
to be damaged in cerebrovascular accident.
Medial striate arteries ascend medial to lentiform
nucleus and supply
l Caudate nucleus
l Internal capsule.
Posteromedial branches
These branches are median in position and originate
from posterior communicating and posterior cerebral
arteries.
They penetrate through posterior perforated subs-
tance and give branches to
Anterolateral (striate) branches
Charcots artery of cerebral hemorrhage
Anteromedial branches
Posterolateral branches
Posteromedial branches
233
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
l Anteromedial part of cerebral peduncle
l Hypothalamus forming floor of third ventricle
l Medial part of thalamus forming lateral wall of
third ventricle.
Posterolateral branches
These branches arise from posterior cerebral artery
lateral to its junction with posterior communicating
artery. Posterolateral branches are bilateral to supply:
l Posterior part of thalamus
l Geniculate bodies
l Posterior part of cerebral peduncle
l Pineal gland
l Tactum of midbrain.
Central branches of circle of Willis are also known
as ganglionic or nuclear branches, because in the
central core of brain, these branches not only supply
important fiber bundles like internal capsule, but also
many of them supply submerged collection of gray
matter which are called basal ganglia or basal nuclei.
All the central branches are example of end arteries
having no anastomosis in precapillary level. So, once
one of these arteries are affected due to hemorrhage,
thrombosis or embolism, area of brain supplied by
that artery will suffer from irreversible damage.
CORTICAL BRANCHES SUPPLYING DIFFERENT
SURFACES OF CEREBRAL HEMISPHERE
Superficial gray matter of cerebral hemisphere
(cerebral cortex) is supplied by cortical branches
of anterior, middle and posterior cerebral arteries.
Before these cortical branches penetrate into the
cortex, they anastomose freely on the surface of the
brain. So, if any branch is occluded, the area will
receive blood supply through collateral circulation.
Anterior cerebral artery
Fig. 15.7A Areas of superolateral surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
234
It is important to note that three cerebral arteries
are concerned with arterial supply of three surfaces
of cerebral hemisphere. It means, each of the surfaces
receive branches from all the three cerebral arteries,
but with variations in their share.
Superolateral Surface (Fig. 15.7A)
Middle cerebral artery is the main artery for super-
olateral surface. It supplies most of the area of this
surface. Important areas supplied by middle cerebral
artery includes, major parts of primary motor and
primary sensory area, frontal eye field, motor speech
area, auditory area.
The areas of superolateral surface not supplied by
middle cerebral artery are
1. A narrow strip of area of about 2.5 cm breadth
below and parallel to superomedial border, from
frontal pole upto parietooccipital sulcus, which
is supplied by bran-ches of anterior cerebral
artery. It includes leg area of primary motor and
primary sensory cortex.
2. Occipital lobe and a narrow strip above and par-
allel to lower border of temporal lobe (except
temporal pole) which is supplied by branches of
posterior cerebral artery.
Medial Surface (Fig. 15.7B)
Maximum area of medial surface (anterior two-thirds)
is supplied by branches of anterior cerebral artery
which covers paracentral lobule.
Areas of medial surface not supplied by anterior
cerebral artery are
1. Temporal pole which is supplied by middle cerebral
artery.
Posterior cerebral artery
Middle cerebral artery

Posterior cerebral
artery
Fig. 15.7B Areas of medical surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
2. Occipital lobe and medial surface of temporal
lobe (except temporal pole) which is supplied by
posterior cerebral artery which therefore supplies
visual area.
Inferior Surface (Fig. 15.7C)
Tentorial surface area (except temporal pole) is supp-
lied by posterior cerebral artery.
Tentorial surface of temporal pole is supplied by
middle cerebral artery.
Larger lateral part of orbital surface of frontal lobe
(Fig. 15.7C) is supplied by middle cerebral artery.
Smaller medial part of orbital surface of frontal
lobe is supplied by anterior cerebral artery.
Anterior cerebral artery
Fig. 15.7C Areas of inferior surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
Blood Supply of Brain and Spinal Cord
Anterior cerebral artery
Middle cerebral
artery
Physiological control of blood flow in cerebral
arteries
1. Cerebral arteries are richly supplied by postga-
nglionic sympathetic fibers which arise from supe-
rior cervical sympathetic ganglion. Stimulation of
these fibers causes cerebral vasoconstriction.
2. However, in normal condition, cerebral blood flow
is under chemical regulation rather than ner-
vous control. Arterial blood flow to the brain is
dependent upon concentration of carbon dioxide,
hydrogen ion and oxygen present in nervous
tissue. Increase in carbon dioxide and hydrogen
ion concentration and lowering of oxygen tension
causes cerebral vasodilatation.
Middle cerebral artery
Posterior cerebral artery
235
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

VENOUS DRAINAGE OF BRAIN veins drain the upper halves of both superolateral
as well as medial surfaces of cerebrum. They drain
At the beginning it is to be noted that veins draining in superior sagittal sinus. Anterior group opens at
brain are quite different from intracranial venous right angle but posterior group of veins opens obli-
sinuses. quely against the direction of blood flow (anterior
to posterior) in superior sagittal sinus. This will
Characteristics maintain their patency even when CSF pressure is
1. Veins of the brain are thin-walled due to absence increased.
of muscles in the walls.
2. These veins are devoid of valves, so blood does not Superficial middle cerebral veins (Fig. 15.8)
have unidirectional flow.
3. Arrangement of veins does not follow the arterial It runs downwards, forwards and medially along the
pattern. length of posterior ramus and then stem of lateral
4. All the veins of brain ultimately drain in intra- sulcus of brain. This vein will receive tributaries from
cranial venous sinus. the area of superolateral surface around posterior
5. Veins are situated initially in subarachnoid space. ramus of lateral sulcus.
But ultimately they pierce arachnoid mater and Superficial middle cerebral vein drains into cave-
meningeal layer of dura mater to drain into venous rnous sinus or sometimes into sphenoparietal sinus.
sinuses.
6. To maintain the patency, some of the veins drains Communications
against the direction of blood flow through the
sinus. Superficial middle cerebral vein communicates with
l Superior sagittal sinus: Through superior ana-
Groups of Veins stomotic vein.
l Transverse sinus: Through inferior anastomotic
Broadly veins of the brain are divided into following veins.
three groups l Deep middle cerebral vein: Present deep to it
l External cerebral veins
on insular cortex.
l Internal cerebral veins
l Terminal veins.
Deep middle cerebral vein
External Cerebral Veins It is situated very deep in lateral sulcus on the surface
of insular cortex and coupled with middle cerebral
Superior cerebral veins (Fig. 15.8) artery.
These veins are 612 in number. They are shorter in It runs downwards and forwards to form basal
length and parallel to each other. Superior cerebral vein joining with anterior cerebral vein.

Superior sagittal sinus

Superior cerebral vein

Superior anastomotic vein

Inferior cerebral vein

Inferior anastomotic vein

Superficial middle
cerebral vein
Transverse sinus
Sigmoid sinus
Superior bulb of internal
jugular vein

Fig. 15.8 Veins in relation to superolateral surface of cerebral hemisphere

236

Anterior cerebral vein (Fig. 15.9)
It is the only vein which is the companion of corresp-
onding artery, i.e. anterior cerebral artery.
It runs over the surface of corpus callosum
and approaches towards base of the brain curving
genu. It receives small tributaries from the area of
medial surface of cerebral hemisphere which is not
drained by superior and inferior sagittal sinuses. As
mentioned earlier, anterior cerebral vein forms basal
vein joining with deep middle cerebral vein.
Inferior cerebral veins
These are multiple small veins draining inferior sur-
face of cerebral hemisphere. They are divided into
two groups. Veins draining orbital surface converge
and terminate into superior cerebral veins or directly
into superior sagittal sinus. Veins of tentorial surface
drain into cavernous sinus.
Internal Cerebral Veins (Figs 15.9 and 15.10)
There are two internal cerebral veins, one on either
side of midline.
Internal cerebral vein begins at the level of interv-
entricular foramen of Monro at the apex of tela chor-
oidea of third ventricle.
This vein is formed by union of following veins.
1. Thalamostriate vein: Drains thalamus and bas-
al ganglion (corpus striatum).
2. Septal vein: Drains septum pellucidum.
3. Choroidal vein: Drains from choroid plexus.
The two internal cerebral veins, one on either side
of midline, run backwards between two layers of tela
choroidea. Below splenium of corpus callosum two
veins join to form great cerebral vein of Gelen.
Inferior sagittal
sinus
Straight sinus
Great cerebral vein of Galen
Basal vein
Fig. 15.9 Veins in relation to medial surface of cerebral hemisphere
Blood Supply of Brain and Spinal Cord
Terminal Veins
Basal vein (Figs 15.9 and 15.10)
This vein is one on either side of midline. It is formed
at anterior perforated substance by union of
l Deep middle cerebral vein
l Anterior cerebral vein
l Striate vein.
Besides the above mentioned tributaries of formation,
basal vein also receives vein from
l Cerebral peduncle
l Structures of interpeduncular fossa
l Tectum of midbrain
l Parahippocampal gyrus
Basal vein finally joins great cerebral vein of Galen.
Great cerebral vein (Figs 15.9 and 15.10)
Great cerebral vein of Galen is a single midline vein.
It is formed by union of two internal cerebral veins
below splenium of corpus callosum. It receives basal
veins from two sides. A little backwards it joins with
inferior sagittal sinus to form straight sinus (Fig.
15.9).
BLOOD SUPPLY OF SPINAL CORD
Arterial Supply (Fig. 15.11)
Spinal cord lies in upper two-thirds of vertebral canal
extending from upper border of 1st cervical vertebra
to lower border of 1st (2nd) lumbar vertebra. Main
arterial channels supplying spinal cord are called
spinal arteries. These are three vertical channels,
which arise from intracranial part (4th part) of
vertebral arteries. After origin, spinal arteries come
Superior sagittal sinus
Anterior cerebral vein
Internal cerebral vein
237
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Septal vein
Thalamostriate vein
Choroidal vein
Internal cerebral vein
Great cerebral vein of Galen
Basal vein joining great
cerebral vein
Fig. 15.10 Terminal veins related to tela choroidea of third ventricle
out of cranium through foramen magnum to enter
vertebral canal. These three arteries are
l One anterior spinal artery
l Two posterior spinal arteries.
Anterior spinal artery
Inside cranium, each of the vertebral arteries gives
out one anterior spinal branch which descends down-
wards and medially towards anterior median line
where they meet each other to form single anterior
spinal artery.
Anterior spinal artery so formed, runs downwards
along anterior median fissure of spinal cord.
Branches
While running along anterior median fissure, at the
level of every segment of spinal cord, anterior spinal
artery gives sulcal branches which penetrate through
spinal cord to anterior two-thirds of spinal cord
covering
1. Anterior gray column, anterior gray commissure,
(and lateral gray column)
2. Anterior and lateral white columns with anterior
white commissure.
Sulcal branches supply anterior two-thirds of
spinal cord in alternate fashion to right and left side
in successive spinal cord segment.
Channel of anterior spinal artery extends upto lower
end of spinal cord but it may show some variations.
238
Septal vein, thalamostriate
vein and choroidal vein join to
form internal cerebral vein
Internal cerebral vein
Tela choroidea
Terminal part of great cerebral
vein of Galen
1. It may be prominent only upto cervical level
beyond which it may be very slender.
2. In some cases, in upper thoracic level and in thor-
acolumbar junction, anterior spinal artery may be
very narrow.
In any of the cases, where anterior spinal artery
is deficient, blood flow to the anterior spinal artery is
reinforced by segmental contribution of other arteries
(discussed below).
Posterior spinal arteries
Posterior spinal arteries are two in number, right and
left. They arise from intracranial part of vertebral
artery or sometimes from posterior inferior cerebellar
artery of respective side. Leaving cranial cavity thro-
ugh foramen magnum, the arteries descend vert-
ically along posterolateral sulcus of spinal cord at the
line of attachment of posterior roots of spinal nerves.
Posterior spinal arteries give off branches in every
segments which enter the substance of spinal cord to
supply its posterior one-third which includes
1. Posterior gray column with posterior gray comm-
issure.
2. Posterior white column.
Variations
Posterior spinal arteries may be very much narrow
in upper thoracic level. It is very much vulnerable

to ischemia in upper three thoracic segments where
reinforcement of the artery is very much essential by
segmental arteries.
Reinforcement of spinal arteries
It is already understood, though both anterior and
posterior spinal arteries may be existent throughout
whole length of spinal cord, anatomically they are
slender in different levels. This effect may interfare
with adequate blood flow in the affected segments of
spinal cord. But it is compensated through reinfor-
cement of the spinal arteries by segmental arteries
at every segment throughout whole length of spinal
cord.
Segmental arteries are horizontal in disposition
and enter vertebral canal through intervertebral fora-
mina. Segmental arteries arise from the following
regional arteries.
1. In cervical region: Deep cervical artery, ascending
cervical artery, and 2nd part of vertebral artery.
2. In thoracic region: Posterior intercostal arteries.
3. In lumbar region: Lumbar arteries, may be su-
pplemented by lateral sacral artery.
Course, distribution and communication of segmental
arteries
Segmental arteries enter vertebral canal through
respective intervertebral foramen. It then divides
into anterior and posterior radicular arteries which
approach respective aspect of spinal cord along the
route of anterior and posterior roots of spinal nerve.
Primary role of the radicular arteries are to supply
corresponding nerve roots. But they continue to run
Posterior radicular artery
Arterial
vasocorona
Branches supplying
nerve roots
Anterior radicular artery
Fig. 15.11 Arterial supply of spinal cord
Blood Supply of Brain and Spinal Cord
further towards the surface of spinal cord for two
purposes.
1. They encircle spinal cord from anterior and poste-
rior aspects of both sides and communicate with
each other. While doing so, along the length of
spinal cord they form a fine arterial reticulum or
network called arterial vasocorona. Branches from
it directly enter the substance of spinal cord.
2. The radicular artery also communicates with the
spinal arteries on the surface to reinforce spinal
arteries. This reinforcement is important for ade-
quate blood flow through spinal arteries, parti-
cularly below cervical level where spinal arteries
are very thin. One of the anterior redicular artery
may be very much prominent to take the place of
lower two-thirds of anterior spinal artery in case
of its deficiency. It is called arteria radicularis
magna. Its position is variable from T1T11
segment.
l Additional feeder arteries: Additional feeder arte-
ries enter the vertebral canal and anastomose with
anterior and posterior spinal arteries. But site of
origin, number and size varies from one individual
to another. One of the large and important feeder
artery is called great anterior medullary artery
of Adamkiewicz. It arises from aorta either in lower
thoracic or upper lumbar level. It is unilateral and in
most of the cases if enters the spinal cord from left
side. When this artery is present, it becomes the major
source of blood flow to lower two-thirds of spinal cord.
VENOUS DRAINAGE OF SPINAL CORD
All the venous channels of spinal cord, like arteries,
are longitudinal in position being parallel to long-axis
Posterior spinal artery
Segmental
artery
Spinal branch of
segmental artery
Anterior spinal artery
239
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
of spinal cord. These are six in number with fixed
position as follows:
1. One anteromedian: It run along anterior median
fissure of spinal cord.
2. Two anterolateral: They run along anterolateral
sulcus in front of attachment of anterior nerve
roots.
These three veins are named anterior spinal veins.
3. One posteromedian: It runs along posterior
median sulcus of spinal cord.
4. Two posterolateral: These veins run along
posterolateral sulcus of spinal cord, posterior to
attachment of posterior roots of spinal nerve.
These three veins are named as posterior spinal
veins.
Communication Network
All the six veins receive tributaries from spinal cord.
These tributaries form a fine network on the pial
surface of spinal cord which is called venous vaso-
corona.
n Drainage: Spinal veins form a plexus inside verte-
bral canal called internal vertebral venous plexus.
Radicular veins arising from it join to form segmental
veins which come out through intervertebral foramen
to drain in regional veins of cervical, thoracic and
lumbar regions.
Communication with Intracranial Veins
Upper end of internal vertebral venous plexus ascend
through foramen magnum to communicate with
Tight junction between
endothelial cells
Fig. 15.12 Blood-brain barrier
240
basilar venous plexus which in turn, establishes
communication with intracranial venous sinuses.
BLOOD-BRAIN BARRIER
Sensitive and delicate tissue of central nervous system
(brain and spinal cord) needs suitable environment
for its normal activity. That is why in one side it
needs selective transport of essential substances from
blood capillaries to extracellular space of nervous
tissue and again it needs restriction of entry of
some injurious and toxic substances. This becomes
possible only because of presence of a barrier between
capillary lumen and extracellular space of nervous
tissue. This is called blood-brain barrier. Though it is
called blood-brain barrier it demarcates blood from
brain as well as spinal cord.
Structure (Fig. 15.12)
Electron microscopic studies reveal following layers
of blood-brain barrier
1. Endothelial cells of wall of capillary: Blood-
brain barrier is characterized by permeability
restriction because endothelial lining presents
tight junction and it is devoid of typical fenes-
trations.
n Basement membrane: Outside the endothelial
cells, there is continuous layer of basement mem-
brane.
Components forming
blood-brain barrier
1. Capillary endothelium
2. Basement membrane
3. Foot process of
astrocytes

2. Foot processes of astrocytes: Surrounding the
capillary wall and closely apposed to it, there are
numerous foot processes of astrocytes.
Selective Permeability
Blood-brain barrier is impermeable to compound
having molecular weight of 60,000 or more. It follows
transport of gases and water readily. Lipid-soluble
substances are able to pass through. The barrier
permits transport of glucose, electrolytes, amino
acids but prevents access of protein. Toxic materials
are prevented from passing through the barrier.
Blood-brain barrier has got enormous importance
in connection with drug therapy and induction of
anesthesia. To have an effect on central nervous
system tissue, a drug for treatment of a disease, must
have ability to pass through blood-brain barrier.
Areas of Brain Devoid of Barrier
In some areas of brain, blood-brain barrier is not
existent. Because selective permeability is not main-
tained in those areas due to absence of tight junction
in endothelial lining. These areas are
1. Pineal gland
2. Neurohypophysis
3. Tuber cinereum
4. Walls of supraoptic recess of third ventricle
5. Area postrema in the floor of fourth ventricle.
Blood-brain barrier in newborn needs special
mention. Although it exists very well in newborn,
there are evidences that it is more permeable to cert-
ain substances than in case of adults.
CLINICAL ANATOMY
Rich blood supply to brain and spinal cord is very
much essential for its high metabolic demand fulfilled
by aerobic combustion of glucose. Both glucose and
oxygen are carried to nervous tissue through the
media of bloodstream. Blood is carried through both
vertebrobasilar system and carotid system. Internal
carotid artery is the major source of arterial blood
flow. Arrest of blood supply to the brain for 10 seconds
result is unconsciousness. It is proved that, if complete
arrest of blood flow continues beyond 1 minute,
neuronal function ceases. Irreversible neuronal tissue
damage starts after 4 minutes and becomes complete
by 10 minutes of vascular occlusion.
Cerebrovascular accidents are one of the most
leading cause of morbidity and mortality in almost
all the parts of globe. It results from hemorrhage,
thrombosis and embolism. In the recent days,
awareness in the community to control high blood
Blood Supply of Brain and Spinal Cord
pressure (hypertension) and dyslipidemia reduced
the incidence of cerebrovascular accidents.
Final distributing arteries are anterior, middle
and posterior cerebral arteries. They present free
anastomosis on the surface of cerebral cortex. But the
central branches via circle of Willis penetrate into the
central core of brain where they may branch further
but no further anastomoses takes place. These central
branches are therefore end arteries.
Factors Responsible for Impairment of
Cerebral Blood Flow
These factors may be many. But most important fac-
tors interfering with normal cerebral blood flow are
1. Alteration of blood pressure: Hypertension or
hypotension
2. Diseases of arteries walls: It is the formation of
atheroma which can occlude the lumen of artery.
It may cause formation of thrombus.
3. Diseases which block the arterial lumen.
It may occur in following two forms
a) Embolism by a dislodged thrombus.
b) Embolism by fat globules.
Cerebral Artery Syndromes
These are the syndromes which occur following occl-
usion of any of the three cerebral arteries. From
knowledge of anatomy it is well-understood that
these kinds of occlusive disorder give rise to various
neurological manifestations. It is not possible as well
as not desirable for the sake of common readers to
discuss these manifestations in detail. Interested
readers may consult textbooks of neuromedicine.
Salient features of cerebral arterial syndromes are
discussed below.
Anterior Cerebral Artery Occlusion
Occlusion of anterior cerebral artery distal to anterior
communicating artery leads to following manife-
stations
1. Contralateral hemiparesis and hemianesthesia of
leg and foot area due to involvement of uppermost
part of both primary motor as well as sensory
areas adjacent to superomedial border of cortex on
lateral and medial surfaces of cerebral hemisphere
which include paracentral lobule.
2. Apathy and personality change due to involvement
of frontal lobe area adjacent to superomedial
border of cerebral cortex.
3. Impairment of power of steriognosis: The patient
will be unable to identify an object. It is due to
lesion of marginal part of superior parietal lobule
adjacent to superomedial border, the area which is
supplied by anterior cerebral artery.
241
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Middle Cerebral Artery Occlusion
Following are the clinical manifestations which will
of course vary as per site of occlusion and degree of
collateral circulation.
1. Contralateral hemiplegia and hemianesthesia
except leg and foot area and supranuclear paralysis
of cranial nerve manifested by paralysis of lower
half of contralateral side of face. These losses are
due to involvement of primary motor cortex and
primary sensory cortex on superolateral surface
of brain except upper marginal part (con-trolling
leg and foot area) which is supplied by anterior
cerebral artery.
2. Aphasia is noted when dominant left cerebral
hemisphere is involved affecting motor and sensory
area for speech (Brocas area or area 44, 45).
3. Contralateral homonymous hemianopia due to
lesion of optic radiation which receives branches
from middle cerebral artery.
Auditory area (area 41 and 42) of superior temporal
gyrus also suffers from ischemia. But in case of
unilateral vascular lesion, there is little impairment
of hearing due to bilateral cortical influence.
Posterior Cerebral Artery Occlusion
Occlusion of posterior cerebral artery leads to
jeopardization of blood supply to visual area of
occipital cortex (area 17). It will cause visual defect
called homonymous hemianopia with sparing of
macular vision. The defect is manifested by loss of
contralateral half of field of vision. Macular vision
is spared because macular area of visual cortex on
lateral surface receives collateral circulation from
middle cerebral artery.
Lesion of Central Branches
Central branches from circle of Willis are end arteries.
These arteries are divided into four sets. Many of
them penetrate into deeper central core of cerebral
hemisphere to supply white matter like internal
capsule and masses of deep-seated gray matter, e.g.
basal ganglia. Lateral striate branches of middle
cerebral artery once damaged, leads to lesion in
posterior limb of internal capsule through which pass
bundles of corticospinal tract. It will therefore result
in contralateral hemiplegia. If vascular lesion affects
retrolentiform and sublentiform part of internal
capsule it will cause contralateral hemianopia and
hemihypoacusis. Vascular lesion of basal ganglia
will lead to various manifestation of extrapyramidal
disorder.
Thrombosis is most common in middle cerebral
artery or its branches, because it is the direct
continuation of internal carotid artery.
242
Vascular Disorder Related to Vertebrobasilar
System
Vertebrobasilar arterial system supplies the parts of
brain situated in posterior cranial fossa. These are
1. Brainstem
2. Cerebellum
3. Occipital lobe of cerebrum.
Different branches of vertebrobasilar system are
concerned for feeding different component of brain.
Some common types of vascular occlusive disorders
are mentioned below
1. Ventral (medial) medullary syndrome: Ven-
tral part of medulla oblongata is lesioned due to
occlusion (thrombosis) of medullary branches of
vertebral artery. It causes crossed paralysis which
is characterized by contralateral hemiplegia and
ipsilateral paralysis of muscles of tongue.
2. Lateral medullary (Wallenberg) syndrome:
Occlusion of posterior inferior cerebellar artery
leads to this condition where posterolateral part of
medulla oblongata and cerebellum is lesioned. It is
manifested by
a) Contralateral hemianesthesia of body and ipsi-
lateral hemianesthesia of face.
b) Dysphagia and dysphonia due to paralysis of
muscles of soft palate, pharynx and larynx.
c) Cerebellar ataxia.
d) Vertigo, nausea, vomiting, nystagmus.
e) Horners syndrome.
3. Millard Gubler Syndrome: It results due to
occlusion of paramedian pontine branches of
basilar artery supplying lower and ventral part
of pons. In this case lesions of descending fibers
of corticospinal tract and emerging fibers of
VIth and VIIth cranial nerve result in following
neurodeficits
a) Contralateral hemiplegia
b) Ipsilateral facial paralysis
c) Ipsilateral medial strabismus (squint) due to
unopposed action of medial rectus muscle.
4. Pontine hemorrhage: It is extensive and bilat-
eral in nature so that clinical condition will cause
all bilateral manifestation due to lesion of pons.
In addition the lesion will present following two
specific features.
n Pinpoint pupil: Due to involvement of ocular
sympathetic fibers.
n Hyperpyrexia: Due to severe lesion in pons which
disconnect the body from heat regulating center in
hypothalamus.
5. Weber syndrome: It occurs due to occlusion of
a branch of posterior cerebral artery supplying
ventral part of cerebral peduncle. It results in
lesion of corticospinal and corticobulbar (corti-

conuclear) tracts and emerging fibers of oculomotor
nerve. Clinical manifestations are contralateral
hemiplegia, paresis of contralateral lower half
of face and tongue, with ptosis, lateral squint,
dilatation of pupil with its no reaction to light and
accommodation.
Cerebral Aneurysms
Aneurysm is the condition which is characterized
by abnormal dilatation of wall of any part of artery.
Cerebral aneurysms are mostly congenital in origin.
Congenital cerebral aneurysm occurs mostly at the
site where two arteries join at the base of brain to from
circle of Willis. This is due to congenital deficiency of
muscle fibers at that site of arterial wall. Multiple
aneurysms giving berry-like appearance in the arte-
rial tree are called Berry aneurysms. Congenital
deficiency of tunica media resulting ballooning of
arterial wall is further complicated by formation of
atheroma.
Local dilatation may initially cause pressure effect
on neighboring structure, such as optic nerve or the
third, fourth or sixth cranial nerve and so producing
symptoms accordingly. Afterwards, aneurysms may
suddenly rupture in subarachnoid space. In this case
there occurs sudden onset of intense headache follo-
wed by mental confusion. Death may occur quickly
or within a few days. Best chance of recovery is there
following clipping or ligation of neck of aneurysms.
Acquired cerebral aneurysms, though rare, occurs
due to softening of arterial wall following lodgement
of an infected embolus. Acquired aneurysms may
also occur in case of arterial disease like atheroma
on normal arterial wall. It may be a complication
of damage of internal carotid artery where it lies in
cavernous sinus.
Intracranial Hemorrhage
Apart from cerebrovascular lesion, intracranial hem-
orrhage may also result from trauma.
Four varieties of intracranial hemorrhage are
following:
Epidural (Extradural) Hemorrhage
It usually occurs due to injuries to meningeal arteries
or veins. Anterior division of middle meningeal artery
is commonly damaged, following a comparatively
minor blow to the side of head which causes fracture
of anteroinferior part of parietal bone. It will injure
the artery. Due to bleeding, extradural hematoma
strips the meningeal layer of dura from endosteum
of skull. Gradually enlarging hematoma produces
pressure effect on the cortical areas, especially the
Blood Supply of Brain and Spinal Cord
underlying precentral gyrus. Through the burr hole 4
cm above the midpoint of zygomatic arch, hematoma
is cleared out to release the pressure and the torn
artery is ligated.
Subdural Hemorrhage
Subdural hemorrhage results from injury (tearing)
of the superior cerebral veins. Close to the site of
their entry to superior sagittal sinus. It results from
excessive anteroposterior movements of brain within
the skull. This occurs due to a blow on front or back of
head. Tearing of superior cerebral vein resulting from
repeated jerky anteroposterior movements of brain
within the skull may occur sometimes when a person
crosses over a series of high speed-breakers sitting in
a speedy car.
When the vein is torn, blood under low pressure
beigns to accumulate in the potential space between
dura and arachnoid. Depending upon the speed of
accumulation of blood it may be of acute or chronic
variety. Chronic form may gradually progress over
the period of several months. When a small blood
clot attracts fluid by osmosis, hematoma expands
gradually and produce various pressure symptoms.
In both the varieties, blood clots are to be removed by
burr holes.
Subarachnoid Hemorrhage
It may result from following causes
1. Leakage or rupture of congenital aneurysms in the
circle of Willis.
2. Hemorrhage from angioma.
3. Contusion or laceration of brain and meninges
following head injury:
Clinical features are
1. Sudden onset of intense headache
2. Stiffness of neck
3. Loss of consciousness.
Diagnosis is confirmed by
1. Lumbar puncture (spinal tap) shows heavily blood-
stained cerebrospinal fluid.
2. Visualization of dense areas of blood through
computed tomography (CT) scan is more confir-
matory.
Prognosis of this clinical condition is fatal and
death follows quickly. In some cases patient may
withstand the first attack of bleeding but ultimately
does not survive for more than a few days.
Cerebral Hemorrhage
In hypertensive patients cerebral hemorrhage occurs
due to rupture of atheromatous artery after middle
243
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
age. Very often thin-walled lenticulostriate branches
of middle cerebral artery are affected. Corticospinal
and corticonuclear fibers of internal capsule are
damaged leading to contralateral hemiplegia and
supranuclear lesion of cranial nerves.
Radiological Investigations of Detection of
Cerebrovascular Disease
Cerebral angiography
This procedure is adopted for the following purposes:
1. For detection of abnormalities of cerebral vascular
pattern, e.g. arteriovenous malformation.
2. For localization of space occupying lesion such as
tumors, hematomas, abscesses.
3. For detection of vascular patern of tumors for the
purpose of diagnosis of their pathology.
Investigation is done under general anesthesia.
Following rapid injection of a radiopaque medium,
series of radiographs are taken quickly at the interval
of 2 seconds. Injection is done either on vertebral
artery, or indirectly through a catheter introduced
into radial or femoral artery.
Computed Tomography (CT) and Magnetic
Resonance Imaging (MRI)
CT and MRI are indispensable techniques for diag-
nosis of various cerebrovascular diseases. The diagn-
osis can be made with speed, accuracy and safety.
Intracranial blood clot can be detected by its density.
These techniques have remarkably replaced the
cerebral angiography.
Vascular lesion of spinal cord
In comparison to the importance of nervous tissue
of spinal cord, its arterial supply is not rich to that
extent. All the three spinal arteries are very slender
and deficient in lower part. Anterior spinal artery
narrows down remarkably beyond cervical level.
Again reinforcing segmental arteries also vary in
number and prominence. Anterior two-thirds of spinal
cord covering the area of anterior (and lateral) gray
column, anterior white column and major anterior
part of lateral white column is supplied by anterior
spinal artery. Occlusion of anterior spinal artery may
produce following clinical manifestations.
1. Bilateral loss of motor function which usually
affects lower limbs (paraplegia) is due to lesion
corticospinal tracts of both side.
2. Bilateral loss of pain and temperature sensations
due to lesion of lateral spinothalamic tract in
lateral white column. This deficit is below the
level lesion.
3. Weakness of muscles and loss of tendon jerks of
244
lower limb due to damage of neurons of anterior
gray column.
4. Loss of control on bladder and bowel function due
to damage of the descending autonomic fibers.
Sense of position and movements, touch sensation
and sense of vibration are not affected as because
blood supply of posterior white column (by posterior
spinal artery) is not jeopardized.
Clinical Anatomy of Blood Brain-barrier
Blood-brain barrier in fetus and newborn
In fetus, newborn baby and premature infants, blood-
brain barrier is not fully developed. It results in
entry of toxic substance into the intercellular space of
nervous tissue. For example bilirubin can readily pass
through for yellowing of brain with a complication
called bilirubin encephalopathy (kernicterus).
Brain trauma and blood-brain barrier
Trauma, either physical or chemical, and inflammation
(e.g. meningitis) may cause disruption of structure
of blood-brain barrier. It may either cause damage
to the endothelium or disruption of tight junctions.
It will lead to free diffusion of large molecules which
include toxic substance, into the nervous tissue.
Tumors and blood-brain barrier
Tumors like anaplastic malignant astrocytoma, gliob-
lastoma and metastatic lesions in brain may present
excessive vascularization. These pathological blood
vessels do not possess blood-brain barriers.
Drug and blood-brain barrier
In reference to their permeability through blood-
brain barrier, drugs are classified into two groups.
Some pass through while some of them do not. In this
context, it is interesting to note the following points.
1. Lipid-soluble drugs possess the power of perme-
ability to pass through blood-brain barrier, e.g.
thiopental and atropine.
2. A drug like phenylbutazone which binds with
macromolecules of plasma protein is unable to
cross the barrier.
3. A drug like penicillin passes through blood-
brain barrier in small amount. It is matter of
great advantage that this drug does not cross the
barrier in large concentration which is very toxic
to nervous tissue.
4. Some drugs are not able to pass through the
blood-brain barrier, like dopamine, deficiency of
which is the cause of disease, parkinsonism. But
L-dopa, the precursor of domamine readily passes
through the barrier. Administration of L-dopa in
Parkinsonism gives good result.
 Reticular Formation
Reticular formation is defined as diffuse, ill-defined
and scattered collections of neurons in central nervous
system which are intermingled with the network
(reticulum) of nerve fibers.
n Situation: Main part of reticular formation is
present althrough the central core (tegmentum) of
brainstem (Fig. 16.1).
Topographically this component of central nervous
system is present in the areas of brainstem which are
not occupied by named and defined nuclei and fiber-
bundles.
Extension of Brainstem Reticular Formation
16
1. Above: It extends into subthalamus, hypothalamus
and thalamus of diencephalon. Further, it has
also been proved that some areas of cerebrum and
cerebellum are also closely related to brainstem
reticular formation.
2. Below: It extends into the spinal cord, specially
the cervical segments. Here reticular formation is
represented by network (reticulum) of nerve cells
and fibers on the lateral aspect of neck of dorsal
gray horn.
n Phylogenetic importance: Reticular formation
is the very significant part of central nervous system

Midbrain

Brainstem
reticular Pons
formation Cerebellum

Medulla Fourth ventricle of

oblongata brain

Fig. 16.1 Brainstem reticular formation extends throughout central tegmental core
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
in lower vertebrates. There it possesses the vital
centers like respiratory and cardiac, which actively
controls respiration, heart rate and blood pressure.
n Principle of function:
1. It maintains the state or level of consciousness,
alertness or awakefulness of an individual.
2. It also helps in arousal from sleep.
3. It contains respiratory and cardiac centers
through which it regulates respiration, heart rate
and blood pressure.
4. It regulates receptive capacity of sensory end
organs and also having effect on sensory centers,
regulates threshold of various sensations.
5. It controls muscular activities through its influence
on cerebral cortex, cerebellum, basal nuclei, red
nucleus, substantia nigra.
6. It regulates visceral, endocrine and emotional acti-
vities through its connection with hypothalamus
and limbic system.
n Architectural variation: Reticular formation is
not only divided in various nuclear groups, but also
shows following variations of neurons.
i. Cell bodies show variations in size, e.g. large,
medium and small.
ii. Variations in length of axons.
iii. Variations in ramification of dendrites.
Classifications of Brainstem Reticular Nuclei
n Primary classification (Fig. 16.2): Primarily,
nuclei of brainstem reticular formation are divided
into three groups, from midline to lateral, they are
named as
1. Raphe nuclei: These are present in the midline
of central core of brainstem. The cell bodies of
neurons are intermediate in size. Neurons of
these nuclei liberate serotonin which acts as
Fig. 16.2 Primary subdivision of brainstem reticular nuclei
246
neurotransmitter. Raphe nuclei is also known as
median column nuclei.
2. Medial column nuclei: From midline this column
is intermediate in position throughout tegmental
core of brainstem. Neurons of this column are large
sized, hence this is called Magnocellular column.
3. Lateral column nuclei: Out of three columns,
cells of this column are smallest in size. The word
parvus means small. That is why this column is
called Parvocellular column.
n Further classification of nuclei (Fig. 16.3):
The above mentioned three columns of nuclei of brai-
nstem reticular formation are divided into many
nuclei. Memorization of all these nuclei by a reader
at this stage is not encouraged. The nuclei which are
functionally important and clinically more significant
are only discussed below.
Median column nuclei (raphe nuclei) (Fig. 16.3)
As already mentioned, nuclei of this column are made
up of medium sized neurons. These neurons produce
a neurotransmitter serotonin.
The nuclei are
1. Dorsal raphe nucleus
This is present in midbrain. Axonal fibers from this
nucleus descend as reticulospinal tract to spinal cord
and relay on sensory neurons of apex of posterior
horn (Fig. 16.4) which carry pain sensation from
peripheral sensory nerves via lateral spinothalamic
tract. Transmission of pain sensation is inhibited as
the posterior horn sensory neurons are influenced by
inhibitory effect of serotonin (neurotransmitter) rele-
ased by neurons of dorsal raphe nucleus of midbrain
reticular formation.
Median (raphe) nuclear column
Medial magnocellular column
Lateral parvocellular column
 Reticular Formation

Periaqueductal nucleus
Cuneiform nucleus
Subcuneiform nucleus Medial column
nuclei
Oral pontine nucleus

Dorsal raphe nucleus Pedunculopontine

nucleus

Central nucleus of Lateral column

Median column Pontine raphe nucleus pons nuclei
nuclei
Central nucleus of
medulla
Magnus raphe nucleus
Caudal pontine
nucleus

Gigantocellular nucleus
(pontine part) Medial column
nuclei
Ventral ret. nucleus
Gigantocellular nucleus
(medullary part)

Fig. 16.3 Important nuclei of brainstem reticular formation; Median column=Red, Medial column= Blue and lateral column= Green

2. Pontine raphe nucleus
This midline nucleus is situated in dorsal part of teg-
mentum of pons and is in the same line with dorsal
raphe nucleus of midbrain.
3. Raphe nucleus magnus
This nucleus is longer and situated in the medulla
oblongata. Nucleus of spinal tract of trigeminal nerve
present in medulla oblongata receives pain sensation
carrying fibers of trigeminal nerve from the same
half of face. Axons of this nucleus, after decussation,
carry pain sensation upwards to thalamus through
trigeminal lemniscus. Axons of raphe nucleus magnus
relay in the neurons of spinal nucleus (nucleus of
spinal tract) of trigeminal nerve and through libe-
ration of serotonin (neurotransmitter) produce inhi-
bitory influence on pain pathway from half of the face
(Fig. 16.5).

Dorsal raphe nucleus in midbrain

Reticulospinal tract

Lateral Peripheral nerve fibers carrying pain

spinothalamic tract sensation

Free nerve ending

Fig. 16.4 Dorsal raphe nucleus exerts inhibitory effect, through release of serotonin, on pain fibers forming lateral spinothalamic tract
247
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Trigeminal nerve
Pons

Magnus raphe nucleus of midline

column of reticular nucleus Upper half of medulla
oblongata

Pain fibers of trigeminal nerve

Axon of magnus raphe nucleus relaying in spinal nucleus of
releases serotonin to exert trigeminal nerve
inhibitory effect on nucleus of
spinal tract of trigeminal nerve

Spinal tract
and
Spinal nucleus of trigeminal nerve
Lower half of medulla oblongata

Fig. 16.5 Magnus raphe nucleus in medulla oblongata exerts inhibitory effect on spinal nucleus of trigeminal nerve from where pain
sensation is carried through trigeminal lemniscus from ipsilateral half of face

Medial column reticular nuclei 2. Oral pontine nucleus

3. Caudal pontine nucleus
This column is intermediate in position. The cell-
4. Gigantocellular nucleus
bodies of this column are large sized. That is why it is
called magnocellular column. (pontine part)
In three parts of brainstem important nuclei of Medulla oblongata 1. Gigantocellular nucleus
this column are as follows. (Fig. 16.2) (medullary part)
Midbrain 1. Periaqueductal nucleus 2. Ventral reticular nucleus
2. Cuneiform nucleus Fundamentally, function of the nuclei of this
3. Subcuneiform nucleus group is to form polysynaptic pathway by establishing
Pons 1. Nucleus coeruleus connections as follows (Fig. 16.6)

Higher centers

Ascending efferent

Other reticular Medial reticular Lateral reticular

nuclei nuclei nuclei
Horizontal efferents Afferents

Descending efferent

Lower centers

Fig. 16.6 Connections of medial column reticular nucleus

248

Nuclei of medial (intermediate) column receive
afferents from lateral column.
Efferents go to following three destinations
1. Ascending efferents To higher centers
2. Descending efferents To lower centers
3. Horizontal efferents To other reticular nuclei.
Lateral column reticular nuclei
This is called parvocellular column as it is made up of
small sized neurons.
Important nuclei of this column are as follows in
different levels of brainstem.
Reticular Formation
Midbrain 1. Pedunculopontine nucleus
Pons 1. Central nucleus of pons
Medulla oblongata 1. Central nucleus of medulla
2. Lateral reticular nucleus
3. Ventral reticular nucleus
Nuclei of lateral column of reticular formation are
fundamentally association component of brainstem
reticular formation. These nuclei receive collaterals
from ascending sensory pathway. These send efferent
to medial column reticular nuclei.

Summary of nuclei of brainstem reticular formation

Median column nuclei

(raphe nuclei) Medial column nuclei Lateral column nuclei
medium sized cells Magnocellular, from Parvocellular from
liberate serotonin polysynaptic connections Association components
Dorsal raphe nuclei Periaqueductal nucleus
Midbrain Cuneiform nucleus
Subcuneiform nucleus Pedunculopontine nucleus
Pontine raphe nuclei Nucleus coeruleus
Oral pontine nucleus
Pons Caudal pontine nucleus Central nucleus of pons
Gigantocellular nucleus
(pontine part)
Medulla Raphe nucleus magnus Gigantocellular nucleus Central nucleus of medulla
oblongata (medullary part) Lateral reticular nucleus
Ventral reticular nucleus Ventral reticular nucleus

Connections of Reticular Formation
To develop clear concept about connections of reticular
formation, it is important as well as interesting to
subdivide the functions of reticular formation into
following two groups.
1. Reticular formation maintains the level of alert-
ness or consciousness of an individual.
2. Reticular formation controls or regulates
a) Autonomic functions like respiration, heart
rate, blood pressure and also some other visc-
eral functions.
b) Muscular activities through its influence on
lower motor neuron, itself being influenced by
cerebral cortex, cerebellum, basal nuclei, subs-
tantia nigra, red nucleus.
c) Receptive capacity of sensory pathways thro-
ugh its projection on sensory neurons (tracts)
of central nervous system.
d) Endocrine and emotional activities through
its connections with hypothalamus and limbic
system.
Above mentioned two groups of functions are perf-
ormed by two components of reticular formations
which are respectively as follows
1. Ascending reticular activating system
(ascending reticular system): This part of
reticular formation is principally lateral column
reticular nuclei. It receives inputs either directly
or through collaterals from various sensory path-
ways. It gives outputs to thalamus and from
where finally to different areas of cerebral cortex.
This circuit is for maintenance of alertness or
consciousness.
2. Descending reticular system: It is influenced
by cerebral cortex, cerebellum, basal ganglia,
substantia nigra, red nucleus. It projects to auto-
nomic centers of brainstem and spinal cord, motor
and sensory neurons of spinal cord, some cranial
nerve nuclei, hypothalamus and limbic system.
It will be now easy to understand the connections
of two systems of reticular formation.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Connections of Ascending Reticular Activating System (ARS)

{
All areas of
cerebral cortex

Efferents

Intralaminar and
reticular nuclei of
thalamus

{
Ascending
reticular activating
system

Afferents

Inputs from Collaterals from

pathway of vision, all ascending
smell, taste, sensory tracts
hearing

l Afferents: 2. Impulse from other sensory pathways, namely

1. Impulse from all ascending sensory tracts (e.g.
spinal lemniscus, trigeminal lemniscus, lateral
lemniscus) is carried to ascending reticular activ-
ating system via collaterals.
250
olfactory, visual, gustatory (taste), auditory.
l Efferents: Initially go to intralaminar and reticular
nuclei of thalamus, and finally from thalamus go to
stimulate all areas of cerebral cortex which will help
to develop alterness by an individual.
 Reticular Formation
Connections of Descending Reticular System

{
Cerebral cortex

Basal ganglia
Afferents Cerebellum

Substantia nigra
Red nucleus

{
Descending reticular system

Autonomic centers Limbic system

of brainstem and Hypothalamus
Efferents spinal cord

Motor neurons of Sensory neurons

anterior horn of of posterior horn
spinal cord of spinal cord

l Afferents from: l Efferents to:

1. Cerebral cortex 3. Basal ganglia 1. Autonomic centers of brainstem and spinal cord
2. Cerebellum 4. Substantia nigra and to regulate respiration, heart rate, blood pressure
5. Red nucleus. and some other visceral function.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
2. Motor neurons of anterior horn cells of spinal cord
to regulate voluntary movements.
3. Sensory neurons of posterior horn cells of spinal
cord to exert inhibitory effect on sensory pathway.
4. Hypothalamus and limbic system to regulate
emotional and endocrine functions.
CLINICAL ANATOMY
1. Midline (median) column nuclei of brainstem
reticular formation produces serotonin, which
act as neurotransmitter. Dorsal raphe nucleus of
midbrain sends reticulospinal fibers which project
on sensory neurons of dorsal gray horn of spinal
cord which carries pain sensation via lateral
spinothalamic tract. Serotonin released at the
synapse between descending axon of dorsal raphe
nucleus and posterior horn cells of spinal cord
exerts inhibitory effect on pain pathway via lateral
spinothalamic tract. So pain is felt less. Raphe
nucleus magnus of medulla oblongata produces
similar effect on spinal nucleus of trigeminal
nerve carrying pain sensation from face. This pain
inhibiting function of reticular nucleus is taken as
252
advantage, to relieve excrutiating pain in some
diseases by stimulating these reticular nuclei.
2. Impulse carried from various sensory pathways
to ascending reticular activating system makes
various areas of cerebral cortex alert. Thus, it
helps in alertness or consciousness and also
arousal from sleep. Like other sensory pathway,
impulse from visual and auditory pathways are
also carried to this part of reticular system via
tectoreticular tract. So, a powerful light or sound
stimulating visual or auditory pathway causes
transmission of impulse via tectoreticular fibers
to ascending reticular activating system, thus
drawing attention or alertness, and even helps in
arousal when a person is sleeping.
3. When we are awake, nuclei of reticular activating
system send continuous discharge to different areas
of brain. Sleep is induced when activity of reticular
activating system is diminished. Some drugs, e.g.
general anesthetics, sedatives, tranquilizers also
reduce activity of reticular system.
In some diseases, patient suffers from coma when
activity of reticular system gets further diminished.
 Limbic System
The word limbic means border or margin. The term
limbic system is used to include a group of structures
which lie in a ring-shaped manner in the demarcating
zone between cerebral cortex and thalamus.
But recent studies showed that limbic system also
includes some other structures beyond demarcating
zone which are concerned with following function
l Emotion
l Behavior
l Drive
l Memory.
Anatomical Components of Limbic System
A. Gray matter:
1. Superficial cortical structures:
l Hippocampal formation
l A ring of cortical areas which is called limbic
lobe. It includes
Cingulate gyrus, isthmus, parahippocampal gyrus
terminating anteriorly as uncus.
2. Subcortical structures: These are present in the
form of some nuclei as follow
l Amygdaloid nuclear complex (also known as
amygdaloid body)
l Septal area (septal nuclei)
l Part of hypothalamus namely mammillary
bodies
l Anterior nucleus of thalamus
l Olfactory areas are also included.
B. White matter: Some important named band of
white matter needs special mention. These are
17
1. Alveus
2. Fimbria
3. Fornix
4. Mammillothalamic tract
5. Stria terminalis.
HIPPOCAMPAL FORMATION (FIG. 17.1)
Hippocampal formation is a composite structure
which is composed of
1. Hippocampus
2. Dentate gyrus
3. Parahippocampal gyrus.
So, at the beginning, it should be very clear to the
readers that hippocampal formation, hippocampus
and parahippocampal gyrus are three different
terminologies.
Hippocampus and parahippocampal gyrus are two
components of hippocampal formation.
Another important point is also to be noted care-
fully. Parahippocampal gyrus is exposed area of limbic
cortex which is visible on medial surface of cerebral
hemisphere. But hippocampus and dentate gyrus are
the hidden parts which form floor of inferior horn of
lateral ventricle.
Hippocampus
Hippocampus is a smooth, curved, elongated elevation
of gray matter which is lying along the floor of inferior
horn of lateral ventricle and it is only clearly observed
when cavity of inferior horn of lateral ventricle is
dissected out (Fig. 17.2).
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Stria terminalis
Choroid fissure
Tail of caudate nucleus

Cavity of lateral ventricle Tapetum

Collateral eminence
Alveus

Hippocampus

Fimbria

Dentate gyrus

Hippocampal
fissure

Parahippocampal
gyrus
Collateral sulcus

Fig. 17.1 Hippocampal formation

Anterior expanded end presents a few shallow
cleft giving the appearance of animals foot. That is
why it is called pes hippocampus. Hippocampus itself
is so named because in coronal section, it looks like
a sea-horse. Convex ventricular surface lined with
ependyma, when viewed on coronal section, presents
in subependymal plane a thin layer of white matter
called alveus.
Alveus is formed by the fibers which converge
medially after originating from the nerve cells of
hippocampus. All the fibers of alveus turns further
posteromedially to form a bundle called fimbria (Fig.
17.3).
The fimbria runs posteriorly to become continuous
with posterior column of fornix (Fig. 17.3). So, it is
clear that axonal processes of neurons of hippocampus

Uncus
Pes hippocampus

Parahippocampal gyrus

Hippocampus
Floor of inferior horn of
lateral ventricle

Posterior horn of lateral ventricle

Fig. 17.2 Hippocampus seen on floor of inferior horn of lateral ventricle

254

which first extend medially but finally posteriorly as
alveus, fimbria and ultimately as posterior column
of fornix. Posterior column of fornix curves round
posterior end of thalamus.
Hippocampus ends posteriorly below splenium of
corpus callosum.
Dentate Gyrus
It is so called because margin of this gyrus is
serrated on denticulated. This narrow and notched
gray matter also extends anteroposteriorly between
fimbria of hippocampus and parahippocampal gyrus.
Parahippocampal gyrus is positioned inferomedially.
Dentate gyrus extends posteriorly parallel to fim-
bria. Turning round splenium of corpus callosum,
dentate gyrus becomes continuous with a thin vest-
igial lamina of gray matter over superior surface
of corpus callosum. This thin sheet of gray matter
covering superior surface of corpus callosum is called
indusium griseum. On the surface of this thin gray
matter lamina on either side of middle there run a
pair of thin thread-like band of white matter called
medial and lateral longitudinal stria.
Posterior end of dentate gyrus, below splenium, is
known as splenial gyrus or gyrus fasciolaris, which in
turn, is continuous as indusium griseum.
Parahippocampal Gyrus
Hippocampus comes directly in formations of floor of
inferior horn of lateral ventricle, but parahippocampal
Pes hippocampus
Hippocampus
Alveus
Fimbria
Posterior column of
fornix
Fig. 17.3 Alveus arising from hippocampus continued as fimbria and finally as posterior column of fornix
Limbic System
gyrus is more superficial in position and positioned
inferolateral to hippocampus (Fig. 17.1). Two are
separated by hippocampal fissure. On the lateral
side, parahippocampal gyrus is separated from med-
ial temporooccipital gyrus by collateral sulcus which
produces an impression on inferior horn of lateral
ventricle called collateral eminence. Collateral
eminence forms a bulge on lateral part of floor of
inferior horn lateral ventricle.
Structural Characteristic of Hippocampal
Formation
Earlier, limbic system used to be termed as rhine-
ncephalon because it was thought that it is only
related to function of olfaction. But actually in human
brain olfaction is related to only a small portion of
limbic system.
Major part of cerebral cortex is highly developed
in man and characterized by six layers of neurons.
This is called neocortex. But limbic area of cortex
is phylogenetically older component of cortex which
is called allocortex. It is made up of neurons of
three layers occupying central part of cerebrum.
Transitional zone between allocortex and neocortex
is called juxta-allocortex where neuronal layer vary
from three to six.
Parahippocampal gyrus is considered to be part of
neocortex and made up of six layers of neurons. As the
cortex of hippocampus is traced, gradual transition of
six layers to three layers is observed. Three layers of
hippocampus (allocortex) are as follows.
Anterior column of
fornix
Body of fornix
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
1. Superficial molecular layer: It is made up of
scattered nerve cells and nerve fibers. The neurons
are smaller in size.
2. Intermediate pyramidal layer: It is made up of
many large sized pyramidal cells.
3. Inner polymorphic layer: It is structurally sim-
ilar to the polymorphic layer of neocortex.
Dentate gyrus is also three layered. But it differs
from structure of hippocampus by the fact that, inter- Anterior
mediate layer is made up of granule cells instead commissure
of pyramidal cells. Neurons of the granular layer of
dentate gyrus are small in size and round or oval in
shape. Their axons terminate in neurons of pyramidal Posterior
column of fornix
cell layer of hippocampus. Some of the fibers of Septal nuclei
granular layer may be directly continued as fibers of
Hippocampus
fimbria.
Subiculum is the site of transition between six Fig. 17.4B Afferent from septal nuclei
layered cortex of parahippocampal gyrus to three
layered cortex of dentate gyrus and hippocampus. 1. From cingulate gyrus: Afferent fibers from
cingulate gyrus curve round downwards and back-
Fibrous Component of Hippocampal Formation ward, and finally forward to reach hippocampus (Fig.
17.4A).
Afferent fibers from various sources reach hippo- 2. From septal nuclei: These are nuclei lying in the
campus which are discussed below. But fibers which midline close to anterior commissure. Fibers pass via
leave as axons of neurons of hippocampus curved on fornix to reach hippocampus (Fig. 17.4B).
the subependymal surface of hippocampus to form 3. Fibers from opposite hippocampus: Fibers
alveus which converge and continues backwards from one hippocampus reach another hippocampus.
as shining band known as fimbria. The fimbria These fibers pass through posterior column of fornix
is continued backward towards posterior end of backwards. Reaching the junction between posterior
thalamus as posterior column of fornix (Fig. 17.3). column and body, instead of continuing forwards
to the body, the fibers cross the midline through
Connections of Hippocampal Formation posterior column of fornix of opposite side to reach
contralateral hippocampus. These fibers are called
Afferent connections
It is the hippocampus which receive afferent conn- Hippocampus
ections from following sources.

Cingulate gyrus

Hippocampal
commissure

Hippocampus Hippocampus Posterior column of

fornix

Fig. 17.4A Afferents from cingulate gyrus Fig. 17.4C Afferents from opposite hippocampus
256

Indusium griseum
Hippocampus
Fig. 17.4D Afferents from indusium griseum
commissure of fornix or hippocampal commissure
(Fig. 17.4C).
4. Fibers from indusium griseum: These fibers
form lateral and medial longitudinal striae. Hipp-
ocampus receive these fibers as axonal process of
neurons of indusium griseum which is considered as
vestigial part of limbic cortex (Fig. 17.4D).
5. Fibers from olfactory associated cortex:
These afferent fibers are received by hippocampus
from anterior part of parahippocampal gyrus which is
also called entorhinal area (Fig. 17.4E).
6. Fibers from dentate gyrus and parahipp-
ocampal: Gyrus pass to the adjacent hippocampus
(Fig. 17.4F).
Efferent connections
Efferent connections from hippocampus are axons
of pyramidal cells lying in intermediate layer. The
Parahippocampal gyrus
Fig. 17.4F Afferents from dentate gyrus and parahippocampal gyrus
Limbic System
Olfactory bulb
Olfactory area
(entorhinal area)
Hippocampus
Fig. 17.4E Afferents from olfactory associated cortex
efferent fibers first lies in subependymal plane as
alveus. The fibers of alveus converge to form a white
band known as fimbria. Fimbria continues posteriorly
as posterior column of fornix. Posterior column from
both sides curve upwards and forwards around
posterior end of thalamus and join together to form
body of fornix. Body of fornix divides into two anterior
columns which pass downwards and forwards in
front of interventricular foramen of Monro. Next at
the level of anterior commissure it divides into two
limbs called postcommissural and precommissural
roots running posterior and anterior to anterior
commissure respectively. Fibers of these two roots
end as efferent fibers of hippocampus in following
destinations (Fig. 17.5).
1. Postcommissural roots:
a) To anterior nucleus of thalamus
Dentate gyrus
Hippocampus
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Body of fornix
Anterior nucleus of thalamus

Precommissural fibers

Posterior column
of fornix
Septal nuclei
Hypothalamic nuclei
Anterior commissure

Postcommissural fibers
Hippocampus

Nucleus of mammillary body

Tegmentum of midbrain

Fig. 17.5 Efferent fibers of hippocampus

b) To nucleus of mammillary body
c) To tegmentum of midbrain.
Efferent from mammillary body further proceeds
to anterior thalamic nuclei via mammillothalamic
tract.
2. Precommissural roots:
a) To septal nuclei
b) Lateral preoptic nucleus
c) Anterior part of hypothalamus.
Functions of Hippocampus
Hippocampus is the prime central component of lim-
bic system.
But through the outlet of hypothalamus, hippo-
campus acts as a center for integration for autonomic
(visceral), endocrine and emotional activities of an
individual.
Hippocampus plays an important role for recent
memory.
Earlier it was regarded as part of olfactory system,
but it does not possess direct relationship with this
function.
this small mass of gray matter is situated at the depth
of temporal lobe. It is connected to anterior end of tail
of caudate nucleus on anterior end of roof of inferior
horn of lateral ventricle.
Connections (Fig. 17.6)
n Afferent: Afferent connections are mostly from
primary olfactory area.
n Efferent: Efferent fibers come out of amygdaloid
body in the form of stria terminalis. Stria terminalis is
a curved band of fibers which follow the similar curve
of caudate nucleus, being adjacent to it, but follow its
tail end and pass along the direction of tail, body and
finally head. Obviously it curves round thalamus and
along the walls of lateral ventricle until it reaches
anteriorly to the level of anterior commissure. The
fibers finally reach following destinations (Fig. 17.6).
1. Septal area
2. Amygdaloid nucleus of opposite side via anterior
commissure
3. Anterior portion of hypothalamus
4. Fibers from posterior end of stria terminalis pass
to Habenular nucleus.

AMYGDALOID BODY Functions of Amygdaloid Body

It is also known as amygdaloid nuclear complex or
amygdala. It is so called because it is an almond-
shaped mass of gray matter which is situated subja-
cent to anterior part of parahippocampal gyrus. So
258
1. Amygdaloid body exerts an effect on internal
needs, drives and instincts of an individual.
2. Amygdaloid body, if active, generates anger, rage,
excitability and fear.

Septal area
Olfactory bulb
Olfactory tract
Fig. 17.6 Connections of amygdaloid body
3. Amygdaloid body possesses an inhibitory effect on
sexual activity.
CLINICAL ANATOMY
Anatomical connections of limbic system are truly
extremely complex. Their significance are also not
clearly understood as on date. So, a reader must not
go for too much taxation of brain.
Limbic system, through the outlet of hypothala-
mus, mainly acts as a center for integration of visceral
(autonomic), endocrine and emotional activities. For
example, some visceral activities appear in reference
to change in emotional status of an individual.
Limbic system controls excitability, rage, anger,
fear of an individual.
Limbic System
Anterior hypothalamic region
Some efferents go to opposite amygdaloid
nucleus through anterior commissure
Habenular nucleus
Stria terminalis
Amygdaloid body
Prepyriform area
Hippocampus functions for collection and recapit-
ulation of recent memory.
Amygdaloid body exerts inhibitory effect on sexual
activity.
n Schizophrenia: It is a psychotic condition chara-
cterized by disordered thinking, hallucinations, blu-
nted affect and withdrawal of emotional activity.
These are the manifestations because of hyperactivity
of limbic system receptors to dopamine. That is why
for management of this disease, limbic receptors are
blocked for dopamine by using some phenothiazine
group of drugs. But these pharmacological agents
may lead to extrapyramidal system disorders, for
which drugs controlling extrapyramidal disorders are
very often coprescribed.
259
 Autonomic Nervous System
A COMPONENT PARALLEL TO SOMATIC NERV-
OUS SYSTEM
Nervous system is functionally divided into following
two components
1. Somatic nervous system
2. Autonomic nervous system.
n Somatic nervous system is the part of nervous
system that controls voluntary functions of body. It
means that, functions which are controlled or governed
as per ones own desire. It may be movements of joint
or voluntary movements of any organ, like movements
of eyeball or tongue, which are results of contraction
of voluntary muscles.
n Autonomic nervous system is the component
of nervous system which controls or regulates invol-
untary functions of body, i.e. those which cannot
be governed as per ones own desire. Units of these
functions are fundamentally following two.
1. Increase rate and force of contraction of
involuntary muscles (smooth as well as car-
diac muscles): Which results in, e.g.
a) Contraction (systole) and relaxation (diastole)
of cardiac muscles resulting in increase of rate
of heartbeat.
b) Contraction of smooth muscles of viscera, blood
vesicles, skin (Arrectores pili).
2. Secretion of exocrine glands: Which may be,
larger and solitary (salivary glands, lacrimal
gland) or minute and multiple like mucous glands
of alimentary and respiratory tracts, sweat glands
of skin.
18
AUTONOMIC NERVOUS SYSTEM AND
ENDOCRINE SYSTEM JOINTLY MAINTAIN
INTERNAL ENVIRONMENT OF BODY
Both these systems jointly maintain together nor-
mal internal environment of body (homeostasis).
Autonomic nervous system regulates activities of
different organs and tissues through its action on
cardiac muscle, smooth muscles and exocrine gland.
Endocrine system through its hormones circulated
in bloodstream controls functions of different organs
and tissue of body. But the difference is with the fact
that, when autonomic nervous system exerts fine and
fast action, endocrine system produces slower and
more diffuse action.
COMPOSITION OF AUTONOMIC NERVOUS
SYSTEM (FIG. 18.1)
Same as somatic nervous system, autonomic nervous
system is made up of following components.
1. Receptors: These are baroreceptors, chemorec-
eptors, osmoreceptors present in the wall of visc-
era. Stretch and pain receptors are also present.
Pain receptors present in the wall of viscera are
stimulated in its ischemic change causing lack of
oxygen.
2. Afferent pathway: This are peripheral sensory
fibers whose cell bodies are situated outside central
nervous system forming peripheral sensory nerve
root ganglia.

Brainstem and spinal cord
2
5 4. Preganglionic (presynaptic) efferent neuron
6 6. Postganglionic (postsynaptic) efferent neuron
Fig. 18.1 Composition of autonomic nervous system
3. Interneurons or connecting neurons: These
are present inside central nervous system and
interconnect afferent autonomic neuron with effe-
rent autonomic neuron.
4. Efferent neurons: There are connector neurons
situated in brainstem and spinal cord. In the
brainstem they are present in the form of cell
group forming motor nuclei of some cranial nerves
(3rd, 7th, 9th and 10th). In the spinal cord these
are motor neurons of intermediate area of T1 to L2
and S2, S3 and S4 segments of spinal cord.
These efferent neurons are preganglionic (presy-
naptic) neurons which form synaptic connections
outside the central nervous system.
5. Autonomic ganglia: This is the special feature
of efferent pathway of autonomic nervous system,
by which it differs from somatic nervous system.
These are the synapses or relay station where
preganglionic neuron ends and postganglionic
neurons start with its cell bodies. These are called
ganglia being relay stations or synapses with
cell bodies of postsynaptic neurons which differ
from posterior root ganglia of spinal nerve and
peripheral ganglia of sensory root of cranial nerve
which are made up of cell bodies of 1st order of
sensory neuron.
Autonomic Nervous System
Central nervous system
1. ReceptorIn visceral wall
2. InputAfferent neuron
3. Connecting neuron
5. Autonomic ganglion (synapse) outside CNS
7. Effector organ
* Smooth muscle
* Cardiac muscle
* Exocrine gland.
6. Postganglionic efferent neurons: These are
situated outside central nervous system. Cell
bodies of these neurons form autonomic ganglia.
Advantage of Autonomic Ganglia (Fig. 18.2)
In case of somatic nervous system, axon of one effe-
rent neuron reaches straightway to effector organ
(skeletal muscle fiber). But in case of autonomic
nervous system, one pregangalionic neuron, reaching
the autonomic ganglia, outside central nervous
system, forms synaptic connections with multiple
postganglionic neurons for widespread action.
SUBDIVISION OF AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC AND PARASYMPATHETIC
Autonomic nervous system is divided into two
parts sympathetic and parasympathetic. It is very
fundamental matter to note at this stage that, both
the parts possess their respective centers inside
central nervous system and their peripheral outflow.
Again peripheral outflow in both the case is made up
of afferent and efferent pathways.
n Interrelationship: There are many effector
organs where one system acts, other does not. For
261
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Somatic efferent neuron

Effector organ
A (voluntary muscle)

1 3
2

Multiple postganglionic Effector organs

Preganglionic autonomic efferent neuron autonomic efferent neurons (involuntary muscle)

Fig. 18.2 Advantage of autonomic ganglia. A. One somatic neuron ends in one voluntary muscle fiber, B. Autonomic efferent neurons
1. One preganglionic neurons from synapses with, 2. Multiple postganglionic neurons to supply, 3. Many effector organs (involuntary
muscle fibers)

example, arrectores pili muscles and sweat glands
of skin are controlled by sympathetic whereas
secretomotor fibers of parasympathetic supplies
exocrine glands, e.g. salivary glands or mucous
glands. Again, there are some organs where both the
system produce physiologically antagonistic effects.
Force of contraction of heart muscles is increased by
sympathetic, diminished by parasympathetic. But
circular muscle fibers of tracheobronchial tree are
stimulated by parasympathetic causing broncho-
constriction, whereas sympathetic causes relaxation
(bronchodilatation) of tracheobronchial musculature.
However, it is the balance between the activities of
two components of autonomic nervous system which
maintain the stability of internal environment of
body, as both operate in conjunction with each other.
Sympathetic and Parasympathetic How One
Differs from the Other?
For maintenance of internal environment (home-
ostasis), though one reciprocates other, sympathetic
and parasympathetic parts of autonomic nervous
262
system differ from each other as per following
criteria
1. Structural Anatomical
2. Functional i) Physiological
ii) Pharmacological.
Structural (anatomical) differences
1. Center: Center for sympathetic system is formed
by antonomic neurons present in intermediolateral
cell column of spinal cord extending from T1 to L2
segments.
Center for parasympathetic system is located
partly in brainstem and partly in spinal cord. In
brainstem the center is present in the form of general
visceral efferent nuclei of following cranial nerves.
l 3rd EdingerWestphal nucleus in upper
half of midbrain.
l 7th Superior salivatory nucleus in lower
half of pons.
l 9th Inferior salivatory nucleus in upper
half of medulla oblongata.
l 10th Dorsal nucleus of vagus in lower half
of medulla oblongata.
 Autonomic Nervous System

1 2

Fig. 18.3A Sympathetic outflow

1. Short preganglionic neuron originating from CNS
2. Long postganglionic neuron ending in target organ autonomic ganglion is close to CNS

In spinal cord, parasympathetic center is present
in the intermediate area of 2nd, 3rd and 4th sacral
segments of spinal cord.
2. Supraspinal control: Parasympathetic and
sympathetic centers, as mentioned above, are
controlled by nuclei posterior and anterior halves
of hypothalamus respectively by hypothalamo-
spinal tract.
3. Autonomic ganglia (Figs 18.3A and B): Auto-
nomic ganglia of both the systems are situated
outside the central nervous system and formed
by synaptic connection between 1st and 2nd order
of efferent neuron along with the cell bodies of
postsynaptic neurons.
Sympathetic ganglia interconnected by vertically
oriented chain of fibers called sympathetic chain
(sympathetic trunk) are situated close to central
nervous system (spinal cord) being paravertebral in
position. The sympathetic chain is formed because
fibers from each ganglia ascend or descend for one or
two segments up and down before proceeding toward
destination. As sympathetic ganglia are close to
central neuraxis, postganglionic fibers are longer to
produce more generalized activities on effector organ.
Parasympathetic ganglia are very close to the target
organ, in the wall of viscera. So postganglionic fibers
are shorter to produce more localized action.
Physiological difference
Both sympathetic and parasympathetic systems work
in subconscious level, but they come into action in
different environment.
Sympathetic system gets activated during emer-
gency, stress or anger. This can be explained with
a classical example. A man walks around a park in
a pleasant afternoon. Suddenly, he is chased by a
rabied street dog. The man runs away very fast to
save himself from the attack of the dog when his
sympathetic system becomes more active with the
following changes in body.
1. Heartbeat increases.
2. Pulse rate becomes rapid with rise of blood
pressure.
3. Pupils get dilated.
4. Vasodilatation of skeletal muscles due to muscular
exercise.
5. Extremities become cold due to peripheral vasoc-
onstriction.
6. Sweating due to hypersecretion of sweat glands.

1 2

Fig. 18.3B Parasympathetic outflow

1. Long preganglionic neuron originating from CNS
2. Short postganglionic neuron present in wall of target organ (viscera) autonomic ganglion is close to or within the wall of viscera
263
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
7. Erection of hairs due to contraction of arrectores
pili.
8. Tightening of anal and urinary sphincters.
Parasympathetic system is concerned with conser-
vation and storage of energy. For example, in a
comfortable holiday, when there is no stress or anxiety
for classes or examinations, a student takes a full
meal and goes for sleep in bed, his parasympathetic
part of autonomic nervous system gets activated with
following changes in the body.
1. Heart rate settles down.
2. Pulse rate gets slower with blood pressure settles
down to normal level.
3. Rate of respiration becomes slower with snoring
due to constriction of muscles of respiratory tree.
4. Digestion of food gets promoted as a result of
secretion of glands causing liberation of enzymes.
5. Peristaltic movement of intestine is increased
with
6. Splanchnic vasodilatation due to redistribution
of blood from skeletal muscles and brain to gastr-
ointestinal tract.
Pharmacological difference (Fig. 18.4)
First, it is to be noted that in both sympathetic as
well as parasympathetic system, neurotransmitter
released from the preganglionic neurons at the
side of synaptic junction of autonomic ganglion is
acetylcholine. Following excitation of preganglionic
neuron, acetylcholine is liberated, which crosses
through synaptic cleft to bind with the receptor at
the postganglionic neuron. Following quick action,
acetylcholine is hydrolyzed by the enzyme acetylc-
holinesterase.
Pharmacological difference between sympathetic
and parasympathetic system are as follows in
nerve ending of postganglionic neurons. Axons of
postganglionic neurons terminate in the form of
specialized nerve ending in the optimum spaces
between the gland cells, smooth or cardiac muscle
fibers. Neurotransmitter of different kind in two
different system pass from postganglionic nerve
ending through the gap to many effector cells. In
case of parasympathetic system, neurotransmitter
is acetylcholine as in synaptic junction between pre-
and postganglionic neurons. But sympathetic postga-
nglionic neurotransmitter are of different types in
different sites as follows.
1. In most of the cases sympathetic postganglionic
neurotransmitter are norepinephrine (noradr-
enaline) which act on effector cells like smooth
muscles of heart, involuntary sphincters, wall of
blood vessels.
2. Cells of suprarenal medulla are structurally and
functionally same as postganglionic sympathetic
264
neuron. These cells liberate epinephrine (adre-
naline) which exerts action on sympathetic effector
cells through bloodstream.
3. Nerve ending of sympathetic postganglionic neu-
rons which terminate in sweat glands and blood
vessels of skeletal muscles, liberate acetylcholine.
SYMPATHETIC PART OF AUTONOMIC NERVOUS
SYSTEM
Sympathetic system is the greater components of
autonomic nervous system and is more widely distri-
buted in the body.
Fundamentally sympathetic nervous system
regulates following unitary functions
1. Smooth muscles: Which may be in wall of blood
vessels, root of hair follicles (arrectores pili) and
wall of viscera.
2. Cardiac muscles
3. Exocrine glands: Which are only sweat glands.
It is also important to note that sympathetic
system produces opposite action on same kind of
effector organs in different sites. For example, it
causes constriction of muscular wall of blood vessels of
skin and gastrointestinal tract, whereas same system
causes vasodilatation of skeletal muscles, heart and
brain. Sympathetic system produces excitatory effect
on smooth muscles of involuntary sphincters of body
and inhibitory effect in smooth muscles of intestine,
bronchial tree and wall of urinary bladder.
Actions of sympathetic component of autonomic ner-
vous system on different effector organs as follows
1. It increase force and rate of contraction of cardiac
muscles, resulting increase of heart rate, pulse
rate and blood pressure.
2. It causes vasoconstriction of skin and alimentary
tract, but vasodilatation of skeletal muscle, heart
and brain.
3. It causes erection of hair due to contraction of
arrectores pili muscles at the root of hair follicle.
4. It increases secretion of sweat gland.
5. It causes dilatation of pupil due to stimulation of
dilator pupillae.
6. It causes excitation of smooth muscles of invol-
untary sphincters of body.
7. It causes inhibitions of smooth muscles of intestinal
and bladder walls, and bronchial tree.
Efferent Component of Sympathetic System
Sympathetic part of autonomic nervous system is
made up of following efferent components
1. Spinal center: This is the collection of nerve
cells in the intermediolateral column if spinal
 Autonomic Nervous System
Parasympathetic Sympathetic

Acetylcholine Acetylcholine_ Acetylcholine

Adrenal
medulla_

Adrenaline_

Acetylcholine_

Capillary

Acetylcholine_ Noradrenaline_ Acetylcholine

Peripheral
Viscera Cardiac muscle Cardiac muscle Blood vessels
Smooth muscle Blood vessels of Smooth muscle Sweat glands
Exocrine gland skeletal muscle of sphincters Arrector muscle
Heart and brain

Fig. 18.4 Pharmacological difference between sympathetic and parasympathetic system

cord extending from T1L2 (may be L3) segments.
These cells are called connector neurons.
2. Effector neuron: These neurons are situated
outside central nervous system (spinal cord)
which receive synaptic connection from axons
of connector neuron. The synaptic connection
with cell bodies of effector neurons from knob-
like structures, paravertebral in position, called
sympathetic ganglia, situated in vertical row. The
ganglia are connected by chain of nerve fibers
called sympathetic trunk (sympathetic chain).
3. Effector organs: Effector organs which receive
axon terminal of effector neuron, are
i. Cardiac muscle fibers.
ii. Smooth muscle fiber of a) Different viscera,
b) Wall of blood vessels, and c) Root of hair
follicles Arrectores pili.
iii. Sweat glands.
4. Supraspinal center: Nuclei of posterior half
of hypothalamus which influence spinal center
through hypothalamospinal tract.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Epidermis of skin
Branch to sweat gland
Spinal nerve
Branch to
arrectores pili
Vascular
(vasoconstrictor) branch
Fig. 18.5 Lateral branches of sympathetic ganglion
Sympathetic efferent outflow
n Fundamental points:
1. Sympathetic efferent outflow going to end in
target organs anywhere in the body possess the
center which is limited in intermediolateral cell
column of spinal gray matter from T1L2 (may be
L3) segment of spinal cord.
2. All sympathetic efferent outflow finally to end in
target organs come out as branches of sympathetic
ganglia.
3. Branches of sympathetic ganglia are of two types
l Lateral branches
l Medial branches.
Lateral branches (Fig. 18.5)
Axons of sympathetic connector neurons come out
through spinal nerve. The fibers are myelinated.
Close to midline, and adjacent to vertebral column,
these fibers leave spinal nerve and join the sympa-
thetic ganglia as preganglionic fibers. As these
fibers are myelinated, they are white in color for
lipid content of myelin sheath. That is why they are
called white rami communicantis. As white rami, the
preganglionic fibers relay in sympathetic ganglia.
Postganglionic fibers, which are nonmyelinated
leave the sympathetic ganglia to rejoin spinal nerve,
are called gray rami communicantis. The gray rami
communicantis, rejoining spinal nerve are the lateral
branches of sympathetic ganglia.
266
Connector neuron of sympathetic system
Sympathetic ganglion
White rami communicantis
Gray rami communicantis arise from
postganglionic effector neurons
It is important to notice at this stage that, white
rami communicantis are myelinated, preganglionic
and topographically distal in position. Gray rami
communicantis are nonmyelinated, postganglionic
and topographically proximal in position. Pre-
and postganglionic status of white and gray rami
respectively may be remembered by a simple
formula Ganglion Gives Gray (GGG).
Lateral branches of sympathetic ganglia, through the
spinal nerve supply
l Arrectores pili muscles of skin
l Sweat glands
l Peripheral blood vessels (smooth muscles of
tunica media).
Medial branches (Fig. 18.6)
Some of the axons of connector neurons from
sympathetic center, passing through white rami
communicantis to sympathetic ganglia, do not relay.
So these fibers do not rejoin spinal nerve through
gray rami. These fibers come out as medial branches
of sympathetic ganglia, still as preganglionic fibers.
They are known as splanchnic branches. These
medial branches of sympathetic ganglia take a long
course to reach the central or proximal arteries of
trunk where they relay in second order of (excitor)
neurons. The ganglia formed here are homologous to
sympathetic ganglia and are named according to the
name of the arteries to which they are related, e.g.
celiac ganglia, aorticorenal ganglia. These ganglia,

Sympathetic trunk
Medial splanchnic branch
Sympathetic effector neurons
in ganglia (and plexus)
related to blood vessels
Fig. 18.6 Medial branches of sympathetic ganglion
along with network of nerves form autonomic plexus
from where postganglionic sympathetic nerves follow
the branch arteries to reach wall of viscera.
At this stage, it is important to note that, some of
the medial branches of sympathetic ganglia come out
as postganglionic fibers to reach the target organ.
Types of Outflow from Sympathetic Ganglia
1. Sympathetic ganglia numbered from 1st thoracic
(T1) to 2nd lumbar (L2), may be L3, are connected
to the corresponding spinal nerve with the help
of white rami (preganglionic) and gray rami
(postganglionic). It is not difficult to understand
that as white rami enter the ganglia, they are
considered as roots of sympathetic ganglia. Wher-
eas, gray rami, as come out of the ganglia are
known as branches of ganglia. As discussed earlier,
these are lateral branches of sympathetic ganglia,
which are distributed through spinal nerve to,
l Sweat glands
l Arrectores pili muscles of skin
l Smooth muscles of wall of blood vessels (Fig.
18.5).
2. It has already been clarified that, medial branches
of sympathetic ganglia are preganglionic. They
reach to the centrally situated, more proximal
arteries of body, where they form autonomic
ganglia named as per the name of the arteries.
Postganglionic fibers are distributed to,
Autonomic Nervous System
Sympathetic connector neuron
Postganglionic sympathetic
fibers accompanying blood
vessel to reach target organ
l Smooth muscles of the wall of viscera including
heart.
l Smooth muscles of wall of visceral blood vessels.
These medial branches are known as splanchnic
branches (Fig. 18.6).
3. Some of the preganglionic fibers, after reaching the
corresponding sympathetic ganglia, may not come
out either as lateral branches or medial branches.
These fibers, either ascend or descend, to reach
one or two ganglia above or below, where they
relay to pass as postganglionic branches of that
ganglia (Fig. 18.7). These fibers of sympathetic
ganglia, ascending or descending for one or two
ganglia level up or down, explain the formation of
sympathetic chain or sympathetic trunk.
n Outflow above T1 and below L2 ganglia: As the
center for sympathetic system extends from T1 to L2
segments of spinal cord, outflow from T1 to L2 ganglia
corresponds to the sympathetic connector neurons of
respective segments of spinal cord.
4. Above T1 segment, there are 8 cervical segments of
spinal cord which give out 8 pair of cervical spinal
nerve. These segments do not possess intermedio-
lateral gray column, so also sympathetic centers.
But 8 cervical sympathetic ganglia are represented
as 3, namely superior, middle and inferior, which
correspond to upper four (C1 to C4), middle two (C5,
C6) and lower two (C7, C8) ganglia respectively.
These cervical sympathetic ganglia receive prega-
nglionic fibers from intermediolateral cell group of
T1 segment. Postganglionic fibers are distributed
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Postganglionic fiber joining

spinal nerve of upper level

Preganglionic fiber ascending

for one or two segments

Preganglionic fiber descending for

one or two segments
Sympathetic trunk (chain)

Postganglionic fiber joining spinal Sympathetic ganglion

nerve of lower level

Fig. 18.7 Preganglionic sympathetic fibers from one segment may ascend or descend for one or two segments up or down to relay in
higher or lower sympathetic ganglia
Note: This explains formation of sympathetic chain or sympathetic trunk

C1
Medial (splanchnic) branches from
superior cervical ganglion
C2

C3

C4

C5

C6 Medial (splanchnic) branch from

middle cervical ganglion
C7 Medial (splanchnic) branch from
inferior cervical ganglion
C8

C1 to C8 nerves 1st thoracic segment of spinal cord

1st thoracic spinal nerve

Sympathetic connector neurons at T1
1st thoracic sympathetic ganglion segment of spinal cord which send
out preganglionic fibers for cervical
sympathetic ganglia

Fig. 18.8 Many of preganglionic fibers from T1 segment of spinal cord ascend to relay in all the three cervical sympathetic ganglia.
Postganglionic fibers leave ganglia as
l Lateral branches (gray rami) to join spinal nerves and l Medial (splanchnic) branches to viscera and their blood vessels.

Note: Cervical spinal nerves are connected to sympathetic ganglia only by gray ramia communicantis
268

as lateral and medial branches as follows (Fig.
18.8).
l Lateral branches from
1. Superior cervical ganglion: As gray rami to
upper four, i.e. C1C4 nerves.
2. Middle cervical ganglion: As gray rami to C5
and C6 nerve.
3. Inferior cervical ganglion: As gray rami to C7
and C8 nerves.
l Medial branches from all the three ganglia are
postganglionic to pass to the viscera of neck
and thorax.
5. Below L2 segment, there is no sympathetic center.
But there are still sympathetic ganglia corre-
sponding to lower lumbar (L3L5) sacral (S1S5)
and one coccygeal nerve. These ganglia receive
preganglionic fiber from connector neurons of
lower thoracic (T11 and T12) and upper lumbar
(L1 and L2) sympathetic centers of spinal cord.
Postganglionic fibers pass from each of these
ganglion to come out as following branches, (Fig.
18.9).
n Lateral branches: As gray rami to corresponding
spinal nerve.
n Medial branches: These branches are mostly
postganglionic and called splanchnic branches. They
form different autonomic plexus in lower part of
posterior abdominal wall and posterior wall of pelvis.
Branches from autonomic plexus supply smooth
muscles of viscera and wall of blood vessels.
Spinal nerve
Only gray rami
communicantis
Fig. 18.9 Branches of sympathetic trunk below L1/L2 segments of spinal cord
Autonomic Nervous System
Detailed Efferent Outflow from Sympathetic
Trunk
Distribution of branches from whole sympathetic
trunk needs to be studied in following three comp-
onents.
l Branches from thoracic sympathetic ganglia.
l Branches from cervical sympathetic ganglia.
l Branches from lumbosacral sympathetic ganglia.
Branches from Thoracic Sympathetic Ganglia
Thoracic part of sympathetic chain is continuous
above with its cervical part and below with its lumbo-
sacral part.
l The thoracic part of sympathetic chain descends
vertically one on each side of thoracic part of
vertebral column.
l At its upper end it crosses the neck of 1st rib, and
then crosses in front of head of the successive ribs.
At its lower end it crosses over anterolateral aspect
of bodies of 11th and 12th thoracic vertebrae.
l The thoracic part of the trunk contains 12 ganglia
numbered as 1st (T1)12th (T12) thoracic ganglia.
l Sometimes, they may be 11 in number, when 1st
ganglion fuses with inferior cervical ganglion to
form cervicothoracic ganglion. It is called stellate
ganglion, as its radiating branches give it a star-
shaped appearance.
Branches (Fig. 18.10)
n Lateral: Conventionally, lateral branches of all
the 12 thoracic ganglia are gray rami which join the
respective thoracic spinal nerve. These branches
T11 to L2 segments
L2 ganglion
Descending fibers of white rami
for sympathetic ganglia below
L3 L1/L2
L4
Medial splanchnic branches
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1 1

2 2

3 3

4 4

5 5

6 6

7
7

8 8

9 9

10 10

11 11

12 12

C B A A B C

Fig. 18.10 Medial splanchnic branches of thoracic sympathetic ganglia

T1T5 ganglia = Postganglionic branches for cardiac, pulmonary, esophageal and aortic plexuses
T5 T12 ganglia = Preganglionic fibers forming thoracic splanchnic nerves
A. Greater splanchnic, B. Lesser splanchnic, C. Least splanchnic nerves

are distributed segmentally through corresponding
spinal nerve to sweat glands and arrectores pili
muscles of skin and, to peripheral blood vessels for
vasoconstriction effect.
n Medial: It is already understood that medial
branches are splanchnic branches. It is important to
note at this stage that, medial splanchnic branches
of 12 pair of thoracic ganglia have the duty to supply
branches not only to thoracic viscera, but also to
upper abdominal viscera.
That is why medial branches of thoracic sym-
pathetic ganglia are classified into following two
groups.
1. Medial branches from T1T5 ganglia to thoracic
viscera.
2. Medial branches from T5T12 ganglia to upper
abdominal viscera.
270
Medial branches from T1T5 ganglia
It is important to note at this stage that, these are
postganglionic fibers. So these are axons of excitor
neurons situated in these sympathetic ganglia which
from synaptic connection with processes of connector
neurons.
Before reaching the target organs these
branches of sympathetic ganglia form plexuses with
parasympathetic fibers of vagus (10th cranial) nerve
close to the viscera. The plexuses are following
1. Cardiac plexus: It is divided into superficial
and deep cardiac plexuses. Sympathetic fibers for
cardiac plexus are not only derived from medial
branches of T1T5 ganglia, but also from medial
branches of 3 cervical sympathetic ganglia. Fibers
for cardiac plexus is also derived from vagus nerve.
Thoracic sympathetic fibers join deep cardiac
plexus.

2. Pulmonary plexus: Sympathetic fibers for
pulmonary plexus are derived from T2T5 ganglia.
The plexus formed with parasympathetic fibers
from vagus nerve is related to root of lung. For the
whole tracheobronchial tree with parenchyma of
lung sympathetic fibers cause bronchodilatation,
vasoconstriction and decreased secretion of mu-
cous glands. Parasympathetic fibers cause bro-
nchoconstriction, vasodilatation and increased
secretion of mucous glands.
3. Esophageal plexus: Sympathetic fibers arising
from T1T4 ganglia possess minor role in formation
of esophageal plexus. These fibers are vasomotor
in nature. Parasympathetic fibers from vagus
are motor, secretomotor and sensory in function.
Thoracic sympathetic fibers supply lower half of
esophagus.
4. Aortic plexus: It is formed by medial branches
of T1T5 sympathetic ganglia. Nerve fibers from
the plexus run along the wall of arteries which are
vasodilator in nature.
Medial branches from T5T12 ganglia (Fig. 18.10)
Following three fundamental points are to be noted in
connection with these branches.
1. These are preganglionic fibers coming out from
medial side of sympathetic ganglia. They relay in
ganglia which are in relation to the arteries close
to midline of body.
2. These branches leave posterior thoracic wall
to reach posterior abdominal wall from where
postganglionic fibers are distributed to the upper
abdominal viscera and the blood vessels along
which they are carried to viscera.
3. Nerves formed by medial branches from T5T12
ganglia are following
l Greater splanchnic nerve: T5 T9 ganglia
l Lesser splanchnic nerve: T10 and T11 ganglia
l Least (Lowest) splanchnic nerve: T12 ganglia
These three nerves are commonly termed as
thoracic splanchnic nerve.
Greater splanchnic nerve (Fig. 18.11):
n Formation: It is formed by union of medial
branches of T5T9 sympathetic ganglia.
n Entry into abdomen: By piercing crus of
diaphragm of respective side.
n Distribution: Preganglionic fibers carried thro-
ugh greater splanchnic nerve terminate in following
three ways.
1. Celiac ganglia: It is bilateral and placed on either
side of celiac trunk. Celiac ganglia receive fibers
of greater splanchnic nerve. Postganglionic fibers
from the ganglia are distributed to the viscera
along the direction of blood vessels arising from
celiac trunk.
Autonomic Nervous System
Celiac ganglia of both sides are connected by net-
work of nerve fibers which form celiac plexus.
2. Aorticorenal ganglia: It is also bilaterally sym-
metrical, situated near origin of renal artery.
Postganglionic fibers run along branches of renal
artery.
Network of nerves around these ganglia forms
aorticorenal plexus.
3. Some fibers of greater splanchnic nerve pass
along the direction of suprarenal arteries to reach
cells of suprarenal medulla with which they
form synaptic connection. This is because, cells of
suprarenal medulla are considered as modified
form of postganglionic sympathetic neurons.
Lesser splanchnic nerve:
n Formation: It is formed by union of medial
branches of T10 and T11 ganglia.
n Entry to abdomen: From posterior thoracic wall,
like greater splanchnic nerve, it enters posterior
abdominal wall by piercing crus of diaphragm of resp-
ective side.
n Distribution: Preganglionic fibers coming from
connector neurons of sympathetic center of T10 and
T11 segments of spinal cord, come out from medial
side of two corresponding ganglia. These fibers relay
in celiac ganglia. Postganglionic fibers from celiac
ganglia are carried to the target organs along the
course of branches of celiac trunk.
Least (Lowest) splanchnic nerve:
n Formation: It is formed by preganglionic medial
branches of T12 ganglia. Sometimes, it may be absent.
n Entry to abdomen: From posterior thoracic
wall, it enters posterior abdominal wall passing deep
to medial arcuate ligament along with sympathetic
trunk.
n Distribution: Preganglionic fibers of least
splanchnic nerve relay in aorticorenal ganglia.
Postganglionic fibers arising from the ganglia follow
the course of branches of renal artery to produce
vasomotor effect.
Cervical Part of Sympathetic Trunk
Cervical part of sympathetic trunks are situated on
either side of cervical part of vertebral column, behind
the carolid sheath and in front of prevertebral layer
of cervical fascia. The trunk presents three cervical
ganglia Superior, middle and inferior. At the upper
end of trunk, superior ganglion is situated close to
base of skull. Middle and inferior ganglia, close to
each other, are situated at the lower end of cervical
part of chain, near root of neck.
Connection of three cervical ganglia with eighth
cervical spinal nerves through gray rami (lateral
branch of ganglia) are as follows
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T5 T5

T6 T6

T7
T7

T8 T8

T9
T9
Celiac trunk

1 1
Celiac plexus
3
Left suprarenal gland

Right suprarenal
gland 3

2
2

Renal artery

Fig. 18.11 Distributions of greater splanchnic nerve preganglionic fibers arise from T5T9 ganglia postganglionic neurons with their
synaptic connections are found in 1. Celiac ganglion 2. Aorticorenal ganglion and 3. Suprarenal medulla

l Superior cervical ganglia: Homologous to upper
four ganglia is connected to C1C4 nerves.
l Middle cervical ganglia: Homologous to next two
ganglia is connected to C5 and C6 nerves.
l Inferior cervical ganglia: Homologous to last two
ganglia is connected to C7 and C8 nerves.
At the upper end, superior cervical ganglia is tied
by its branches which radiate in different direction.
It is large and elongated ganglion, may be as long as
2.5 cm in size.
Inferior cervical part of sympathetic trunk is
continuous with thoracic part in front of neck of 1st
rib.
Branches from cervical sympathetic ganglia
(Fig. 18.12)
Cervical sympathetic ganglia receive preganglionic
fibers from T1T4 segments of spinal cord. The
fibers, while ascending from upper thoracic ganglia
272
upwards, relay one after another to the three cervical
sympathetic ganglia, form each of the three ganglia,
postganglionic fibers emerge in following two forms
1. Lateral: These are nothing but gray rami
communicantis which join cervical spinal nerves.
2. Medial: Like lateral branches, medial branches
of cervical sympathetic ganglia are also postga-
nglionic which are of following two kinds
a) Vascular: Run along the walls of different
arteries of head and neck.
b) Splanchnic: To supply some viscera.
Superior cervical ganglion
n Lateral branches: These are four gray rami
communicantes to join C1C4 nerves.
n Medial Branches:
1. Internal carotid nerve: It is a very prominent
branch which arises from the upper end of fusiform
 Autonomic Nervous System
Short ciliary nerve

Branch to sweat gland

of face

Deep petrosal
Nerve of nerve Facial artery
pterygoid canal
Internal carotid nerve

Superior cervical
ganglion Pharyngeal branch

Cardiac branch

Thyroid, tracheal and

esophageal branches

Lateral branches (gray

rami)

Middle cervical ganglion

Vertebral nerve
Cardiac branches

Vertebral artery

Ansa subclavia
T1 T4 segments of
spinal cord

T1 ganglion

Fig. 18.12 Branches of cervical part of sympathetic trunk

superior cervical ganglion. It catches internal
carotid artery at the base of skull and possesses
widespread distribution along its different bra-
nches. Network of nerves along the wall of artery
form internal carotid plexus. Some of the important
distribution of this plexus are following
a) Nerves running along ophthalmic branches of
the artery supply dilator pupillae muscle.
b) Deep petrosal nerve: Arising from internal
carotid plexus, this nerve, joining with greater
petrosal nerve (parasympathetic fibers from
facial nerve) forms nerve of pterygoid canal,
which joins sphenopalatine ganglion.
c) Sympathetic fibers to communicate with
ciliary ganglion: These fibers run initially
along ophthalmic branch of internal carotid
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
artery, then join with long ciliary nerve to
communicate with ciliary ganglion.
2. Branches along external carotid artery:
These fibers from superior cervical ganglion run
along external carotid artery and its branches
which are mainly vasomotor. Important branches
from external carotid plexus are following.
a) Sympathetic branches along facial artery
supply vasoconstrictor fibers and also fibers to
the sweat glands of one half of face.
b) Sympathetic fibers communicating otic and
submandibular ganglion.
3. Pharyngeal branch: It forms pharyngeal plexus
along with pharyngeal branches of glossophar-
yngeal and vagus nerve.
4. Cardiac branch: Cardiac branch from left sup-
erior cervical ganglion form superficial cardiac
plexus whereas right joins deep cardiac plexus.
Middle cervical ganglion
n Lateral branches: These are two rami comm-
unicantes to join C5 and C6 nerves.
n Medial Branches:
1. Tracheal and esophageal branches: These
branches accompany the arteries supplying the
organ and are vasomotor in nature.
2. Thyroid branch: This branch runs along inferior
thyroid artery.
3. Cardiac branch: Cardiac branch of both middle
cervical ganglia takes part in formation of deep
cardiac plexus.
Inferior cervical ganglion
n Lateral branches: Two lateral branches from
inferior cervical ganglion are gray rami comm-
unicantes to join C7 and C8 nerves.
n Medial branches:
1. Ansa subclavia: This branch from inferior cervical
ganglion forms a loop around subclavian artery to
join middle cervical ganglion. Branches from the
ansa form plexus around subclavian artery.
2. Vertebral nerve: It is so called because it forms
plexus around vertebral artery. Along with 2nd
part of the artery nerve ascends through foramen
transversarium of upper six (C1C6) cervical
vertebrae.
3. Cardiac branch: Cardiac branch from inferior
ganglion of both sides join deep cardiac plexus.
PARASYMPATHETIC PART OF AUTONOMIC NERV-
OUS SYSTEM
General Considerations
1. Parasympathetic system is the smaller component
of autonomic nervous system in comparison to its
sympathetic counterpart.
274
2. This system gets activated for conservation or
restoration of energy, thereby keeps the body in
restful condition.
3. Like sympathetic system, it is also made up of
afferent as well as efferent components.
4. Afferent component of parasympathetic system
carries mainly the physiological sensations from
the receptors present in the wall of viscera. For
example, sense of awareness of distension of urinary
bladder is carried through parasympathetic affe-
rent pathway, whereas pathological pain from
wall of urinary bladder is carried by sympathetic
afferent pathway.
5. Efferent pathway (parasympathetic outflow) of
parasympathetic nervous system is composed of
following components.
i. Centers: cranial (in brainstem) and spinal (in
spinal cord).
Cranial centers: These are nothing but general
visceral efferent nuclei of four cranial nerves
present in brainstem, 3rd (oculomotor), 7th
(facial), 9th (glossopharyngeal) and 10th
(vagus) nerves.
Spinal centers: These are neuronal group pre-
sent in intermediomedial area of spinal cord
gray matter of S2, S3 and S4 segments.
Neurons of centers of parasympathetic system,
like those of sympathetic are preganglionic
neurons or connector neurons.
ii. Preganglionic fibers: These are longer in com-
parison to those of sympathetic and pass in the
form of visceral efferent fibers of 3rd, 7th, 9th
and 10th cranial nerves, and pelvic splanchnic
nerves formed by union of visceral efferent
fibers carried through S2, S3 and S4 spinal
nerve.
iii. Autonomic ganglia: They are close to the target
organ (viscera), so postganglionic fibers are
very short.
6. Gross manifestations of parasympathetic activity
i. Eyeball: Constriction of pupil due to contrac-
tion of sphincter pupillae.
l Increase in curvature of lens helping
accommodation due to contraction of ciliary
muscle.
ii. Cardiovascular channel:
l Slowering of heart rate (bradycardia) with
diminished force of contraction.
iii. Respiratory tract:
l Constriction of smooth muscles of trach-
eobronchial tree and secretion of mucous
glands.
iv. Gastrointestinal tract:
l Increase of peristalsis and secretion of
mucous glands.

v. Urinary tract:
l Contraction of detrusor muscle. substantia nigra and crus cerebri.
Parasympathetic efferent pathways originate fun-
damentally from the following sites
1. Cranial: From 4 parasympathetic cranial nerve
nuclei which are
a) EdingerWestphal nucleus of oculomotor
nerve (III): Present in midbrain at the level of
superior colliculus.
b) Superior salivatory nucleus of facial nerve
(VII): Present in lower half of pons.
c) Inferior salivatory nucleus of glossopharyngeal
nerve (IX): Present in upper part of medulla
oblongata.
d) Dorsal nucleus of vagus nerve (X): Present in
lower part of medulla oblongata.
2. Spinal: It is the intermediate area of gray matter
of S2, S3 and S4 segments of spinal cord which is
considered to be spinal center for parasympathetic
system.
Efferent outflow from Edinger-Westphal nucleus
(Fig. 18.13)
Edinger-Westphal nucleus is the parasympathetic
efferent nucleus of oculomotor nerve. It is situated
closely apposed and ventrolateral to main (somatic
motor) nucleus of the nerve in the periaqueductal gray
matter of midbrain at the level of superior colliculus.
Axons of the cells of this nucleus, traverse the
tegmentum of midbrain from behind forwards along
Autonomic Nervous System
with somatic motor fibers to pass through red nucleus,
Emerging out of midbrain through lateral wall of
sulcus in between two halves of cerebral peduncle,
the fibers follow the course of main trunk of nerve, its
inferior division and finally branch to inferior oblique.
Finally from branch to inferior oblique it leaves to relay
in a tiny ganglion. It is called ciliary ganglion which
is situated near the apex of orbit in the space between
optic nerve and lateral rectus muscle. Postganglionic
parasympathetic fibers emerge from ciliary ganglion
in the form of 810 short branches which are called
short ciliary nerves which finally divide into 1520
divisions which pierce sclera around optic nerve and
pass over the surface of choroid to supply sphincter
pupillae and ciliary muscles.
Communications of ciliary ganglion (Fig. 18.14)
Communications are the nerve fibers which join the
ciliary ganglion from its posterior side which are
known as roots of the ganglion as follows.
1. Parasympathetic root: As mentioned above,
this is made up of preganglionic parasympathetic
fibers which emerge from Edinger-Westphal nuc-
leus and pass through oculomotor nerve to relay in
ciliary ganglion (Fig. 18.14A).
2. Sympathetic root: Fibers of this root originate
as postganglionic fibers from superior cervical
ganglion and enter cranial cavity through internal
carotid plexus. Sympathetic fibers for the orbit

Somatic efferent nucleus

Oculomotor nerve nuclei

{ Edinger-Westphal nucleus

Oculomotor nerve
Preganglionic parasympathetic fiber (visceral
Ciliary ganglion efferent fiber)
Somatic efferent fiber
LPS

Short ciliary nerves SR

Sphincter IO
pupillae
IR MR
Ciliary muscle

Fig. 18.13 Parasympathetic efferent pathway from Edinger-Westphal nucleus of oculomotor nerve
275
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Short ciliary nerve to sphincter pupillae

Short ciliary nerve to ciliary muscle

Ciliary ganglion

A Parasympathetic root of ciliary ganglion

Short ciliary nerve to dilator pupillae

Short ciliary nerves to blood vessels

of eyeball and orbit

Ciliary ganglion
Ophthalmic artery
Sympathetic root
Internal carotid artery

Internal carotid nerve

Superior cervical ganglion

Short ciliary nerve to cornea

Short ciliary nerve to sclera,

cornea and uveal tract

Ciliary ganglion
Nasociliary nerve
Sensory root
C

Fig. 18.14 Communication roots of ciliary ganglion. A. Parasympathetic root, B. Sympathetic root, C. Sensory root

travel via ophthalmic artery. From this fibers, a
root joins the ciliary ganglion. As this sympathetic
root of fibers is already postganglionic sympathetic
fibers, it traverses ciliary ganglion uninterrupted,
finally to pass through short ciliary nerve to
276
supply dilator pupillae and wall of blood vessels
(Fig. 18.14B).
3. Sensory root: This is the branch from nasociliary
nerve which joins posterior end of ciliary ganglion.
While traversing the ganglion without relay it

divides into multiple branches which pass through
short ciliary nerves for sensory innervations of
eyeball (Fig. 18.14C).
Branches of ciliary ganglion
These are nothing but bunch of short ciliary nerves
which contain parasympathetic, sympathetic and
sensory fibers for following distribution.
1. Parasympathetic: To sphincteral pupillae and
ciliary muscle.
2. Sympathetic: To dilator pupillae and blood ves-
sels of eyeball.
Branch of facial nerve
carrying preganglionic Ganglion where preganglionic Target organs
parasympathetic fibers fibers relay
Autonomic Nervous System
3. Sensory: To sclera, cornea and uveal tract.
Efferent outflow from superior salivatory nucleus
Superior salivatory nucleus is the parasympathetic or
general visceral efferent nucleus of facial (VII) nerve
which is situated in lower half of pons. Preganglionic
efferent outflow from the nucleus comes out in the
form of two branches of facial nerve which relay
respectively in two different ganglia from where
postganglionic fibers are distributed to two different
groups of target organs which are summarized as
follows.

1. Mucous glands of pharynx, nasal

Greater
superficial petrosal Sphenopalatine ganglion cavity and palate
nerve
2. Lacrimal glands

Submandibular and sublingual

Chorda tympani nerve Submandibular ganglion
salivary glands

However, it is important to note that, through n Parasympathetic distribution through gre-

both of the above two different distributions, target ater superficial petrosal nerve (Fig. 18.15):
organs supplied are all exocrine glands. Greater superficial petrosal branch of facial nerve
Lacrimal gland Facial colliculus

Nucleus of abducent
Lacrimal nerve carrying postganglionic nerve
secretomotor fibers

Motor root of facial

nerve

Zygomatic nerve
Section of pons
Maxillary nerve
Superior salivatory nucleus of
Sphenopalatine ganglion facial nerve

Nasal branch

Greater superficial petrosal nerve

Deep petrosal nerve

Palatal branches
Superior cervical ganglion
Pharyngeal branch

Nerve of pterygoid canal

Fig. 18.15 Parasympathetic efferent pathway from superior salivatory nucleus of facial nerve (via sphenopalatine ganglion)
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
carrying preganglionic parasympathetic fibers arises
from geniculate ganglion. It joins with deep petrosal
nerve to form nerve of pterygoid canal. Deep petrosal
nerve carries sympathetic fibers from superior
cervical ganglion along internal carotid artery.
Parasympathetic fibers along greater superficial
petrosal nerve relay via nerve of pterygoid canal in
sphenopalatine ganglion. Postganglionic fibers from
the ganglion pass through following branches to
supply target organs which are different exocrine
glands.
1. Pharyngeal branches: To the mucous glands of
pharynx.
2. Palatine branches: To mucous glands of palate.
3. Nasal branch: To mucous glands of nasal cavity.
4. Branch for lacrimal gland: It passes to the
gland via following route.
Sphenopalatine ganglion anterior root of comm-
unication to maxillary nervemaxillary nerve Zygo-
matic branch Zygomaticotemporal branchcomm-
unication to lacrimal nerve lacrimal nerve to
lacrimal gland.
n Parasympathetic distribution through
chorda tympani nerve (Fig. 18.16): Chorda tym-
pani branch of facial nerve carrying preganglionic
parasympathetic fibers arises 6 mm above stylom-
astoid foramen. Coming out of tympanic cavity
and finally outside cranium, it joins lingual nerve
in infratemporal fossa. Carried through lingual
nerve fibers relay in the submandibular ganglion
Motor root of facial nerve
Geniculate ganglion
Lingual nerve
Sublingual
gland
Postganglionic secretomotor
fibers supplying sublingual gland
Submandibular duct
Fig. 18.16 Parasympathetic efferent pathway from superior salivatory nucleus of facial nerve (via submandibular ganglion)
278
placed on hyoglossus muscle in submandibular
region. Postganglionic parasympathetic fibers are
secretomotor in nature to supply submandibular and
sublingual salivary glands.
Efferent outflow from inferior salivatory nucleus
(Fig. 18.17)
Inferior salivatory nucleus is the parasympathetic or
general visceral efferent nucleus of glossopharyngeal
nerve which is situated in upper part of medulla
oblongata. Preganglionic efferent outflow from the
nucleus comes out from the glossopharyngeal nerve
as its tympanic branch at base of skull. From the
tympanic branch parasympathetic fibers reach par-
otid gland through following route.
Inferior salivatory nucleus glossopharyngeal
nerve tympanic branch tympanic plexus in middle
ear cavity lesser superficial petrosal nerve otic
ganglion trunk of mandibular nerve its posterior
division auriculotemporal nerve auricular branch
to parotid gland.
Efferent outflow from dorsal nucleus of vagus
(Fig. 18.18)
Dorsal nucleus of vagus is a composite nucleus,
being mixed in nature with a motor and a sensory
component. Sensory part of the nucleus receives
inputs from different viscera (of thorax and
abdomen) which receive efferent fibers from its motor
component. Dorsal nucleus of vagus is situated in
Abducent nerve nucleus
Facial colliculus
Section of pons
Superior salivatory nucleus
Facial nerve
Chorda tympani nerve
joining lingual nerve
Submandibular ganglion
Submandibular gland
 Autonomic Nervous System

Inferior salivatory nucleus

Section of medulla oblongata

Tympanic plexus

Tympanic branch of
glossopharyngeal nerve Jugular foramen
Glossopharyngeal nerve
Lesser superficial petrosal Superior ganglion
nerve
Inferior ganglion
Foramen ovale transmitting Postganglionic parasympathetic
two roots of mandibular secretomotor fibers to parotid gland
nerve
Otic ganglion

Anterior division
and
Posterior division of
mandibular nerve Auriculotemporal nerve

Fig. 18.17 Parasympathetic efferent pathway from inferior salivatory nucleus of glossopharyngeal nerve

Dorsal nucleus of
vagus nerve

Vagus nerve

Cardiac branches for

cardiac plexus

Pulmonary branches for ant

and postpulmonary plexuses

Esophageal branches

Gastric nerves

Branches for biliary tree

Enteric branches for small intestine

Large intestinal branches upto right

two- thirds of transverse colon

Fig. 18.18 Distribution of parasympathetic fiber through vagus nerve in abdomen

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
medulla oblongata beneath the ependyma of floor of
4th ventricle opposite the vagal triangle.
As the vagus nerve is characterized by its long
course like a vagabond, parasympathetic efferent
distribution through this nerve is widespread to many
organs in neck, thorax and abdomen.
Before the distribution of parasympathetic fibers
of vagus is further studied, following fundamental
points are to be noted.
1. Preganglionic fibers carried through vagus nerve
are very long.
2. These fibers may straightway pass upto wall or
surface of the viscera.
3. In some cases these fibers form a plexus along
with sympathetic fibers, in relation to the arteries
supplying the organ.
4. However, long preganglionic fibers of both the
above mentioned varieties, relay in small localized
parasympathetic ganglia on the surface or wall of
the viscera.
5. Small postganglionic fibers are short for localized
and discrete actions to the target organs of follow-
ing kinds.
i. Smooth muscles, action on which may be exci-
tatory, e.g. bronchial musculature, smooth
muscles of wall of gut, or inhibitory, e.g.
cardiac muscle.
ii. Exocrine gland These are to increase secr-
etion of mucous glands of tracheobronchial
tree foregut and midgut.
iii. Visceral blood vessels Vasoconstrictor fibers
for coronary arteries but vasodilator fibers for
viscera.
n Parasympathetic distribution through vagus
nerve (Fig. 18.18):
1. Cardiac branches: Parasympathetic fibers to
heart, like sympathetic, are for myocardium,
conducting system and coronary vessels. Cardiac
branches are cervical (superior and inferior) and
thoracic. These branches form cardiac plexuses
(smaller superficial and larger deep) along with
sympathetic (T2 T5). Cardiac plexuses are situated
in relation to pulmonary trunk and bifurcation of
trachea. Postganglionic parasympathetic fibers
from cardiac plexus, on activation, result
i. Cardioinhibition: Reduction of rate and force
of contraction of cardiac muscle.
ii. Constriction of coronary arteries.
Activation of sympathetic fibers of cardiac plexus
cause cardioacceleration and coronary vasodilatation.
2. Pulmonary branches: Parasympathetic fibers
to the lungs (bronchial tree), like sympathetic,
are for bronchial musculature, mucous glands
and blood vessels. Pulmonary branches of vagus,
280
unlike cardiac branches are only thoracic in origin.
These branches, along with sympathetic fibers
(T2 T5), form anterior and posterior pulmonary
plexuses which are situated in front and behind
root of lung respectively.
Postganglionic parasympathetic fibers from pulm-
onary plexus on activation, result in
i. Bronchoconstriction: Constriction smooth mus-
cles of tracheobronchial tree.
ii. Enhanced mucus secretion: Secretion of mucous
glands of respiratory tree is increased.
iii. Slight vasodilatation.
Stimulation of sympathetic fibers of pulmonary
plexus causes bronchodilatation and diminished glan-
dular secretion.
3. Esophageal branches: Parasympathetic fibers
for esophagus are derived from both vagi which
form esophageal plexus with sympathetic fibers
from T1 T4 segments. Parasympathetic fibers are
visceromotor for musculature and secretomotor
for mucous glands. Sensory fibers from esophagus
are also carried by vagus. Sympathetic fibers of
esophageal plexus are vasomotor in nature.
4. Gastrointestinal branches: In embryonic life,
initially whole gastrointestinal tract used to be
placed along midline and embryological surfaces
of the gut used to be right and left which remain
demarcated by ventral and dorsal border. Upto
right two-thirds of transverse colon, where ends
the midgut, parasympathetic nerve fibers are
derived from both vagi.
n Gastric branches: Left and right vagal fibers
form anterior and posterior gastric nerves respectively
to be in relation to anterior and posterior surfaces of
stomach.
n Enteric branches: Beyond supply of stomach,
fibers of both the vagus nerve are continued along
the blood vessels to supply the small gut, midgut
portion of large gut and also associated organs. Along
with the sympathetic fibers from splanchnic nerves
they form plexuses, e.g. celiac plexus and superior
mesenteric plexus. Parasympathetic fibers which are
still preganglionic, proceed beyond these plexuses to
relay in short postganglionic neurons in two different
planes of wall of the gut to form following two plexuses
(Fig. 18.19).
i. Auerbach (Myenteric) plexus: This is placed in
the plane between longitudinal and circular
muscle coats of intestine. Postganglionic neur-
ons from this plexus (relay station) supply
motor branches to the musculature of the gut.
Stimulation of this parasympathetic pathway
increases peristaltic movement of gut with
inhibition of sphincters.

Auerbach (myenteric) plexus
Preganglionic fibers of vagus
nerve
Meissner (submucous)
plexus
Fig. 18.19 Parasympathetic plexuses in the wall of intestine
Sympathetic fibers for the gut upto right two-
thirds of transverse colon pass via celiac and
superior mesenteric plexuses carrying fibers
from greater and lesser splanchnic nerve. Stim-
ulation of these nerve fibers causes sphincteric
contraction and splanchnic vasoconstriction.
ii. Meissner (submucousal) plexus: These plexuses
are the sites of relay station with short postga-
nglionic parasympathetic neurons beneath the
mucous membrane in the submucous layer of
intestine. From these plexuses postganglionic
secretomotor fibers supply intestinal mucous
glands.
n Enteric nervous system: The above mentioned
two plexuses extend continuously along the length
of almost whole gastrointestinal tract starting from
esophagus to anal canal. Out of the two, activity of
Auerbach or myenteric plexus leads to coordinated
purposeful contraction of smooth muscles of gut
resulting its peristalsis and segmental movements.
At the site of reflex, sympathetic postganglionic
neurons are found to terminate on postganglionic
parasympathetic neurons. These exert an inhibitory
effect on parasympathetic activity. Parasympathetic
sensory neurons are also found to relay in myenteric
plexus to form a local reflex arc. As it has been
found that the gut-wall plexus through formation of
local reflex arc may act for segmental movement of
intestine, even when isolated from central nervous
system and it extends throughout the entire gut-wall.
It is referred as Enteric nervous system.
5. Branches to gallbladder and biliary tree:
Parasympathetic fibers for gallbladder and biliary
tree are derived via hepatic plexus from celiac
Autonomic Nervous System
Mucous glands
Submucous coat
Circular muscle
Longitudinal muscle
plexus. But the fibers are from vagus nerve. These
motor fibers of vagus arc for contraction of smooth
muscles of gallbladder and bile duct. But it is
inhibitory to ampullary sphincter of Oddi.
Efferent outflow from spinal parasympathetic center
Spinal parasympathetic center is made up of general
visceral efferent neuronal group present in the
intermediate (intermediomedial) area of gray matter
of S2, S3 and S4 segments of spinal cord.
Principles of distribution
n Exit from spinal center: Parasympathetic pre
ganglionic efferent fibers come out of spinal cord
via ventral (motor) root of S2, S3 and S4 nerves, and
finally through ventral rami of the same nerves. But
ultimately parasympathetic fibers, leaving these
spinal nerves join together to form pelvic splanchnic
nerve (Fig. 18.20).
n Target organs:
1. As the name suggests, pelvic splanchnic nerve
supplies all pelvic viscera in both male and female.
2. In addition, it provides both motor as well as
secretomotor fibers for the wall of hindgut.
n Routes of distribution: Primarily, preganglionic
parasympathetic efferent fibers carried via pelvic
splanchnic nerve, along with sympathetic contr-
ibution, form a plexus in the pelvic cavity which
called pelvic plexus or inferior hypogastric plexus.
The plexus is situated in extraperitoneal fat, lateral
to rectum and posterolateral to urinary bladder as
well as reproductive organs of pelvis. From inferior
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Inferior mesenteric plexus
S2
Pelvic splanchnic
nerve
{ S3
S4
Urinary bladder
Fig. 18.20 Distribution of parasympathetic fibers from pelvic splanchnic nerve
hypogastric plexus fibers are distributed along two
directions as follows.
1. For the pelvic viscera, fibers pass either directly
or in reverse direction of the course of branches of
internal iliac artery.
2. Branches run upwards to join superior hypogastric
plexus which is situated below bifurcation of
abdominal aorta and between two common iliac
arteries. Finally the fibers ascend further to
inferior mesenteric plexus. Through this plexus
parasympathetic fibers are distributed along the
reverse direction of branches of inferior mesenteric
artery to the wall of hindgut starting from left one-
third of transverse colon.
Like foregut and midgut, as supplied by vagus,
in the wall of hindgut, preganglionic relay with
postganglionic neurons, parasympathetic distribution
forms myenteric (Auerbach) and submucousal (Mei-
ssner) plexuses.
Purpose of distribution
1. Hindgut (upto rectum):
a) Visceromotor fibers: For coordinated peristaltic
movement via myenteric plexus.
b) Secretomotor fibers: For secretion of mucous
glands via submucous plexus.
2. Urinary bladder: Contraction of detrusor mus-
cles and relaxation of involuntary sphincters.
282
Left one-third of
transverse colon
Superior hypogastric
plexus
S2
S3
S4 } Pelvic splanchnic
nerve
Inferior hypogastric plexus
3. Uterus: Parasympathetic fibers of pelvic splan-
chnic nerve antagonises contractile effect of symp-
athetic fibers on uterine musculature.
4. Erectile tissue of genital organs: Parasym-
pathetic fibers of pelvic splanchnic nerve increases
vascular congestion through vasodilatation of ere-
ctile tissue.
CLINICAL ANATOMY OF AUTONOMIC NERVOUS
SYSTEM
It is already understood that autonomic nervous
system is not isolated, rather it is a part of nervous
system. That is why, in some clinical conditions affec-
ting nervous system in general, autonomic nervous
system is also affected. Again, there are some situations
where autonomic nervous system (sympathetic or
parasympathetic or both) is selectively lesioned.
Following are the two fundamental causes of
lesion of autonomic nervous system,
1. Injury
2. Diseases.
INJURIES TO AUTONOMIC NERVOUS SYSTEM
Parasympathetic
It may be cranial or spinal. Causes of damage to the
cranial component of parasympathetic system is

head injury. Head injury may cause impairment of
function of following components of parasympathetic
system.
l Oculomotor nerve: It is affected when head
injury is associated with herniation of uncus
of temporal lobe. Visceral efferent fibers
of the nerve supply sphincter pupillae and
ciliary muscles. So damage of the nerve cau-
ses loss of light reflex with dilation of pupil
due to nonfunctioning of sphincter pupillae.
Accommodation reflex is also affected due to
nonfunctioning of ciliary muscle along with
medial rectus and sphincter pupillae.
l Facial nerve containing visceral efferent fibers
with other functional components may be
affected in fracture of base of skull affecting
internal auditory meatus of petrous part of
temporal bone. Lesion of preganglionic secreto-
motor fibers to the lacrimal gland causes
impaired lacrimation. Salivary secretion is
not fully impaired, as parotid gland remains
functioning, because it is supplied by visceral
efferent fibers through glossopharyngeal nerve.
Spinal injury affecting the parasympathetic sys-
tem along with sympathetic system leads to disorders
of bladder, bowel and sexual function.
Sympathetic
It is the sympathetic trunk which in injured opposite
the level of cervicothoracic (stellate) ganglion at the
root of neck. This injury may occur due to stab or
gunshot wound. It may also occur due to traction by
cervical rib. Beside injury, metastatic lesion at the
root of neck may affect stellate ganglion. Clinical
condition arising from this lesion is known as Horner
syndrome which is described below.
DISEASES INVOLVING AUTONOMIC NERVOUS SYSTEM
Sympathetic System
1. Horner syndrome: Clinical manifestations of
this syndrome occur due to interruption of symp-
athetic nerve supply to the head and neck. Center
(connector neurons) for the sympathetic outflow
to head and neck lies in lateral horn cells of first
thoracic segment of spinal gray matter. Proximally
it gets supraspinal control through reticulospinal
tract descending from brainstem reticular form-
ation. Preganglionic sympathetic fibers for head
and neck arising from 1st thoracic segment ascend
through cervical part of sympathetic chain. After
relay in cervical sympathetic ganglia, postgan-
glionic fibers are distributed to head and neck
through following branches
Autonomic Nervous System
i. Lateral branches: Gray rami to join cervical
spinal nerve to arterial wall and sweat gland.
ii. Medial splanchnic branches.
iii. Internal carotid branch: It runs along internal
carotid artery to enter inside the cranium.
Apart from vascular branches, fibers along
ophthalmic artery, entering the orbit supply
dilator pupillae and part of levator palpebrae
superioris.
A patient may suffer from Horner syndrome due to
lesion of anyone of following three level of sympathetic
pathway for head and neck.
}
1. First neuron lesion Affecting
reticulospinal tract. Due to degeneration
diseases like
2. Second neuron lesion Affecting * Multiple sclerosis
1st thoracic segment of spinal * Syringomyelia
gray matter.
}
3. Third neuron lesion Affecting Due to
cervicothoracic ganglion (stellate * Penetrating injury at
ganglion). root of neck
* Traction by cervical rib
* Metastatic lesion at root
of neck
1. Horner syndrome: Important clinical man-
ifestations:
i. Miosis: Constriction of pupil due to unopposed
action of sphincter pupillae for nonfunctioning
dilator pupillae.
ii. Ptosis: Partial dropping of upper eyelid due to
paralysis of levator palpebrae superioris.
iii. Anhidrosis: Dryness of one half of the face with
head and neck due to impaired secretion of
sweat gland.
iv. Flushing or blanching of same half of face due
to loss of vasoconstrictor effect on skin.
2. Raynaud disease: It is a vasospastic disease due
to hyperactivity of vasoconstrictor sympathetic
fibers affecting digital arteries of fingers. It is a
bilateral disorder which is precipitated by exposure
to cold and smoking. In case of smokers nicotine
aggravates vasospasm. Clinical manifestations are
pain, pallor and cyanosis due to impaired vascular
supply. Fingertips show black discoloration with
formation of dry gangrene.
3. Buerger disease: It is arterial occlusive disease
of lower limb. Ischemia of muscles of leg causes
pain due to muscular cramps intermittently. That
is why the disorder is named as intermittent clau-
dication.
Parasympathetic System
Argyll Robertson pupil
It is a disorder in a patient of neurosyphilis due to
lesion of pretectal nucleus of midbrain which is one of
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
the cell stations in light reflex pathway. The disease
is characterized by narrow pupil with no reaction to
light due to interruption of light reflex pathway which
is as follows.
Retina optic nerve optic chiasma optic
tract lateral geniculate body superior brachium
pretectal nucleus Edinger Westphal nucleus
oculomotor nerve ciliary ganglionshort ciliary
nerve sphincter pupillae.
In case of Argyll Robertson pupil, accommodation
reflex is not disrupted as it is not passing through
pretectal nucleus and its pathway is as follows.
Retinaoptic nerveoptic chiasmaoptic tract
lateral geniculate bodyoptic radiationprimary visual
cortex (Area 17) superior longitudinal fasciculus
Frontal eye fieldcorticonuclear tractoculomotor
nucleus (somatic efferent as well as visceral efferent)
oculomotor nerve to supply medial rectus, sphincter
pupillae and ciliaris for accommodation.
A simple formula mentioned below may be helpful
to remember manifestation of ArgyllRobertson
pupil.
{
ARP (Accommodation Reflex
Present)
ARP (ArgyllRobertson Pupil)
PRA (Pupillary Reflex Absent)
Adie tonic pupil
This is a syndrome characterized by following clinical
presentations.
1. Diminished or absent light reflex due to disorder
of function sphincter pupillae.
2. Slow or delayed dilatation of pupil in the dark.
3. Slow or delayed accommodation to near vision
because of suppressed function of ciliary muscle
which is concerned for increase of curvature of lens.
All the above features are supposed to be due to
suppression of parasympathetic ocular function.
Frey syndrome
It is a clinical condition that is found to occur following
healing of a penetrating wound of face over parotid
gland. During healing process, injured nerves of this
area of face communicate with one another, as done by
auriculotemporal nerve supplying parasympathetic
postganglionic secretomotor fibers to parotid gland
with great auricular nerve supplying sweat glands of
this area of face. So stimulation of salivary secretion
during mastication of food causes sweating of area of
face supplied by great auricular nerve.
Hirschsprung disease
This disease is also called megacolon. It is a congenital
disease characterized by failure of development
Auerbach (myenteric) plexus with absence of
284
postganglionic parasympathetic neurons in the wall
of distal part of colon. So this part of colon does not
show peristaltic activity, for which part of the colon
proximal to it presents huge dilatation with stagnant
faecal matter.
COMBINED SYMPATHETIC AND PARASYMPA-
THETIC LESION CAUSING URINARY BLADDER
DYSFUNCTION IN SPINAL CORD INJURY
Detrusor muscle of urinary bladder is supplied by
parasympathetic fibers from S2, S3 and S4 segments
through pelvic splanchnic nerve which is called nerve
of evacuation. Sympathetic fibers for urinary bladder
arising from L1 and L2 segments of spinal cord is
called nerve of filling which supplies sphincter vesicae
or internal urethral sphincter.
Sensory impulse from the urinary bladder is
carried through both parasympathetic as well as
sympathetic pathways. When urinary bladder is
distended, stretch receptors in the wall of bladder are
stimulated and impulse for sense of fullness of bladder
is carried through sensory fibers of pelvic splanchnic
nerve to the spinal cord. Dorsal column (fasciculus
gracilis) is the tract for awareness of distension of
bladder. But pain sensation, e.g. in case of carcinoma
or calculus, traveling through sympathetic fibers
ascend through lateral spinothalamic tract which
carries somatic pain sensation. That is why patient
with symptom of intractable pain due to carcinoma
of urinary bladder is managed by lateral cordotomy
without any disturbance to awareness for fullness of
bladder which passes through dorsal column.
DISRUPTED MOTOR FUNCTIONS OF BLADDER
Atonic Bladder
It is the dysfunction of urinary bladder during the
initial phase of spinal shock following spinal injury.
Spinal shock phase lasts from a few days to a few
weeks. If the level of spinal injury is above S2, S3,
S4 segmental level of spinal cord, during the period
of spinal shock, the bladder losses its normal tonic
affect due to temporary withdrawal of all cord
function. In normal condition, an individual can
temporarily suspend the act of micturition by
voluntary contraction of external urethral sphincter
with maintenance of detrusor muscle tone even
with awareness of fullness of bladder. In case of
spinal shock, awareness for fullness is lost with
loss of voluntary contraction of external sphincter
which becomes relaxed and atonia of detrusor which
becomes relaxed, but internal sphincter is tightly

closed. So atonic bladder with overdistension, tightly
closed internal sphincter and relaxed external
sphincter causes overflow of urine.
When period of spinal shock is over, dysfunction of
urinary bladder may be one of the following two types
depending upon the level of lesion.
Automatic Bladder
This type of bladder disfunction is observed if the
lesion is above the level of S2, S3 and S4 segments of
spinal cord. These sacral segment are called spinal
micturition center which possesses excitatory effect
on detrusor muscle and inhibitory effect on sphincter
vesicae (internal urethral sphincter). Paracentral
lobule is called cortical micturition center which
possesses inhibitory control on sphincter urethrae
(external urethral sphincter). If the spinal cord lesion
is above S2, S3 and S4 segments, it means that con-
trol of cortical micturition center by descending tract
is lost and spinal center (S2, S3 and S4) remains
functioning. So following changes are observed.
1. External urethral sphincter is relaxed.
2. When the bladder is distended, impulse from
stretch receptor is carried to S2, S3 and S4
segments by afferent fibers of pelvic splanchnic
nerves. Stimulation of motor neuronal roots of
same segments through interneurons completes
the activity of local segmental reflex arc to lead to
contraction of detrusor with relaxation of internal
sphincter which results emptying of bladder.
So through activity of local reflex pathway, bladder
once distended, becomes empty automatically. That is
why it is called automatic bladder.
Autonomous Bladder
This type of dysfunction of urinary bladder occurs
when spinal injury causes lesion in sacral segments
(namely S2, S3 and S4) of spinal cord. In this case
bladder is deprived of both supraspinal voluntary
control as well as local reflex control. Voluntary
control is lost because influence of descending tract
is cut off. Again local reflex pathway circuit is cut
off due to lesion of local sacral center. Urinary
bladder is, therefore, released from its nervous
control and enjoys its autonomy for which it is called
autonomous bladder. The bladder wall becomes
flaccid and urine is getting accumulated more and
more with overdistension of the organ. As the sphin-
cters are ineffective, overdistension of bladder is
characterized by continuous dribbling.
Autonomic Nervous System
VISCERAL PAIN
Before this topic is discussed, following general points
are to be taken into consideration in connection with
afferent autonomic pathway.
Different kinds of sensations carried from the
viscera are sense of compression, distension (stretch)
and pain.
Pain sensation carried from the viscera is due
to lack of oxygen as a result of ischemia, or due to
accumulation of metabolites.
Different kinds of sensations are carried from
viscera through afferent fibers of both sympathetic
as well as parasympathetic components of autonomic
nervous system.
Afferent fibers of sympathetic system are
carried from the viscera which travel through the
sympathetic ganglion to join the spinal nerve via gray
rami communicantes.
Cell bodies of first order of neuron of both
sympathetic as well as parasympathetic system are
also situated in posterior root ganglia like somatic
sensory pathway.
Impulse, entering the spinal cord, stimulates
afferent tract neurons in the base (lamina VII) of
posterior horn of T1 L2 and S2, S3 and S4 segments
of spinal cord. These neurons are visceral afferent
cell group. Visceral afferent tract fibers ascend as
axons of the cells. But these fiber tracts ascend in
common, intermingling with somatic afferent tracts
for example lateral and anterior spinothalamic tracts.
Before passing through the ascending tracts,
pain sensation is mostly carried through peripheral
sympathetic pathway. But in case of viscera like
urinary bladder, pain sensation are of two different
kinds, physiological and pathological. Physiological
pain, due to stimulation of stretch receptors in
detrusor muscle wall of bladder is carried through
parasympathetic afferent fibers entering S2, S3 and
S4 segments of spinal cord. Then, it ascends through
dorsal column. Impulse reaching the sensory cortex
through this pathway leads to awareness for fullness
of bladder. Pathological pain due to irritation of
bladder wall nerve endings by vesical calculus
or due to carcinoma of urinary bladder is carried
through T11L2 sympathetic ganglia to corresponding
segments of spinal cord via lateral spinothalamic
tract. Advantage of this dual sensory pathway is
utilized by neurosurgeons by performing selective
lateral cordotomy for relief of intractable bladder pain
in a patient of bladder carcinoma, in which case sense
of fullness of bladder passing through dorsal column
is not disturbed.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Explanation of Referred Visceral Pain
Visceral pain is diffuse and poorly localized. But
somatic pain is comparatively more intense and
localized more accurately. But in general, when
pain fibers (sympathetic as well as parasympathetic)
from viscera are stimulated, instead of being felt
at the site of viscera, it is felt over the belt of skin
(dermatome) supplied by somatic nerve of same
segment of spinal cord supplying viscera. It is called
referred pain. Explanation of referred pain is not
absolutely clear. But it is based on the following two
theories.
1. Pain fibers from viscera and corresponding derm-
atome ascend through same ascending tract in
central nervous system. Sensory area of cerebral
cortex is unable to locate exactly site of origin of
pain, viscera or dermatome. As already mentioned
that pain from dermatome is more sharply and
accurately felt than viscera, sensory cortex locates
that pain is arising from the dermatome.
2. In normal condition, nociceptors of dermatome are
constantly charged by noxious stimuli, which is
not so in case of viscera. So when pain fibers from
viscera are stimulated, sensory cortex interprets
that impulse is coming from the respective derm-
atome.
Important Visceral Pain
n Cardiac pain: Nature of cardiac pain varies from
mild discomfort in the chest to severe crushing pain.
Sympathetic pain fibers are stimulated in the
myocardium due to ischemia which results in oxygen
deficiency and accumulation of metabolites in the
myocardial wall. Impulse is carried via cardiac
branches of sympathetic trunk to the lateral horn
cells of upper four thoracic segments (T1T4) of spinal
cord.
It is very important to note at this stage that cardiac
pain is not felt in heart. Pain is felt over the skin area
supplied by T1T4 nerves, which is corresponding
dermatome areas of chest wall. Intercostobrachial
nerve is the lateral cutaneous branches of T2 nerve
which supplies the area of skin of medial side of arm.
That is why cardiac pain felt also along medial side of
arm of left side which is the dominant side in respect
of inclination of cardiac position to the left.
Ischemia (infarction) of inferior wall (diaphra-
gmatic surface) of heart leads to epigastric pain.It
is because of irritation of diaphragmatic surface of
fibrous pericardium supplied by T7, T8 and T9 nerves
which also supply skin area of epigastrium.
286
n Gallbladder pain: Diseases of gallbladder those
commonly give rise to pain are inflammation (chol-
ecystitis) and calculus (cholelithiasis).
Sympathetic pain fibers travel through celiac
plexus and then along greater splanchnic nerve (T5
T9). So pain is felt over T5T9 dermatome which is the
area over lower chest wall and upper abdomen.
When inflammation spreads over parietal perit-
oneum over peripheral part of diaphragm of right side,
pain is felt over right upper quadrant of abdominal
wall and area over inferior angle of scapula of right
side.
n Pain over tip of right shoulder: Spread of inf-
lammation from gallbladder finally to the parietal
peritoneum over central part of diaphragm irritates
phrenic nerve (C3, C4 and C5). That is why referred
pain is felt over tip of right shoulder which is supplied
by supraclavicular nerve having root value of C3 and
C4 .
STOMACH PAIN
Most commonly, referred pain from stomach is felt
in epigatrium. Sympathetic pain fibers from stomach
travel through celiac ganglion and finally along
greater splanchnic nerve (T5T9). So severe gastric
pain is felt over lower chest and upper abdominal wall
which is supplied by T5T9 spinal nerves.
APPENDICULAR PAIN
In case of appendicitis, pain is felt due to distension of
wall and spasm of muscle fibers of the wall following
inflammation. Sympathetic pain fibers travel through
superior mesenteric plexus and finally along lesser
splanchnic nerve (T10 segment only). So referred pain
is felt in the region of umbilicus which area is supplied
by Xth intercostal nerve.
With the advancement of inflammatory process,
parietal peritoneum opposite right iliac fossa over the
appendix is involved. This area of parietal peritoneum
is supplied by right T12 and L1 nerve. Because of
inflammation of parietal peritoneum, severe localized
somatic pain is felt over right iliac fossa from where
impulse is carried by T12 and L1 somatic nerves.
RENAL PAIN
If the pain is of renal origin, due to infection, calculus
or any other pathology, it is felt over loin. Sympathetic
fiber carrying pain sensation from kidney passing
through aorticorenal ganglion and finally via least
(lowest) splanchnic nerve (T12) enter T12 segment of
spinal cord. That is why pain is felt in loin over the
skin belt supplied by subcostal nerve (T12).

URETERIC PAIN
A calculus in the lumen of ureter is characterized by
severe agonizing pain. By mistake, it is commonly
termed as renal colic. Pain is felt due to distension
or spasm of muscular wall of ureter. Pain fibers from
ureter traverse via T11 L2 sympathetic ganglia
to the corresponding spinal cord segments. Due
to impaction of stone, obstruction in the ureter is
gradually forced down as a result of muscular spasm.
That is why pain is felt radiating from loin to groin,
the area which is supplied by T11 L2 nerves. As
Autonomic Nervous System
the ureter receives its sympathetic innervation from
T11L2 segments, manifestations of ureteric colic
will be following:
1. Severe agonizing pain radiating from loin to groin.
2. Pain in scrotum or labium majus.
3. Pain over uppermost part of front of thigh which is
supplied by femoral branch of genitofemoral nerve
(L1 and L2).
4. Retraction of testis due to reflex spasm of crem-
aster muscle which is supplied by genital branch
of genitofemoral nerve (L1 and L2).
287
 Cranial Nerves
n Fundamental points:
l As 31 pairs of spinal nerves are peripheral outflow
from spinal cord, 12 pairs of cranial nerves are
peripheral outflow from brain.
l Unlike spinal nerve, cranial nerves are not seg-
mental in origin.
l All spinal nerves are mixed in nature composed
of both motor and sensory roots. But in case of
cranial nerve, some are mixed, again some are
either purely motor or purely sensory.
l Spinal nerves have separate site of attachment
of motor and sensory roots. But in case of mixed
cranial nerves motor and sensory fibers may come
out of brain commonly, e.g. glossopharyngeal (9th)
and vagus (Xth) nerves. In some cases, motor and
sensory roots come out separately, but close to
each other, e.g. trigeminal (Vth) and facial (VIIth)
nerves.
l Like spinal nerves, mixed cranial nerves are:
1. Trigeminal (Vth cranial) nerve
2. Facial (VIIth cranial) nerve
3. Glossopharyngeal (IXth cranial) nerve
4. Vagus (Xth cranial) nerve.
n Motor cranial nerves are:
1. Oculomotor (IIIrd cranial) nerve
2. Trochlear (IVth cranial) nerve
3. Abducent (VIth cranial) nerve
4. Accessory (XIth cranial) nerve
5. Hypoglossal (XIIth cranial) nerve.
n Sensory nerves are:
1. Olfactory (Ist cranial) nerve
2. Optic (IInd cranial) nerve
3. Vestibulocochlear (VIIIth cranial) nerve.
19
l Out of 12 pairs of cranial nerves, Ist cranial
(olfactory) nerve and IInd cranial (optic) nerve
differs from IIIrd to XIIth cranial nerves as follows.
Olfactory nerve carrying impulse for olfaction
(smell) and optic nerve carrying impulse for vision
(sight) protrude from basal aspect of forebrain
(cerebrum). So their centers are situated in forebrain.
Other cranial nerves (IIIrdXIIth) come out of the
surface of brainstem. Their centers are situated inside
the three components (midbrain, pons and medulla)
of brainstem in the form of cranial nerve nuclei.
OLFACTORY NERVE AND OLFACTORY PATHWAY
Fundamental Points
1. Olfactory nerve, the Ist cranial nerve, is a special
somatic afferent nerve carrying sense of olfaction
or smell.
2. Olfactory nerve forms the part of olfactory pathway
which starts from olfactory receptor cell, through
chain of two orders of neurons to the olfactory
cortex.
3. Function of olfactory pathway is more sharp in
some animals like dogs which are considered
as Macrosmatic. In contrast human being are
considered as Microsmatic.
4. Olfactory receptor cells located in nasal mucosa are
the nerve cells which act as end organs stimulated
by air molecules carrying odors. These neurons are
the only examples which are exposed to the body
surface (nasal mucous membrane) (Fig. 19.1).

Frontal air sinus
Superior nasal concha
Lateral wall of nose
Fig. 19.1 Olfactory epithelium area which lodges bipolar olfactory neurons acting as olfactory end organ (receptors), from where
originate bunch of olfactory nerves
5. Olfactory receptor neurons undergo a degenerative
process through continuous cycle, and these are
replaced or renewed by fresh cells developed by
basal cells of nasal mucous membrane.
6. Leaving the olfactory receptor neurons, olfactory
pathway is made up of only two orders of neurons
before it reaches the olfactory cortex.
7. Olfactory pathway is the only sensory pathway
which does not pass through any component of
nucleus of thalamus.
Components of Olfactory Pathway
1. Olfactory receptors (neuroreceptors) present in
specialized area of nasal mucosa and olfactory
nerves.
2. Two orders of neurons.
3. Olfactory area of cerebral cortex present in
temporal lobe.
Olfactory receptors and olfactory nerve (Fig. 19.2)
End organs or receptors for olfactory pathway are
specialized neurons present in specialized area of
mucous membrane of nasal cavity called olfactory
epithelium.
Olfactory epithelium
This epithelium lines uppermost part mucous mem-
brane of nasal cavity which is
i. Uppermost part of lateral wall of nose along
with sphenoethmoidal recess above the level of
superior nasal concha.
ii. Uppermost part of nasal septum (medial wall
of nose), which is formed by perpendicular
plate of ethmoid bone.
Cranial Nerves
Olfactory bulb
Olfactory tract
Sphenoidal air sinus
Olfactory nerves
Olfactory area of nasal
cavity
Soft palate
iii. Roof of the nose between above mentioned
lateral and medial walls.
l Cells of olfactory epithelium (Fig. 19.2):
1. Receptor cells: Which are specialized bipolar neu-
rons.
2. Supporting cells: These are tall columnar inter-
stitial cells which intervenes between receptor
cells having supportive function.
3. Basal cells: These are shorter cells resting on
basement membrane intermingled with other
cells. Basal cells are progenitor cells concerned
with replacement (renewal) of receptor cells.
Olfactory receptor cells are specialized bipolar
neurons scattered among supporting cells. Perip-
heral processes of these bipolar cells are wider and
extend to the surface of nasal mucous membrane.
Form the end of peripheral process, a number
of short cilia arise which project into the mucus
covering olfactory mucous membrane. These are
called olfactory hairs. These projecting olfactory
hairs react to odors of inhaled air and stimulates
olfactory receptor cells.
Central processes of olfactory receptors are
finer which form olfactory nerve fibers. These finer
fibers aggregate to form 20 bunches. These are
nonmyelinated. These 20 bunches of finer nonm-
yelinated fibers form olfactory nerves. It is clear
therefore, unlike other cranial nerve, in each side,
olfactory nerve is multiple in number.
First order of neurons (Fig. 19.2)
Bunch of olfactory nerve, the central processes of
olfactory receptor cells, pass upwards from roof nose
through foramina in cribriform plate of ethmoid bone
to reach anterior cranial fossa. Reaching anterior
cranial fossa, olfactory nerves terminate in first
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Olfactory bulb
Cribriform plate
of ethmoid bone
Fig. 19.2 Bipolar olfactory receptor cells present in olfactory epithelium of nasal mucosa form contact with first order of neurons of
olfactory pathway in olfactory bulb
order of neurons of olfactory pathway which are
present inside an ovoid flattened structure lodged on
orbital surface of frontal lobe of cerebrum. It is called
olfactory bulb. Neurons present inside olfactory bulb
are of following types.
l Mitral cells
l Tufted cells
l Granule (Stellate) cells.
Mitral cells are largest cells in olfactory bulb.
Incoming fibers of olfactory nerve form synaptic
connections with mitral cells. These synaptic junc-
tions also receive connection from tufted cells and
granule cells. Junctional areas of these cells with
olfactory nerve ending are known as glomeruli.
Axons of these cells, within olfactory bulb, which are
1st order of neurons, pass backward to be continued
as olfactory tract.
n Olfactory tract: It is a narrow and flat band of
white matter extending from olfactory bulb to run
backwards along olfactory sulcus on orbital surface
of frontal lobe of cerebrum. Olfactory tract passes
backward upto anterior perforated substance of base
of the brain where it divides in an angular fashion
into lateral and medial olfactory striae. Anterior
perforated substance is embrassed anterolaterally
and anteromedially by lateral and medial olfactory
striae. The two straie form olfactory trigone (Fig.
19.3).
Medial olfactory stria carries axons from cells of
olfactory bulb which cross the midline as a component
of anterior commissure to pass to olfactory bulb of
290
Granula cell
Tufted cell
Olfactory tract
Mitral cell
Basal cells
Olfactory
Supporting cells epithelium
Olfactory cells
Mucus in contact with
olfactory hairs
opposite side. Lateral olfactory stria carries axons of
1st order of neurons present in olfactory bulb to the
primary olfactory area beyond anterior perforated
substance.
Intermediate olfactory stria is a short band of
fibers, being occasionally present, passes from the
angle of olfactory trigone to a small elevation on
anterior perforated substance which is called olfactory
tubercle (Fig. 19.3).
Second order of neurons (Fig. 19.3)
Lateral olfactory stria, as continuation of olfactory
tract relays in second order of neurons which are
present in periamygdaloid and prepyriform areas
of temporal lobe of cerebrum. These areas, placed
beyond anterior perforated substance and close to
amygdaloid body are known as primary olfactory
cortex.
Primary olfactory cortex sends nerve fibers to other
centers of brain. These connections are concerned
with integration of olfactory function with emotional
and autonomic activities.
Olfactory cortex
It is called entorhinal area (area 28). This area is made
up of uncus and anterior part of parahippocampal
gyrus. It receives fibers from second order of neurons
situated in primary olfactory areas. That is why is
called secondary olfactory cortex.

Olfactory bulb
Olfactory tract
Medial olfactory stria
Anterior perforated substance
Secondary olfactory cortex
Fig. 19.3 Parts of olfactory pathway related to inferior surface of brain
CLINICAL ANATOMY
Loss of sense of smell is known as anosmia. It may be
due to variable causes of peripheral to central origin.
Pathology of the disorder may be in different level of
olfactory pathway starting from olfactory epithelium
of nasal mucosa. Cause may be minor as nasal obstr-
uction following attack of common cold. Again, it
may be due to meningioma of anterior cranial fossa
pressing olfactory bulb and tract or it may be effect of
lesion of olfactory cortex.
Sense of smell is tested clinically separately for
both the nostril.
Sense of smell and sense of taste are clinically
interrelated. Smelling of aroma of delicious food helps
in appreciation of taste.
OPTIC NERVE AND VISUAL PATHWAY
Optic nerve is the second cranial nerve. It is special
sensory nerve. It forms a part of visual pathway.
Visual pathway is the special somatic afferent
pathway concerned with reception and transmission
of visual impulse and perception of vision or sight.
Like other sensory pathway visual pathway is also
composed of receptor, orders of neurons and sensory
cortex.
n Extent of pathway: From retina of eyeball to
sensory cortex in occipital lobe of cerebrum.
Cranial Nerves
Lateral olfactory stria
Olfactory tubercle
Neurons of primary olfactory cortex
Components of Visual Pathway
1. Retina Rods and cones cells Receptor
Bipolar cell First order of
neurons multipolar ganglionic
cells Sencond order of neurons
}
2. Optic nerve
3. Optic chiasma Axons of ganglionic cells
4. Optic tract (second order of neurons)
5. Lateral geniculate Third order of neurons
body (metathalamus) (in thalamic level)
6. Optic radiations - Axons of neurons of lateral
(Geniculocalcarine tract) geniculate body
7. Visual center of Area 17 of Broadmann in
cerebral cortex medial surface of occipital
lobe of cerebrum
Receptors layer of rods and cones (Fig. 19.4)
These cells are arranged in a single row of retina. Both
the type of cells are elongated having a peripheral
part and a central part. Structurally outer part of two
types of cells differs. Outer part is cylindrical in rod
cells and conical in cone cells. These outer components
of the cells contain pigments. Both these type of cells
are called photoreceptors, as they are stimulated by
light. It is the pigment component of the cells that
converts light energy into nerve impulse (action
potential).
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Pigmented epithelium

Rod cell

Cone cell

Bipolar neuron

Multipolar ganglionic neuron

Axons of ganglionic neurons

forming optic nerve

Fig. 19.4 Receptors (rods and cones) and first two orders of neurons of visual pathway present in retina

Comparison of rods and cones

Rod cells Cone cells

Pigment content Rhodopsin Iodopsin

Disposition Most abundant in peripheral Thickly populated in central

part of retina, absent in central part of retina
part of retina only cell in macula lutea
(central part of retina)

Stimulating factor Stimulated by light of lower Stimulated by light of higher

intensity (dim light) intensity (bright light)

Function Twilight vision Sharp vision or acuity of vision

(concerned for) (scotopic vision) and color vision (photopic vision)

Number in one retina 100 millions or more 7 millions

First and second order of neurons (Fig. 19.4)
(placed in retina)
First order of neurons are bipolar cells, so its cell
body is fusiform in appearance. Its peripheral process
makes contact with inner or central end of rods and
cones in an end to end fashion. So ratio of receptor
cells and bipolar cells is almost 1:1. Central process
(axons) of bipolar cells form synaptic connection
with dendrites of second order of neurons called
ganglionic cells.
Second order of neurons are called ganglionic cells
which are multipolar with multiple dendrites. These
cells are larger in size with bigger nuclei, as compared
292
to bipolar cells. Secondary multiple dendrites of one
ganglionic cells form synaptic junction with axons of
more than one bipolar cells. So number of ganglionic
cells are far less than bipolar cells. It is histologically
evident by larged size and lesser number of nuclei of
ganglionic cells in comparison to small sized, more
number of nuclei of bipolar cells.
n Some important points on retina (in conn-
ection with visual pathway):
1. Outermost layer of retina is a layer of pigmented
epithelium. Melanin pigment of this epithelial
layer absorbs light and thereby prevent reflection
of light from outer coats of eyeball.

2. Next to pigmented epithelium, from outside inw-
ards, cellular layer are rods and cones, bipolar
cells and ganglionic cells.
3. Layer of pigmented epithelium (choroid side) is
separated from layer of rods and cones (inner or
vitreous side) by a loose membrane called Bruchs
membrane.
4. Posterior pole retina (center of posterior equator)
contains only cone cells with a yellowish color,
called macula lutea which is the area of retina
concerned for sharpest vision. Center of macula
presents a small depression (pit) called fovea cen-
tralis.
5. Axons of ganglion cells are long and convergent
which form optic nerve. These fibers are innermost
layer of retina, separated from vitreous body by
hyaloid membrane.
6. Fibers of optic nerve converge and pierce through
the retina, choroid and sclera at a point which is a
small circular area called optic disk. It is 34 mm
medial (nasal) to posterior pole (macula lutea) of
retina. As optic disk contains of nerve fibers, but
no photoreceptor cells, it is called blind spot.
n Axons of second order of neurons: These fibers
come out of eyeball as optic nerve which is continued
further backwards as optic chiasma and optic tract.
n Relations between retina and field of vision:
Retina of each eyeball is divided into inner (nasal)
and outer (temporal) half. Field of vision of each eye is
also similarly subdivided. Now, it is important to note
that temporal half of retina receives visual impulse
from nasal half of visual field and vice versa. Again
each half of retina is divided into upper and lower
quadrants which receive visual impulse from opposite
quadrants of field of vision.
OPTIC NERVE
It is already understood that optic nerve is made up of
axons of ganglionic cells (2nd order of neurons) placed
in retina. The fibers of optic nerve converge on optic
disk of retina. Optic nerve comes out of eyeball finally
piercing sclera 34 mm medial to posterior pole.
Optic nerve fibers are myelinated. But the fibers,
though belong to a peripheral nerve, are myelinated
by oligodendrocytes (not Schwann cell). For this
reason, optic nerve is compared to fiber-tract of
central nervous system.
Optic nerve leaves orbital cavity to enter cranial
cavity through optic canal. It runs backwards and
medially to unite with the nerve of other side to form
optic chiasma.
Cranial Nerves
OPTIC CHIASMA
Optic chiasma is attached to the base of the brain
forming anterior most component of interpeduncular
fossa. At its anterolateral angle joins the optic nerve
in both sides. Posterolateral angle continues as optic
tract. It means that fibers of optic nerve continues
backwards as optic tract through optic chiasma. But
the optic chiasma is formed because of decussation of
half of the fibers of optic nerve of both side.
Decussation of Fibers
Fibers of optic nerve continued from medial (nasal)
half of retina, which receive visual impulse (light
energy) from lateral (temporal) field of vision decu-
ssate in the optic chiasma to be carried through optic
tract of other side. Obviously, the fibers from lateral
(temporal) half retina concerned with medial (nasal)
half of field of vision, run along the optic tract of same
side.
OPTIC TRACT
First it is to be followed that optic tract is made up of
fibers which are continuation of optic nerve and these
are still nothing but axons of ganglionic cells (second
order neuron) placed in retina. Next, it is to be very
clear that optic tract of any side carries fibers from
lateral (temporal) half of same retina and medial
(nasal) half of opposite retina concerned with opposite
field of vision. From this, it is the time to understand
that right optic tract carries fibers from temporal
(right) half of right retina and nasal (also right) half
of opposite retina. Similarly left optic tract carries
fibers from temporal (left) half of left retina and nasal
(also left) half of opposite retina.
n Quadrantic representation of retina: Each
half of retina, right or left, is divided into upper and
lower quadrants. Each quadrant of retina is related
to opposite quadrant of field of vision. It means upper
quadrant of one-half retina receives visual impulse
from lower quadrant of opposite half of field of vision
and vice versa.
Course and Termination of Optic Tract
Optic tract, starting from posterolateral angle of
optic chiasma, runs posterolaterally around cerebral
peduncle to relay in neurons of lateral geniculate
body, a component of metathalamus projecting from
posterior end of thalamus.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
LATERAL GENICULATE BODY (THIRD OF NEURONS)
It is a component of metathalamus, other one being
medial geniculate body. Lateral geniculate body is a
small oval projection from posterior pole (pulvinar)
of thalamus. It is made up of six concentric layers of
neurons where relay fibers of optic tract which are
terminal part of axons of second order of neurons, the
multipolar ganglion cells placed in retina.
Axons of lateral geniculate body, the third order of
neurons, have following destinations.
1. Continuation of visual pathway: These fibers
pass backward as component of retrolenticular
part of internal capsule to end in visual cortex (area
17). This area is on upper as well as lower lips of
calcarine sulcus on medial surface of occipital lobe
of cerebral hemisphere. This bundle of fibers are
known as optic radiation or geniculocalcarine tract.
2. As superior brachium to midbrain: Superior
brachium is band of fibers which extend from
lateral geniculate body to superior colliculus of
midbrain. Fibers of this band relay in following
two groups of cells in midbrain for two different
purposes.
a) To tectum (at the level of superior colliculus):
These fibers form the afferent component of
spinovisual reflex pathway or visual body
reflex pathway.
b) To pretectal nucleus: These fibers form afferent
component of pupillary light reflex pathway.
Cells of lateral geniculate body is subdivided into
lateral and medial halves which possess somatotopic
relationship with other components of visual pathway.
n Somatotopic relationship of visual pathway:
l Upper quadrant of field of vision
x 1. Receptors: Rods and cones of retina.
Lower quadrant Lateral half Lower lip
of retina (L) of lateral of visual
geniculate body cortex (L)
So, (L)
l Lower quadrant of field of vision
Upper quadrant Medial half Upper lip
of retina (U) of lateral of visual
geniculate body cortex (U)
MACULAR VISION
Visual impulse from central field of vision project
on macula lutea (yellow spot) which is the small
central area of retina, on the posterior pole. This area
contains only cone cells of photoreceptors. That is why
the macular area is concerned with sharpest vision
294
and color vision. Optic nerve fibers from macular
area of retina, through relay in lateral geniculate
body, end in posterior end of both the lips of calcaline
sulcus continued on superolateral surface of occipital
lobe of cerebral hemisphere. Visual cortex (area 17)
on medial surface of occipital lobe is supplied by
branches of posterior cerebral artery, but macular
visual area on superolateral surface is supplied by
branches of middle cerebral artery.
Visual Association Area
Both the upper and lower lips of visual cortex (area
17) are superimposed by visual association cortex
area, area 18 and area 19, one over other. This area is
concerned with recognition of an object and perception
of its color.
Visual Reflexes
These are some reflex path, afferent components of
which are formed by visual pathway.
Direct and consensual light reflexes
When light is projected on one eye (retina), normally,
pupil of both eyes, which is a small circular aperture
in iris, constricts.
Constriction of pupil of the eye, on which light
is projected, is the effect of direct light reflex.
Constriction of the pupil of the eye, on which light
is not projected, even if it is passively closed, is the
effect of consensual light reflex, when light projects
on another eye.
Components of light reflex pathway (Fig. 19.5)
2. Afferent pathway: The fibers formed by chain of
bipolar cells, ganglionic cells and their axons as
optic nerve, optic chiasma and optic tract. Some
fibers from optic tract, passing through superior
brachium to pretectal nucleus of midbrain. Axons
from prectectal nucleus, which is close to and at
the level of superior colliculus, relay in Edinger-
Westphal nucleus of oculomotor nerve of same
side as well as opposite side.
3. Center: It is Edinger-Westphal nucleus of oculo-
motor (IIIrd cranial) nerve. This nucleus is the
parasympathetic efferent nucleus. Situated close
to somatic afferent nucleus of the same cranial
nerve at the level of superior colliculus of midbrain.
Axons from this parasympathetic efferent prega-
nglionic neurons travel via oculomotor nerve to
supply two muscles, i.e. constrictor pupillae and
ciliary muscles.
 Cranial Nerves
Field of vision

Temporal Nasal Nasal Temporal

Retina of right eyeball

Retina of left eyeball Right half Left half

Left half Right half

Short ciliary nerve

Ciliary ganglion
Frontal eye
field Oculomotor nerve
Optic nerve
Optic chiasma
Corticonuclear
fibers
Optic tract

Lateral geniculate body

Oculomotor Pretectal nucleus

nucleus

Optic radiation
(geniculo-
Occipitofrontal calcarine tract)
fasiculus

Visual area

Fig. 19.5 Visual pathway with routes for light reflex and accommodation reflex

4. Efferent pathway: Oculomotor nerve of same
side as well as opposite side. Via nerve to inferior
oblique, which is a branch from inferior division,
preganglionic fibers relay in ciliary ganglion. Post-
ganglionic fibers enter eyeball via short ciliary
nerve.
5. Effector organ: Constrictor pupillae muscle of
same side as well as opposite side.
Accommodation Reflex (Fig. 19.5)
It is the reflex pathway through function of which
eyeball is adjusted from vision of a distant object
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
to the vision of a near object. For this reflex action
following three changes occur in eyeball.
1. Constriction of pupil: It is caused by constrictor
pupillae.
2. Medial convergence of both eyeball: It is
caused by contraction of medial rectus of both side.
3. Increase of curvature of lens: It is caused by
relaxation of suspensory ligament of lens which is
due to contraction of ciliary muscles.
Components of accommodation reflex pathway
1. Receptors: Rods and cones of retina.
2. Afferent pathway: It is composed of following
three components
a) Total visual pathway: Retina optic nerve
optic chiasma optic tract lateral geniculate
body optic radiation visual cortex (area 17)
of occipital lobe.
b) Superior longitudinal fasciculus: These are
long association fibers extending from area 17
of occipital lobe to frontal eye field of frontal
lobe.
c) Corticonuclear or corticobulbar fibers: These
fibers extend from frontal eye field to somatic
efferent nucleus and EdingerWestphal nucl-
eus of oculomotor nerve.
3. Center:
a) Somatic efferent nucleus of oculomotor nerve
which supplies medial rectus muscle.
b) EdingerWestphal (parasympathetic efferent)
nucleus of oculomotor nerve which supplies
ciliary muscle as well as constrictor pupillae
muscle.
4. Efferent pathway: Oculomotor nerve fibers.
5. Effector organ: Following three muscles.
a) Medial rectus
b) Ciliaris
c) Constrictor pupillae.
Spinovisual Reflex (Visual Body Reflex)
Due to projection of visual impulse on eye (retina)
following types of automatic (reflex) movements occur
in our body.
1. Reflex movement of eye, head and neck, and even
trunk toward the source of light.
2. On projection of light of higher intensity there
may occur automatic protective closure of eyelids.
3. Automatic scanning movement of eyes and head
side to side occur while reading line by line.
For these types of reflex activities, neural pathway
is as follows.
1. Receptor: Rods and cones of retina.
296
2. Afferent component: Retina neurons optic
nerve optic chiasma optic tract lateral
geniculate body superior brachium.
3. Center: Neurons of tectum of midbrain at the
level of superior colliculus.
4. Efferent component:
a) Tectobulbar tract which end on motor nuclei of
some cranial nerves which are concerned with
movement of eyeball, eyelid, head.
b) Tectospinal tract which is concerned with
movement of neck and trunk.
5. Effector organ: These are voluntary muscles of
eyeball, eyelid, head, neck and trunk.
Corneal Reflex
Light touching of cornea or conjunctiva with a small
piece of cottonwool causes reflex blinking of eyelids of
both eyes. This is the effect of functioning of a reflex
called corneal reflex.
Corneal reflex differs from above mentioned
reflexes by the point that visual pathway does not
have only contribution to afferent component of this
reflex path.
Components of the reflex pathway
1. Receptors: Touch receptors in conjunctiva and
cornea.
2. Afferent pathway:
a) Nasociliary branch of ophthalmic division of
trigeminal nerve through which touch fibers
end in superior sensory nucleus of the nerve
situated at the level of pons.
b) Fibers of medial longitudinal fasciculus conn-
ecting superior sensory nucleus of trigeminal
nerve with motor nucleus of facial nerve.
3. Center: Motor nucleus of facial nerve of both side.
4. Efferent pathway: Temporal and zygomatic
divisions of the terminal branches of facial nerve.
5. Effector organ: Orbicularis oculi muscle of
eyelids of both eyes.
CLINICAL ANATOMY
CLINICAL EXAMINATION OF RETINA
It is known as fundal examination. Fundus or post-
erior part of retina is examined with the help of
ophthalmoscope. While carrying out the examination,
physician should systematically examine different
structures as per following sequence.
n Optic disk: Optic disk looks creamy pink in color.
Its central part is found hollowed with prominent
lateral margin.

n Retina: Retina is found to be reddish pink in
color. Its normal clear appearance signifies that it is
free from hemorrhage and exudates.
n Blood vessels: Blood vessels include four radia-
ting arteries with accompanying veins. Sites of
arteriovenous crossing are to be carefully examined,
as because veins normally should not be indented by
arteries.
n Macula: Macula looks comparatively darker than
the surrounding retina. It is visualized by asking
the patient to look toward the source of light of
ophthalmoscope.
Cranial Nerves
inner neural layer of retina, because these two layers
are developed from outer and inner layers of optic
cup respectively. But outer surface of pigmented
epithelium is firmly attached to layer of choroid (uveal
tract). A blow on the eye may lead to separation of
neural layer from pigmented layer of retina, leading
to a condition called detachment of retina. Fundal
examination reveals irregular wavy appearance of
neural layer of retina. Clinically detachment of retina
causes progressive impairment of vision.
Detachment of retina is a condition which may be
potentially congenital in origin.

DETACHMENT OF RETINA VARIOUS KINDS OF LOSS OF VISUAL FIELD (FIG. 19.6)

Normally, there remains a plane of cleavage or Visual defects may result when surrounding area is
potential space between outer pigmented layer and affected by following pathology.

1 1

2 2

1 1

4 2
3 3

4 4

5 5

6
6

7 7
7

Fig. 19.6 Lesions of visual pathway at different levels causing various types of visual field defects
1. Right sided circumferential blindness due to retrobulbar neuritis
2. Total blindness of right eye due to damage of right optic nerve
3. Right nasal hemianopia due to partial lesion of right marginal part of optic chiasma
4. Bitemporal hemianopia due to lesion of central part of optic chiasma
5,6,7. Right sided homonymous hemianopia due to lesion of optic tract, optic radiation and visual cortex of right side
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1. Expanding tumor: Like pituitary tumor or meni-
ngioma.
2. Cerebrovascular accidents: Effect will be wide-
spread when lesion occurs in the pathway where
the nerve fibers are more tightly packed, e.g. in
optic nerve and optic tract.
Circumferential Blindness
This clinical condition is characterized by loss of circu-
mferential field of vision of one eye affected. It occurs
due to optic neuritis, as a complication of infection of
sphenoidal or ethmoidal sinus. Optic neuritis causes
infection of peripheral fibers of optic nerve while it is
passing through optic canal.
Total Blindness
Complete lesion of one optic nerve will result total
blindness which is characterized by loss of complete
(both right and left) field of vision of one eye.
Hemianopia
The term anopia means loss of vision. Hemianopia is
characterized by loss of half of field of vision. First, it is
to be very clear that clinically when the manifestation
of hemianopia is studied, it is considered to be in
relation to loss of right or left of field of vision, but not
the temporal and nasal half. If the same half, e.g. right
or left (not temporal or nasal half) of field of vision is
lost in both eyes, it is called homonymous hemianopia.
But if right half of field of one eye and left half of field
of another eye (e.g. both temporal field) are affected, it
is called heteronymous hemianopia.
In this connection, it is also to be remembered
that light from one half of field of vision projected to
opposite half of retina, loss of one half of field of vision
is the effect of lesion of opposite half of retina (right or
left).
Beyond optic nerve, nasal fibers of both retina
decussate to go the opposite side to form optic chiasma.
Beyond optic chiasma, optic tract carries fibers from
temporal half of same retina and nasal half of opposite
retina. Lesion beyond optic nerve may occur in any of
the following sites.
1. Optic chiasma
2. Optic tract
3. Lateral geniculate body
4. Optic radiation
5. Visual cortex of occipital lobe.
Lesion of optic chiasma
This may be of following two types. These are:
n Lesion of peripheral part: It is usually unilateral
and may occur in any side. It causes damage to the
298
temporal fibers so there will be loss of nasal field of
vision of one eye. The defect is called unilateral nasal
hemianopia.
Lesion of central part of optic chiasma may occur
due to pressure effect by pituitary tumor. It will cause
lesion of central decussating nasal fibers resulting
loss of temporal half of field of vision of both eyes. It
means loss of right half of field of vision of right eye
and left half of field of vision of left eye. That is why
the visual defect is called heteronymous hemianopia.
Lesion beyond optic chiasma
Lesion in optic tract, optic radiation (geniculo-
calcarine tract) or visual cortex will cause homo-
nymous hemianopia. Lesion anywhere in right side
will lead to loss of left half of field of vision of both
eyes. A special point to note that, if lesion occurs in
both the lips of calcarine sulcus (area 17), which is
primary visual area, homonymous hemianopia will
be the effect with sparing of macular vision because
area for macular vision extends on superolateral
surface of occipital pole where extends posterior end
of visual area. Upper and lower lips corresponds
with lower and upper quadrant of field of vision of
opposite side. So, lesion of one lip upper or lower only
will cause inferior or superior quadrantic hemia-
nopia respectively.
ARGYLL ROBERTSON PUPIL
It is the clinical condition observed in a patient
suffering from neurosyphilis, which is characterized
by selective lesion of pretectal nucleus of midbrain
which is in the route of pupillary light reflex, but not
connected with pathway of accommodation reflex.
Pathway for papillary light reflex is retina optic
nerve optic chiasma optic tract lateral geniculate
body superior brachium pretectal nucleus
EdingerWestphal nucleus oculomotor nerve
ciliary ganglion short ciliary nerve sphincter
pupillae.
Pathway for accommodation reflex is, retina
optic nerve optic chiasma optic tract lateral
geniculate body optic radiation visual cortex of
occipital lobe occipitofrontal fasciculus frontal
eye field corticonuclear tract oculomotornucleus
(motor nucleus as well as EdingerWestphal nucleus)
oculomotor nerve medial rectus, ciliary muscle
and sphincter pupillae.
So, in Argyll Robertsons pupil (ARP), due to lesion
in pretectal nucleus, accommodation reflex present
(ARP), but pupillary reflex absent (PRA).

CRANIAL NERVES ARISING FROM BRAINSTEM
These are IIIrdXIIth cranial nerves. Their nuclei
are located in different levels of three components of
brainstem Midbrain, pons and medulla oblongata.
Out of these 10 pairs of cranial nerves, some are either
purely motor or purely sensory, whereas some are
mixed. Roots of the nerves come out through the ventral
surface of brainstem except the IVth (trochlear) nerve
which emerges from dorsal surface of midbrain. Some
of the cranial nerves emerge from brainstem surface
in the form of multiple roots, e.g. Xth (vagus), XIth
(accessory) and XIIth (hypoglossal) nerves. In case
of the mixed nerves, e.g. Vth (trigeminal) and VIIth
(facial) nerves, motor and sensory roots comes out of
brainstem separately and join afterwards.
Motor nuclei of these (IIIrd to XIIth) cranial
nerves develop from cell columns of basal plate (Fig.
19.7) which are of 3 functional types as follows
1. Somatic efferent
2. Special visceral efferent (branchial efferent)
3. General visceral efferent (visceral efferent).
A cranial nerve may have one or more than one
functional types of motor nuclei. Again sensory fibers
of one cranial nerve may be one or more than one
functional varieties of following sensory nuclei,
1. Somatic afferent
{ General somatic afferent
Special somatic afferent
2. Special visceral afferent (branchial afferent)
3. General visceral afferent (visceral afferent).
A cranial nerve, while going to be studied, is to be
considered under following headings.
1. Numbers, significance of the name, if any
2. Type
3. Purpose of distribution
4. Functional components
5. Nuclei
6. Supranuclear connections of motor nuclei
7. Intraneural course (course inside brainstem)
8. Surface attachments in brainstem
9. Intracranial course, and distribution, if any
10. Exit from cranium
11. Extracranial course and distribution
12. Clinical anatomy.
OCULOMOTOR NERVE
Introduction
Oculomotor nerve is the third cranial nerve. It is so-
called because it is the main motor nerve for oculus
or eyeball. Though it does not supply all the muscles,
but supplies majority of extrinsic as well as intrinsic
muscles of eyeball which are as follows
1. Extrinsic: Out of seven muscles five are supplied,
which are
Cranial Nerves
i. Superior rectus
ii. Inferior rectus
iii. Medial rectus (not lateral rectus)
iv. Inferior oblique (not superior oblique), and
v. Levator palpebrae superioris.
Superior oblique is supplied by IVth cranial (tro-
chlear) nerve and lateral rectus is supplied by VIth
cranial (abducent) nerve.
2. Intrinsic: Out of three, two muscles are supplied
by oculomotor nerve, which are
i. Sphincter pupillae (not dilator pupillae)
ii. Ciliary muscle or ciliaris.
Type
Oculomotor nerve is a purely motor nerve which is very
clear from areas of distribution as described above.
Functional Components
1. Somatic efferent: This component of fibers of
oculomotor nerve supplies 5 out of 7 extrinsic
muscles of eyeball (except superior oblique and
lateral rectus). All these 7 muscles of eyeball are
developed from preoccipital somites of paraaxial
mesoderm.
2. General visceral efferent: These fiber compon-
ent of the nerve is to supply two out of three
intrinsic muscles, which are smooth muscles. So
the general visceral efferent fibers are parasy-
mpathetic efferent fibers.
The above two components of fibers of oculomotor
nerve come out from their respective nucleus.
3. General somatic afferent: These fiber compo-
nent which are sensory, carry proprioceptive
sensation from extrinsic muscles of eyeball. It is
an interesting point to note here that a nerve,
even which is purely motor, may contain at best
40 percent sensory fibers to carry proprioceptive
sensation from the muscle. In case of oculomotor
nerve, these proprioceptive general somatic affe-
rent fibers, entering brainstem end in mesence-
phalic nucleus of trigeminal nerve.
Nucleus
Following are the two motor nuclei of oculomotor
nerve.
1. Somatic efferent nucleus: Main motor nucleus
to supply extrinsic (voluntary) muscles. This
nucleus of both sides merge together ventral to
cerebral aqueduct.
2. General visceral efferent: It is named as
EdingerWestphal nucleus which is the paras-
ympathetic efferent nucleus.
Both the nuclei are closely apposed to each
other in the periaqueductal gray matter and placed
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Special somatic afferent

General somatic afferent Alar lamina
Special visceral afferent
General visceral afferent
General visceral efferent
Special visceral efferent Basal lamina
Somatic efferent

Floor plate Sulcus limitans

Gen som. aff. Sp som. aff.

Som eff. Sp. visc. eff. Gen. visc. eff. Gen. visc. aff. Sp. visc. aff. Ex Prop Ex Prop

3
3
Midbrain EdingesWestphal
nucleus
Mesenceph 5
nucleus
4

5 Superior
Pons salivatory Superior 5
nucleus sensory nucleus S
Dorsal
7 7
6 8 L
8
I 8 M
9 9 7 I
S Ventral Vest. nuclei
Medulla 10 N 5 coch ncl.
12 9
oblongata Nucleus of
11 10 sp. tract
10 10

11 Dorsal nucleus Dorsal Nucleus tractus

Upper end of solitarius 5
nucleus
spinal cord C2

C5
Nucleus ambiguous

Basal lamina Alar lamina

Fig. 19.7 Nuclei of cranial nerves (IIIrdXIth) in different level of brainstem

ventrolateral to aqueduct of Sylvius at the level of
superior colliculus of midbrain.
Connections of nucleus
1. The somatic efferent nucleus receives connection
from motor area of cerebral cortex of both sides by
corticobulbar or corticonuclear tract.
300
2. The visceral efferent nucleus (EWN) receives
connection from pretectal nucleus of both sides,
thus completing the pathway for pupillary light
reflex.
3. The oculomotor nucleus is connected through
central tegmental chain of nerve fibers to nuclei
of Trochlear (IV), Abducent (VI) and Vestibul-
ocochlear (VIII) nerves. This connection is
 Cranial Nerves
called medial longitudinal fasciculus which is
for coordination of reflex eye movements during
alteration of equilibrium (balance) of the body.
Posterior
Intraneural course (inside midbrain) cerebral artery

The nerve, arising from the nucleus which is more

dorsally placed, passes ventrally through central
Oculomotor
tegmental core and finally traverses the following nerve
structures from behind forwards (Fig. 19.8).
Superior
1. Red nucleus cerebellar
2. Substantia nigra artery
Basilar artery
3. Crus cerebri through which pass corticospinal and
corticobulbar (corticonuclear) tract.

Exit from brainstem

On either side of midline, the nerve comes out thro-
ugh the lateral wall of a midline sulcus between two Vertebral
halves of cerebral peduncle (Fig. 19.8). artery

Fig. 19.9 Oculomotor nerve proceeds forward between

Intracranial course posterior cerebral artery and superior cerebellar artery
Inside the cranium, oculomotor nerve proceeds forw-
ards step by step as follows The nerve pierces dura mater at the angle
between anterior ends of attachments of anterior free
It passes forwards through the window bounded
and posterior fixed margins of tentorium cerebelli
by posterior cerebral artery above and superior cere-
which are attached to anterior and posterior clinoid
bellar artery below, lateral to basilar artery (Fig.
processes of sphenoid bone respectively (Fig. 19.10).
19.9).
In the lateral wall of cavernous sinus Oculomotor
Here the nerve may be compressed by an aneurysm
nerve along with trochlear (IV), and ophthalmic (V1)
developed at the junction of basilar artery and post-
and maxillary (V2) divisions of trigeminal nerve,
erior cerebral artery.
Anterior Oculomotor nerve
Exit of oculomotor nerve
clinoid piercing dura
process mater
Crus cerebri

Substantia
nigra Anterior free margin
of tentorium cerebelli

Posterior
clinoid process
Red nucleus

Posterior
fixed margin
of tentorium
cerebelli

Tegmentum
Somatic efferent
nucleus
Section of midbrain
EdingerWestphal nucleus
Fig. 19.10 Oculomotor nerve pierces dura mater at angle
Fig. 19.8 Nuclei of oculomotor nerve with its intraneural between anterior attachments of free and fixed margins of
course and exit from brainstem tentorium cerebelli
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Base of brain Endothelial Optic nerve
lining
Hypophysis cerebri Cavernous
Superior division
sinus
Oculomotor
nerve (sup. div)
Oculomotor
nerve (inf. div)
SR
Trochlear
nerve MR LR

Ophthalmic
nerve

Maxillary
nerve
Hypophyseal fossa IR
(of sphenoid) Oculomotor
Ciliary IO
Meningeal nerve
dura ganglion
Endosteal dura
Internal carotid artery Abducent nerve Inferior division Short ciliary nerves

Fig. 19.11 Superior and inferior division of oculomotor nerve Fig. 19.13 Extracranial course and distribution of oculomotor
in relation to lateral wall of cavernous sinus nerve

from above downwards, passes forwards along the compartment of superior orbital fissure. Superior
lateral wall of cavernous sinus. In the anterior part and inferior divisions of the nerve are separated by
the nerve divides into superior and inferior branches nasociliary nerve (Fig. 19.12). Abducent nerve is
(Fig. 19.11). inferolateral to these nerves.
Exit from cranium (to enter the orbit)
Extracranial course and distribution (in the orbit)
Oculomotor nerve leaves the cranium to reach the (Fig. 19.13)
orbit lodging eyeball. It passes out through middle
Oculomotor nerve may enter undivided in the orbit
Superior ophthalmic vein where division may occur. Superior division passes
Rec. meningeal br. of lac. artery upwards lateral to optic nerve to supply.
Trochlear nerve 1. Superior rectus first and a branch pierces this
Superior division muscle to supply
and 2. Levator palpebrae superioris from its inferior
Inferior division of
oculomotor nerve surface.
Inferior division supplies following muscles
1. Medial rectus
2. Inferior rectus
3. Inferior oblique.
General visceral (parasympathetic) efferent fibers
are carried so far through nerve to inferior oblique
Nasociliary from where the fibers leave finally to relay in ciliary
nerve
ganglion. This very tiny ganglion with a size like that
of a pins head, is situated behind eyeball and lateral
Abducent Frontal to optic nerve but medial to lateral rectus muscle.
nerve nerve

Inferior ophthalmic vein

Lacrimal POSTGANGLIONIC BRANCHES OF CILIARY GAN-
nerve GLION (FIG. 19.14)
Fig. 19.12 Exit of two divisions of oculomotor nerve through
middle compartment of superior orbital fissure (right superior The ganglion send out 810 short branches which are
orbital fissure seen from behind) called short ciliary nerves which in turn divide into
302

Sensory root
Nasociliary nerve
Sympathetic root from int. carotid plexus
Fig. 19.14 Communication and branches of ciliary ganglion
1520 branches. These branches pierces sclera and
runs over the surface of choroid to reach forwards to
supply
1. Ciliary muscle (ciliaris)
2. Sphincter pupillae.
ROOTS OF COMMUNICATION TO CILIARY GAN-
GLION (FIG. 19.14)
1. Motor root: This is nothing but parasympathetic
preganglionic fiber leaving the nerve to inferior
oblique muscle and relaying in ciliary ganglion.
2. Sensory root: This fiber comes from nasociliary
nerve and traversing ciliary ganglion uninter-
rupted, supplies sensory branches to eyeball via
short ciliary nerves.
3. Sympathetic root: This root also joins the ciliary
ganglion from behind and without relaying comes
out of ciliary ganglion to pass through short ciliary
nerves to the eyeball.
Origin of Sympathetic Root
These are postganglionic fibers arising from superior
cervical ganglion. The fibers form internal carotid
plexus along internal carotid artery and enter cranial
cavity. From internal carotid plexus fibers reach
orbit along ophthalmic artery and in the form of
sympathetic root join the ciliary ganglion. Through
ciliary ganglion passing without interruption fibers
of sympathetic root of communication are finally
distributed through same short ciliary nerves to
1. Dilator pupillae
2. Blood vessels of eyeball.
CLINICAL ANATOMY
Lesion of oculomotor nerve may be of following types
n Intercranial lesion: Causes of this type of lesion
may be
Cranial Nerves
Ciliary ganglion
Eyeball
Components of a short ciliary nerve
Nerve to inferior oblique
a) Head injury leading to herniation of uncus of
temporal lobe of brain.
b) Aneurysm of junction between basilar artery
and posterior cerebral artery.
Effect of Lesion
1. Ptosis: Drooping of upper eyelid due to paralysis
of levator palpebrae superioris.
2. Lateral strabismus (Lateral squint): It is due
to unopposed action of lateral rectus because of
paralysis of medial rectus.
3. Midriasis (Dilatation of pupil): Due to para-
lysis of sphincter pupillae. It leads to loss of light
reflex.
4. Loss of accommodation reflex: Accommodation
is a process by which vision is adjusted from distant
object to near object. For this three changes occur
in the eyeball which are as follows.
a) Medial convergence of both eyeballs: Caused by
medial rectus
b) Constriction of pupil by sphincter pupillae
c) Increase in curvature of lens: Due to relaxation
of suspensory ligament of lens which is the
result of contraction of ciliary muscle.
As all these three muscles are supplied by oculo-
motor nerve, its lesion will lead therefore to loss of
accommodation.
5. Proptosis: It is forward bulging of eyeball because
of laxity of paralyzed five out of seven extrinsic
muscles of eyeball.
6. Diplopia (Double vision): Due to paralysis of
extrinsic muscles, eyeball of paralyzed side will no
more be in same axis of normal side. This change
is the cause for double vision or diplopia.
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n Webers syndrome: It is a clinical condition
occurring due to damage of intraneural part of
oculomotor nerve. It is vascular lesion caused by
occlusion of branch of posterior cerebral artery supp-
lying ventral part of midbrain. It is manifested by
contralateral hemiplegion due to damage of crus
cerebri with ipsilateral oculomotor nerve palsy prese-
nting above mentioned ocular disorders.
TROCHLEAR NERVE
Introduction
Trochlear nerve is IVth cranial nerve which supplies
one out of seven extrinsic (extraocular) muscles of
eyeball which is superior oblique. This nerve is so called
because it runs in relation to the fibrocartilaginous
pulley (trochlea) around which, the tendon of superior
oblique muscle hooks. The only muscle supplied by
it, superior oblique, hooks round a fibrocartilaginous
pulley or trochlea (Fig. 19.15).
Type
Trochlear nerve is a purely motor nerve.
Functional Components
1. Somatic efferent: It is the component which
supplies superior oblique muscle which, along
with other extraocular muscles develops from
preoccipital myotome of paraaxial mesoderm.
2. General somatic afferent: Though trochlear
nerve is a purely motor nerve, it contains some
proprioceptive sensory nerve fibers which carry
the proprioceptive sensation from the muscle.
Cerebral peduncle
Superior cerebellar peduncle
Superior medullary velum
Fig. 19.15 Nucleus and intraneural course of trochlear nerve with its exit from posterior aspect of brainstem (midbrain), after which it
winds round superior cerebellar peduncle and then cerebral peduncle
304
Entering the brainstem these fibers end in mes-
encephalic nucleus of trigeminal nerve.
Nucleus (Fig. 19.15)
Somatic efferent nucleus is the only nucleus of troch-
lear nerve which is situated
i. In ventromedial part of periaqueductal gray
matter
ii. In front of cerebral aqueduct
iii. At the level of inferior colliculus of midbrain.
Connections of nucleus
1. Corticobulbar or corticonuclear tract: These
are the descending fibers projecting from motor
areas of cerebral cortex to nuclei of both sides.
2. Medial longitudinal fasciculus: This fiber bun-
dle passing through central tegmental core of
brainstem connects vestibular nuclei at pontome-
dullary junction with nuclei of oculomotor (III),
trochlear (IV) and abducent (VI) nerves which
supply extraocular muscles. This fasciculus helps
in reflex movement of eyeball in case of change in
equilibrium or balance of body.
Intraneural course (Fig. 19.15)
The nerve emerging from the nucleus, passes back-
wards winding round the lateral aspect of aqueduct
of Sylvius to reach the dorsal tectal part of midbrain,
while doing this, the fibers of the nerve decussate to
join nerve of opposite side.
Exit from brainstem
Trochlear nerve is the only cranial nerve that emerges
from dorsal aspect of brainstem (Fig. 19.15).
Trochlear nerve nucleus
Intraneural course of trochlear nerve
Trochlear nerve emerges from
brainstem piercing superior medullary
velum
 Cranial Nerves
l Same as oculomotor nerve, trochlear nerve also
Cerebral
peduncle passes forwards through the arterial window
bounded (Fig. 19.17).
Above by posterior cerebral artery
Below by superior cerebellar artery
Medially by basilar artery.
l In the lateral wall of cavernous sinus: Trochlear
nerve comes in relation to lateral wall of cavernous
sinus piercing dura mater on the posterosuperior
aspect of roof of the venous sinus. It then passes
forwards between oculomotor nerve and ophthalmic
division of trigeminal nerve. In the anterior part
of lateral wall of the sinus if crosses oculomotor
nerve to approach superolateral compartment of
Superior cerebellar superior orbital fissure (Fig. 19.18).
peduncle
Exit from cranium (to reach orbital cavity) (Fig. 19.12)
Trochlear nerve
The nerve leaves the cranium to reach orbit passing
Fig. 19.16 Emerging from back of brainstem (midbrain), trochlear through lateral (superolateral) compartment of supe-
nerve winds round superior cerebellar peduncle and then rior orbital fissure, medial to exit of frontal and
cerebral peduncle to run forward lacrimal divisions of ophthalmic nerve.
The nerve comes out from back of midbrain below Extracranial course (in the orbit) (Fig. 19.19)
inferior colliculus, piercing superior medullary velum
on either side of frenulum veli. In the orbit, trochlear nerve runs forwards and med-
ially over the eyeball to supply superior oblique pierc-
Intracranial course ing its superior (orbital) surface.

Finally to pass from behind forwards, the intracranial CLINICAL ANATOMY

course of the nerve is as follows
l The nerve runs forwards curving round the supe-
rior cerebellar peduncle and then lateral aspect of
cerebral peduncle (Fig. 19.16).
Isolated lesion of trochlear nerve, though rare, will
cause diplopia, if head is moved downwards. Because
in this position of head, both superior oblique
muscles, by intorsion bring both eyeballs in same axis
in normal individual.

TRIGEMINAL NERVE
Posterior cerebral
artery
Introduction
Trochlear nerve Trigeminal nerve is so called because it presents
three primary divisions Ophthalmic, maxillary
Superior cerebellar and mandibular. It is Vth cranial nerve and mixed
artery in nature.
Basilar artery Functional Components
n Motor: It is the special visceral efferent component
of fibers which is concerned with innervation of mus-
cles developed from 1st branchial arch mesoderm.
Vertebral n Sensory: It is the general somatic afferent comp-
artery onent of following two types
l Exteroceptive: This component receives sensation
from
i. Skin: Touch, pressure, pain and temperature
Fig. 19.17 Trochlear nerve passes forward between posterior cere- sensation from skin of face which is divided
bral and superior cerebellar arteries, lateral to basilar artery into three areas overlying three parts of
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Trochlear nerve leaves cranium through lateral

compartment of superior orbital fissure
Anterior clinoid process

Trochlear nerve runs forward along lateral wall

of cavernous sinus
Posterior clinoid process

Trochlear nerve pierces dura mater

posterosuperior to cavernous sinus

Anterior margin of foramen magnum

Section of midbrain

Trochlear nerve comes out of brainstem on its

Tentorium cerebelli posterior aspect and curves round forward

Fig. 19.18 Intracranial course of trochlear nerve

face developed from frontonasal process, iv. Mucous lining of paranasal air sinuses.
maxillary process and mandibular process l Proprioceptive: This component carries sensations
supplied respectively by ophthalmic, maxi- from muscles of mastication, temporomandibular
llary and mandibular division of trigeminal joint and fibrous joints (gomphosis) at the roots of
nerve.
teeth of both upper and lower jaw.
ii. Mucous membrane of oral cavity and nasal
cavity.
iii. Sensitive areas of eyeball, e.g. conjunctiva, Nuclei (Fig. 19.20)
cornea, ciliary body and iris. n Motor nucleus: It is the special visceral efferent
nucleus axons from which finally travel through
mandibular division of trigeminal nerve to supply
muscles developed from mesoderm of first branchial
Fibro- arch. The motor nucleus is situated in upper half of
cartilaginous
pons.
pulley
n Sensory nuclei: Trigeminal nerve has three
Superior oblique Eyeball
muscle different nuclei of general somatic afferent nature,
present in three different components of brainstem
receiving three different types of sensations as follows:
1. Nucleus of spinal tract: It is present throughout
the length of medulla oblongata extending upwards
in the lower end of pons and downwards upto
2nd cervical segment of spinal cord. It receives
pain and temperature sensation via all the three
divisions of trigeminal nerve.
2. Superior sensory nuclei: This nucleus is present
in pons. It receives touch and pressure sensation
via the same three divisions of trigeminal nerve.
3. Mesencephalic nucleus: It is the nucleus rece-
Optic nerve
iving proprioceptive sensations from muscles of
Lateral compartment of
superior orbital fissure
mastication, temporomandibular joint and joints
Trochlear nerve
at the root of teeth. This nucleus is so called as it
Fig. 19.19 Extracranial course and distribution of trochlear nerve is situated in midbrain (mesencephalon).
306
 Cranial Nerves
and fibers from medullary nucleus ascend with
horizontally directed fibers from superior sensory
nucleus and motor nucleus at the level of pons to
converge. Finally all the convergent fibers come out of
brainstem through a common site at the level of pons
Mesencephalic
(Fig. 19.20).
nucleus
Exit from brainstem (Fig. 19.21)
It is important to note that motor and sensory roots of
Superior sensory
Motor (special trigeminal nerve comes out of brainstem separately.
visceral efferent)
nucleus Both the roots come out of brainstem close to each
nucleus of
trigeminal nerve other at the junction of basilar part of pons and
middle cerebellar peduncle. Motor root is medial to
Nucleus of spinal
Sensory root
sensory root.
nucleus
(Vth nerve)
Intracranial course
Motor root (Vth
nerve) Trigeminal nerve arises from brainstem in posterior
cranial fossa. But, first it reaches middle cranial fossa
crossing over the superior border of petrous part of
temporal bone close to apex of the part of the bone
(Fig. 19.22).
Fig. 19.20 Nuclei of trigeminal nerve In the middle cranial fossa, course of trigeminal
nerve is divided as follows
Supranuclear connection i. Proximal to trigeminal ganglion
Like motor nuclei of other cranial nerve, motor nucleus ii. Distal to trigeminal ganglion.
of trigeminal nerve is connected by corticonuclear or
corticobulbar fibers to motor areas of cerebral cortex. Trigeminal Nerve Proximal to Trigeminal
Ganglion
Intraneural course
Trigeminal ganglion (Fig. 19.23) is a prominent
First, it is to be noted that exit of trigeminal nerve semilunar ganglion of considerable size located in
is on the ventral aspect of junction between basilar a small depression called trigeminal cave on anter-
part of pons and middle cerebellar peduncle. But osuperior surface of apex of petrous part of temporal
nuclei extend through the whole length of brainstem. bone. Posterior (proximal) margin of the ganglion is
Therefore, fibers from midbrain nucleus descend concave where ends the sensory root of trigeminal

Lateral sensory root and

Sensory root Medial motor root of
Motor root trigeminal nerve
Trigeminal ganglion

Ophthalmic nerve
Maxillary nerve

Mandibular nerve

Fig. 19.21 Exit of motor (medial) and sensory (lateral) roots of trigeminal nerve. Relation of both the roots with trigeminal ganglion is
also seen
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Sensory root of Superior border of petrous
trigeminal nerve part of temporal bone
Semilunar ganglion Motor root of trigeminal nerve
Common tendinous ring

Midbrain

Pons
Superior orbital
fissure

Foramen rotundum
Medulla oblongata

Foramen ovale

Petrous part of temporal bone

(vertical section)

Fig. 19.22 Intracranial course of trigeminal nerve

nerve. From the convex anterior margin of the gan-
glion arise three sensory divisions of the nerve,
namely ophthalmic, maxillary and mandibular nerve.
Trigeminal (semilunar) ganglion is made up of cell
bodies of 1st order pseudounipolar neurons of trige-
minal pathway. So sensory trunk of trigeminal nerve
represents the central (axonal) process and three sen-
sory divisions on convex side of ganglion represent
the peripheral dendritic process of the 1st order of
sensory neurons.
Distal to trigeminal ganglion, three sensory
divisions of trigeminal nerve are related to wall of
cavernous sinus. Ophthalmic and maxillary division
Maxillary nerve Cell bodies of sensory
neurons
Ophthalmic nerve
pass forwards in relation to lateral wall of sinus.
Mandibular division approaches foramen ovale below
the sinus.
Motor root of trigeminal nerve passes forwards,
not through the ganglion but deep to it to run along
with mandibular sensory divisions. The whole of
motor root of trigeminal nerve therefore continues
distally as motor root of mandibular nerve.
Trigeminal Nerve Beyond Trigeminal Ganglion
Following two points are to be clearly understood at
this stage.
1. Beyond trigeminal ganglion, i.e. from its distal
convex margin, the trigeminal nerve is distributed
as its three primary branches, ophthalmic, maxi-
llary and mandibular.
2. Motor root of trigeminal nerve is continued, beyond
trigeminal ganglion, as motor root of mandibular
branch. Sensory and motor roots of mandibular
nerve run separately but closely apposed to each
other upto foramen ovale.

OPHTHALMIC NERVE
Ophthalmic nerve is purely sensory division of
trigeminal nerve to enter orbital cavity. The nerve,
through some of its branches carries postganglionic
sympathetic fibers.
Sensory root of n Origin: Ophthalmic nerve arises from upper part
trigeminal nerve of convex distal margin of trigeminal (semilunar)
Sensory root of
Semilunar ganglion
ganglion (Fig. 19.21).
mandibular nerve
n Intracranial course: It is very short to run along
Fig. 19.23 Trigeminal (semilunar) ganglion lateral wall of cavernous sinus below trochlear nerve.
308

At the anterior end of the sinus, the nerve reaches
superior orbital fissure.
n Division: Ophthalmic nerve divides into following
three branches before it reaches superior orbital fissure.
l Lacrimal
l Frontal
l Nasociliary.
n Exit from cranium: All the three branches of
ophthalmic nerve leave cranium through superior
orbital fissure to reach orbit (Fig. 19.22).
Lacrimal and frontal branches pass through lateral
compartment and nasociliary branch passes through
central compartment of superior orbital fissure.
Lacrimal Nerve (Fig. 19.24A)
It runs from behind forwards in the lateral part of
orbit along upper border of lateral rectus muscle.
The nerve is so called because it terminates in
lacrimal gland. Through the gland, branches are also
distributed to conjunctiva and lateral part of upper
eyelid.
Beside these sensory distributions, lacrimal nerve
carries postganglionic parasympathetic secretomotor
fibers for lacrimal gland. These fibers are received from
zygomaticotemporal nerve. These are postganglionic
fibers from pterygopalatine (sphenopalatine) ganglion.
So, lacrimal nerve is composed of both sensory (own)
and motor (borrowed) components.
Frontal Nerve (Fig. 19.24B)
This nerve runs straightway forwards over the eye-
ball, above levator palpebrae superioris and below
periosteum of orbital roof. Midway between apex and
base of orbit, frontal nerve divides into supraorbital
and supratrochlear nerve.
Supraorbital nerve, being in the same line, is
considered to be the continuation of frontal nerve.
It turns upwards round supraorbital margin at
supraorbital notch to supply skin of forehead and
scalp as far backwards upto lambdoid suture.
Other branches to
l Skin of upper eyelid
l Conjunctiva
l Frontal air sinus.
From the above distribution, it is clear to under-
stand that, in case of frontal sinusitis referred pain is
felt in forehead and scalp.
Supratrochlear nerve is so called because it runs
forwards and medially above the fibrocartilaginous
pulley (trochlea) for tendon of superior oblique muscle.
It turn upwards round medial end of supraorbital
margin to reach inferomedial part of forehead to give
branches to
l Skin of inferomedial part of forehead
Cranial Nerves
l Skin of upper eyelid
l Conjunctiva.
Nasociliary Nerve (Fig. 19.24C)
Nasociliary nerve enters orbit passing through central
compartment of superior orbital fissure in between
two divisions of oculomotor nerve.
After entering the orbit, nasociliary nerve initially
lies between optic nerve and lateral rectus muscle.
Then it crosses above optic nerve to run forward along
the medial side of eyeball. Close to anterior part of
medial wall of orbit, nasociliary nerve divides into
two terminal branches infratrochlear and anterior
ethmoidal nerve.
Branches of nasociliary nerve
1. Communicating branch to ciliary ganglion:
It is attached to the back of ciliary ganglion. It
traverses through ciliary ganglion and comes out
from the ganglion to divide into multiple branches
to pass through 1520 short ciliary nerves for
sensory supply to eyeball.
2. Long ciliary nerves: These are 23 in number.
These branches arise from nasociliary nerve on the
medial side of optic nerve. They pierce sclera to run
forward over choroid to give sensory branches to
choroid, ciliary body, iris and cornea. Long ciliary
nerve also carry postganglionic sympathetic fibers
to supply dilator pupillae muscle.
3. Posterior ethmoidal branch: It is a small bra-
nch of nasociliary nerve arising close to posterior
part of medial wall of orbit. It leaves the orbit
through posterior ethmoidal canal to supply post-
erior ethmoidal and sphenoidal air sinuses.
4. Infratrochlear nerve: It is one of the terminal
branches of nasociliary nerve which runs forward
as a continuation of main nerve. It is so called
as it passes below the fibrocartilaginous pulley
for tendon of superior oblique muscle. It gives
branches to the following
i. Skin of upper as well as lower eyelids
ii. Skin of root of nose
iii. Conjunctiva
iv. Lacrimal sac.
Terminal ends of infratrochlear and supratrochlear
nerves are connected by a small communicating twig.
5. Anterior ethmoidal nerve: It is another
terminal branch of nasociliary nerve. It runs
distally through following areas in sequence, but
everywhere for a short distance.
i. In the orbit it presents brief course with no
branch.
ii. In the nasal cavity close to ethmoidal labyrinth
to supply ethmoidal air sinuses.
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Lacrimal gland

Zygomaticotemporal nerve gives out

secretomotor fibers for lacrimal nerve

Lateral rectus muscle

A Lacrimal nerve
Supratrochlear nerve

Supraorbital nerve

Levator palpebrae superioris

B Frontal nerve

Infratrochlear nerve

Anterior ethmoidal nerve

Posterior ethmoidal nerve

Long ciliary nerves

Sensory branches passing

through ciliary ganglion

C Nasociliary nerve

Fig. 19.24 Course and distribution of three branches of ophthalmic nerve

iii. Next it enters anterior cranial fossa for a
short distance where it runs forward over the
cribriform plate of ethmoid bone. It leaves
cranial fossa through a narrow slit lateral to
crista galli to enter again nasal cavity.
310
iv. In the nasal cavity it divides into two internal
nasal branches, medial and lateral. Medial
branch supplies nasal septum. Lateral branch
supplies small area over upper part of lateral
wall of nose and finally leaves nasal cavity
 Cranial Nerves

Zygomatic branch divides into zygomatico-

facial and zygomaticotemporal nerve

Sphenopalatine ganglion

Maxillary nerve emerging through

foramen rotundum

Palpebral
Terminal
branches { Nasal
Labial
Pterygoid canal

Anterior superior
alveolar nerve
Pharyngeal branch
Middle superior
alveolar nerve
Nasal branch

Anterior palatine nerve Posterior superior

alveolar nerves
Posterior palatine nerve

Fig. 19.25 Distribution of maxillary nerve

below a small notch on inferior margin of nasal
bone to reach exterior of nose.
v. On the exterior of nose it supplies skin of ala,
vestibule and tip of nose as external nasal
branch.
ii. In intraorbital groove and canal: Beyond infe-
rior orbital fissure in floor of orbit.
iii. Beyond infraorbital foramen, in face.
Distribution (Fig. 19.25)

MAXILLARY NERVE Branches in sphenopalatine fossa

Introduction 1. Direct branches from trunk

Like ophthalmic nerve, maxillary nerve is also purely
sensory division of trigeminal nerve.
Its sensory branches are distributed to
i. Roots of teeth of upper jaw.
ii. Mucous membrane of palate, small area of
pharyngeal wall, nasal cavity.
iii. Mucous membrane of maxillary air sinus.
iv. Skin over zygomatic area, lower eyelid, ala of
nose and upper lip.
Exit From Cranium
Just after origin from convex margin of trigeminal
(semilunar) ganglion, maxillary nerve emerges from
cranium through foramen rotundum to reach pteryg-
opalatine (sphenopalatine) fossa.
Parts of Maxillary Nerve
The nerve is divided from behind forward in its course,
into following parts.
i. In sphenopalatine fossa: Where it is connected
to sphenopalatine ganglion by two roots.
i. Posterior superior alveolar nerves: These are
thin multiple branches which supply roots of
molar teeth passing through small apertures
on posterior surface of body of maxilla.
ii. Zygomatic branch: It arises from maxillary
nerve in sphenopalatine fossa but primarily
enters the orbit through inferior orbital fissure.
It divides into zygomaticofacial and zygom-
aticotemporal branches which leave the orbit
through two separate canals and respectively
supply areas of skin over zygomatic bone and
behind zygomatic bone.
2. Branches traversing sphenopalatine ganglion:
Some sensory nerves, as branches of maxillary
nerve traverse through sphenopalatine ganglion
before reaching destination. These branches
are
i. Pharyngeal branch: Slender twig passes back-
ward through palatovaginal canal to supply
small area of mucous membrane of pharynx.
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Lacrimal gland
Postganglionic
secretomotor ZT
fibers joining ZF
lacrimal nerve
Sphenopalatine
ganglion
Nasal branch
Palatine branch
Pharyngeal branch
Fig. 19.26 Communication and branches of sphenopalatine ganglion
ii. Palatine branch: It runs downwards through a
bony canal to divide into anterior (greater) and
posterior (lesser) palatine nerves which supply
mucous membrane of hard and soft palate
respectively.
iii. Nasal branch: It runs medially to supply
mucous membrane of nasal cavity passing
through sphenopalatine foramen.
Branches from infraorbital groove and canal
n Middle and anterior superior alveolar nerve:
These are two separate sets of alveolar branches
which run along the body of maxilla and divide into
branches to supply the roots of middle (premolar) and
anterior (canine and incisor) sets of teeth respectively.
All the three sets of superior alveolar nerves also
supply mucous membrane of maxillary air sinus.
Branches in face (beyond infraorbital foramen)
These are the three terminal branches of infraorbital
nerve which is continuation of maxillary nerve beyond
inferior orbital fissure.
i. Palpebral To supply skin of lower eyelid
ii. Nasal To supply skin of ala of nose
iii. Labial To supply skin of upper lip.
SPHENOPALATINE GANGLION (FIG. 19.26)
Sphenopalatine (pterygopalatine) ganglion is the
largest of the four parasympathetic ganglion of
312
Maxillary nerve
Nerve of pterygoid canal
Greater superficial
FR petrosal nerve
Geniculate ganglion
Deep petrosal nerve
Internal carotid
artery
Superior cervical ganglion
head and neck. It is so called because it is situated
in sphenopalatine (pterygopalatine) fossa being sus-
pended by two roots from maxillary nerve.
This ganglion presents 3 roots of communication
which joins the ganglion from behind. The commu-
nications are
1. Parasympathetic
2. Sympathetic
3. Sensory.
Parasympathetic Root
This is nothing but made up of preganglionic
parasympathetic secretomotor fibers to relay in the
ganglion. These fibers arise from geniculate ganglion
of facial nerve as greater superficial petrosal nerve
which joins with deep petrosal nerve (carrying
sympathetic fibers) to form nerve of pterygoid canal.
As a component of nerve of pterygoid canal these
fibers join the ganglion from behind to relay there.
Postganglionic parasympathetic distribution
Postganglionic branches are secretomotor to supply
different exocrine glands as follows.
i. Pharyngeal branch: Passes from the ganglion
backward traversing palatovaginal canal to
supply mucous glands of pharyngeal wall.
ii. Palatine branches: Pass downward as anterior
(greater) and posterior (lesser) palatine nerves
to supply mucous glands of hard palate and
soft palate respectively.

iii. Nasal branches: Passes medially through
sphenopalatine foramen to supply mucous
glands of nasal cavity.
iv. Lacrimal branch: This is postganglionic secre-
tomotor fibers for lacrimal gland. From the
ganglion, secretomotor fibers for lacrimal
gland pass through following routes.
Sphenopalatine ganglionanterior root of
communication of maxillary nerve maxillary
nerveZygomatic branchZygomaticotempor-
al branchcommunication with lacrimal ner-
velacrimal nerve to supply lacrimal gland.
Sympathetic Root
This is made up of postganglionic fibers from superior
cervical ganglion. Initially these fibers pass through
plexus around internal carotid artery. Finally the
fibers pass as deep petrosal nerve which form nerve
of pterygoid canal along with greater superficial
petrosal nerve. Via nerve of pterygoid canal fibers of
sympathetic root join sphenopalatine ganglion.
Sympathetic distribution (branches)
Sympathetic fibers traversing the ganglion unint-
errupted come out as pharyngeal, palatine and
nasal branches to supply respective areas which are
vasomotor in nature.
Sensory Root
It is composed of fibers of maxillary nerve which
join sphenopalatine ganglion through posterior root
connecting the nerve with ganglion.
Sensory distribution (branches) from the ganglion
are through the same pharyngeal, palatine and na-
sal branches which have already been discussed as
branches of maxillary nerve indirectly arising from
sphenopalatine ganglion. It is therefore clear that
pharyngeal, palatine and nasal branches from sphe-
nopalatine ganglion are composed of three functional
components, parasympathetic, sympathetic and sen-
sory.
MANDIBULAR NERVE
Mandibular division of trigeminal nerve is the only
mixed part of trigeminal nerve made up of both motor
as well as sensory components. So motor component
of trigeminal nerve joins as a whole in mandibular
nerve. Mandibular nerve supplies
1. Muscles developed from mesoderm of first bran-
chial arch which are 8 in number (4+2+2).
a) 4 muscles of mastication: Masseter, temporalis,
lateral pterygoid and medial pterygoid.
b) 2 tensors: Tensor palati and tensor tympani.
c) 2 muscles coupled in digastric triangle: Ante-
rior belly of digastric and mylohyoid.
Cranial Nerves
2. Skin of face overlying the area developed from
mandibular process.
3. Roots of teeth of lower jaw.
4. Mucous membrane of floor of mouth and anterior
two-thirds of tongue.
5. Proprioceptive sensory fibers from muscles of
mastication, temporomandibular joints and root of
teeth of lower jaw.
Intracranial Course
Sensory root of mandibular division of trigeminal
nerve arises from distal convex side of trigeminal
ganglion. Motor root of trigeminal nerve is continued
distally beneath trigeminal ganglion as motor root of
mandibular nerve. Both motor and sensory root of the
nerve descend vertically to approach foramen ovale.
Exit from Cranium
Separate motor and sensory roots of mandibular
nerve comes out of cranial cavity through foramen
ovale to reach infratemporal fossa.
Extracranial Course and Distribution
(Fig. 19.27)
In infratemporal fossa, motor and sensory roots unite
to form trunk of mandibular nerve below foramen
ovale. The trunk of the nerve is medially related to
otic ganglion to which it is connected by small root.
The trunk of the nerve immediately divides into
anterior and posterior divisions.
Before division, trunk gives following two bran-
ches
i. Nerve to medial pterygoid: It supplies medial
pterygoid muscle. This branch also sends
motor branches to tensor palati and tensor
tympani muscles.
ii. Recurrent meningeal branch: It is the sensory
branch to supply meninges of brain. It passes
backward to reenter cranial cavity with a
recurrent course to pass through foramen
spinosum which is in front of spine of sphenoid.
That is why this nerve is also called nervus
spinosus.
Distribution from the Divisions
It can be compared with distributions from anterior
and posterior divisions of femoral nerve. Anterior
division of mandibular nerve gives all muscular bran-
ches and one sensory branch. But from posterior
division one muscular branch arises with all sensory
branches. It is just reverse of branching pattern of
femoral nerve.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Trigeminal ganglion Sensory root

Ophthalmic nerve
Motor root } of trigeminal nerve

Maxillary nerve Rec. meningeal branch

Foramen ovale Auriculotemporal nerve

Otic ganglion
Nerve to medial pterygoid
Nerve to masseter
Postganglionic secretomotor
fibers to parotid gland

Deep temporal nerve

Middle meningeal artery

Buccal nerve Nerve to lateral pterygoid

Lingual nerve

Mylohyoid nerve
Inferior alveolar nerve

Fig. 19.27 Distribution of mandibular division of trigeminal nerve

Branches from Anterior Division (Fig. 19.28) Sensory branch

They are related to lateral pterygoid muscle. It is known as buccal nerve. It becomes superficial
n Muscular branches: emerging between two heads of lateral pterygoid. The
1. Nerve to masseter: Cones round posterior part of nerve supplies skin over the buccal region of face. It is
upper border of lateral pterygoid muscle to pass to be noted here that buccal branch of facial nerve is
laterally and enter deep surface of masseter motor nerve which supplies buccinator muscle.
muscle.
2. Deep temporal nerves (anterior and posterior): Branches from Posterior Division
Emerge deep to upper border of lateral pterygoid
Sensory branches
muscle to pass upwards and supply temporalis
muscle. i. Lingual nerve
3. Nerve to lateral pterygoid: It enters deep (medial) ii. Inferior alveolar nerve
surface of the muscle. iii. Auriculotemporal nerve.
Deep temporal nerves
Nerve to masseter

Buccal nerve
Inferior alveolar nerve

Mylohyoid nerve
Lingual nerve

Fig. 19.28 Some of the branches of mandibular nerve related to lateral pterygoid muscle
314

Motor branch
It is called mylohyoid nerve. It does not arise directly
from posterior division but it is a branch of inferior
alveolar nerve. It supplies anterior belly of digastric
and mylohyoid muscles.
LINGUAL NERVE (FIGS 19.29 AND 19.30)
Lingual nerve arising from posterior division of
mandibular nerve carries general somatic afferent
fibers for anterior two-thirds of tongue.
It carries therefore general sensation from anterior
two-thirds of tongue.
It passes from behind forwards on the hyoglossus
muscle and presents a curved (looped) course with
convexity downwards.
It terminal part hooks round anterior end of subm-
andibular duct.
In intratemporal fossa, lingual nerve is joined at
an acute angle by chorda tympani branch of facial
nerve whose fibers are carried along lingual nerve.
It is because of chorda tympani nerve fibers carried
through, lingual nerve is joined with submandibular
ganglion which is suspended by two roots.
Distribution of Chorda Tympani Nerve
Through Lingual Nerve
Chorda tympani nerve is like that blind person which,
to reach its destination, needs a guide which is lingual
nerve.
Lingual nerve
Styloglossus muscle
Submandibular duct
Fig. 19.29 Lingual nerve joined by chorda tympani branch of facial (VII) nerve with distribution of fiber components
Cranial Nerves
Fiber components of chorda tympani nerve
distributed along the course of lingual nerve are
following
1. Special visceral afferent: These are carried
from upper part of nucleus tractus solitarius. Cell
bodies of first order of neurons of this sensory
pathway are situated in geniculate ganglion.
These fibers of chorda tympani nerve carry taste
sensations from anterior two-thirds of tongue.
2. General visceral efferent: These are pregan-
glionic parasympathetic secretomotor fibers aris-
ing from superior salivatory nucleus. Carried
along with the fibers of lingual nerve, these fibers
relay in submandibular ganglion from where
postganglionic fibers are distributed to subma-
ndibular and sublingual salivary glands.
INFERIOR ALVEOLAR NERVE (FIGS 19.30 AND
19.31
It is the only mixed component of posterior division
of mandibular nerve having sensory as well as motor
fibers.
The only motor branch is the mylohyoid nerve.
Inferior alveolar nerve, after its origin from
posterior division of mandibular nerve between
lingual nerve and auriculotemporal nerve, lies deep
to lateral pterygoid muscle initially.
But finally to reach mandibular foramen, it eme-
rges from lower border of muscle.
Special visceral afferent
component
and
General visceral efferent
component
of
Chorda tympani nerve
Submandibular ganglion
Submandibular gland
Hyoglossus muscle
315
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Auriculotemporal nerve Posterior division of
mandibular nerve
Lingual nerve
Inferior alveolar nerve
Sphenomandibular
ligament Mylohyoid nerve
Fig. 19.30 Branches of posterior division of mandibular nerve
seen from medial side of mandible
Before the nerve enters mandibular foramen, it lies
between the sphenomandibular ligament attached to
lingula and the ramus of mandible (Fig. 19.30).
Entering the mandibular foramen, inferior alveo-
lar nerve runs through a curved canal within the
lower part of ramus and the body of mandible called
mandibular canal which extends from mandibular
foramen to mental foramen. laterally then upwards behind temporomandibular
Branches
1. Muscular branch (Fig. 19.30)
It is the mylohyoid nerve which arises from inferior
alveolar nerve proximal to mandibular foramen and
pierces sphenomandibular ligament to reach digastric
triangle and to supply mylohyoid and anterior belly of
digastric muscles.
2. Sensory branch (Fig. (19.30 and 19.31)
i. Articular branches: Short multiple branches
sprout from inferior alveolar nerve while it
passes through canal. These are alveolar bran-
ches to supply roots of teeth of lower jaw.
ii. Cutaneous branch: After giving incisive bran-
ches for incisor teeth, terminal part of inferior
alveolar nerve emerges out through mental
foramen as mental nerve to supply skin over
mental region of face.
AURICULOTEMPORAL NERVE (FIG. 19.32)
Auriculotemporal nerve, a branch of posterior division
of mandibular nerve, is a purely sensory nerve.
316
Auriculotemporal nerve
Lingual nerve
Alveolar branches
Mental branch Inferior alveolar nerve
Fig. 19.31 Distribution of inferior alveolar nerve seen from lateral
side of ramus and body of mandible
l It arises in the infratemporal fossa.
l It runs initially horizontally backward.
l It splits and reunites to enclose middle meningeal
artery which passes upward to pass through foramen
spinosum.
After passing medial to neck of mandible horiz-
ontally backward, it changes its directions, first
joint and in front of auricle to reach the temple.
Branches
1. Temporal branch (superficial temporal)
It is terminal part of the nerve which runs upwards in
front of auricle to supply skin of temple.
2. Auricular branch
This branch is for distribution to following areas
i. Anterosuperior part of skin of lateral surface
of auricle.
ii. Anterior half of wall of external auditory
meatus.
iii. Anterior half of outer surface of tympanic
membrane.
3. Articular branch
To the temporomandibular joint.
4. Secretomotor fibers for parotid gland carried
through auriculotemporal nerve
These are postganglionic fibers arising from otic
ganglion. Preganglionic fibers arising from inferior

Articular branch
Auriculotemporal
nerve
Fig. 19.32 Distribution of auriculotemporal nerve
salivatory nucleus at medulla oblongata, pass initially
through tympanic branch of glossopharyngeal nerve
to tympanic plexus on the promontory of medial
wall of tympanic cavity. Then fibers pass through
lesser superficial petrosal nerve to the otic ganglion.
Postganglionic fibers from the ganglion joining the
trunk of mandibular nerve travel via auriculotemporal
nerve to reach parotid gland.
CLINICAL ANATOMY OF TRIGEMINAL NERVE
Trigeminal nerve, though mixed nerve, is the only
cranial nerve whose sensory distribution through
three primary divisions are widespread. It supplies
somatic sensory branches not only to the skin of face,
forehead, part of scalp with temple and external
ear, but also it gives branches to the roots of teeth of
both the jaws, sensative components of eye, mucous
membrane of mouth and part of tongue, and also
air sinuses. So irritation of any of the branches may
lead to perception of pain along the distribution of
branches of trigeminal nerve which is called trige-
minal neuralgia. Pain is felt over the whole area of
one side of face, ear, temple and scalp. It happens to
be excruciating pain originating from teeth (caries),
cancer of tongue, severe sinusitis, ophthalmitis.
n Trigeminal block: In case of excruciating pain
due to trigeminal neuralgia, if it is not relieved by
medication, local anesthetic is injected at the site of
trigeminal ganglion or the nerve roots arising from it.
n Localized nerve block: For extraction of tooth
from upper or lower jaw maxillary (infraorbital) and
mandibular nerve block are the choice close to the
site of infraorbital foramen and mandibular foramen
respectively.
Cranial Nerves
Temporal branch
Auricular branch
Glandular branch carrying
secretomotor fibers to
parotid gland
Parotid gland
n Headache: If site of origin of pain is ear, eyes or
teeth, pain is felt as generalized headache.
n Referred pain: When site of origin of pain is one,
referred pain is felt over the area of skin supplied by
same nerve or its branch.
1. In case of frontal sinusitis pain is felt over the
skin area of forehead as both frontal sinus as well
as skin of forehead are supplied by supraorbital
nerve.
2. In case of caries tooth (upper or lower jaw) pain is
felt in ear.
3. In case of cancer of tongue, patient feels pain over
ear as well as temple.
ABDUCENT NERVE
Introduction
It is VIth cranial nerve. It is so called because the
only muscle supplied by this nerve, the lateral rectus,
causes abduction or lateral deviation of eyeball.
Type
Abducent nerve is a purely motor nerve.
Functional Component
Only motor fiber component is somatic efferent
supplying one of the seven extrinsic (extraocular)
muscle of eyeball which are developed from pre-
occipital myotome of paraxial mesoderm.
Nucleus
Somatic efferent nucleus of abducent nerve is situated
on the dorsal surface of pons on the floor of IVth
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Dura mater

Abducent
Superior medullary velum nerve
forming upper part of root
of fourth ventricle

Facial
colliculus Medial
eminence
Hypoglossal
triangle
Middle cranial Posterior cranial
fossa fossa

Exit of abducent
Floor of fourth ventricle nerve from brainstem Abducent nerve
Petrous part of nucleus
temporal bone Olive of medulla

Fig. 19.33 Abducent nerve nucleus is situated beneath facial
colliculus which is situated in upper part of median eminence
on floor of 4th ventricle
ventricle on upper part of medial eminence beneath
a round bulge called facial colliculus. It is so called
because abducent nerve nucleus is hooked on its
surface by emerging fibers of facial nerve (Figs 19.33
and 19.34).
Connections of nucleus
Fig. 19.35 Abducent nerve fibers, arising from nucleus in the
pons, emerge from brainstem above olive, pass upward and
forward to reach middle cranial fossa from posterior cranial
fossa piercing dura mater and crossing petrous part of
temporal bone
2. Abducent nucleus, along with nuclei of oculomotor
and trochlear nerve is connected to vestibular
nucleus through medial longitudinal fasciculus
which is concerned with reflex movement of eye-
ball on alteration of balance of body.

1. The nerve nucleus is connected to motor area of Intraneural course (Fig. 19.34)
cerebral cortex (opposite side as well as same side)
by corticonuclear or corticobulbar tract. Abducent nerve fibers, arising from the nucleus,
proceed from behind forwards traversing
Exit of facial nerve Exit of abducent nerve i. Trapezoid body
Basilar part of pons ii. Medial lemniscus
iii. Basilar part of pons.
Medial lemniscus
Exit from brainstem (Fig. 19.35)
The nerve comes out of brainstem above olive of med-
ulla oblongata at pontomedullary junction.

Intracranial course
In posterior cranial fossa
Abducent nerve, in posterior cranial fossa, runs
upwards and forwards and pierces dura mater post-
erolateral to posterior clinoid process (Figs 19.35 and
19.36).
Facial nerve Facial colliculus Trapezoid body
nucleus In middle cranial fossa
Abducent nerve nucleus
The nerve crosses upper border of patrous part of
Fig. 19.34 Intraneural course of abducent nerve temporal bone, close to apex, to reach middle cranial
318
 Cranial Nerves
Anterior clinoid process

Posterior clinoid Lateral rectus

process
Abducent nerve

Abducent nerve
Foramen magnum piercing dura
(anterior margin) Internal carotid artery
Superior division of
Fig. 19.36 Abducent nerve pierces dura mater in posterior cranial oculomotor nerve
fossa posterolateral to posterior clinoid process and reaches
inferolateral to interal carotid artery
Abducent nerve
fossa where it comes in relation to inferomedial asp-
ect of cavernous sinus. At this site abducent nerve is Nasociliary nerve
inferolateral to internal carotid artery (Fig. 19.37). Inferior division of
oculomotor nerve
Exit from cranium Fig. 19.38 Exit of abducent nerve through middle compartment of
superior orbital fissure and its distribution to lateral rectus
To reach orbital cavity, abducent nerve emerges
through central or middle compartment of superior
orbital fissure inferolateral to two divisions of oculo- CLINICAL ANATOMY
motor nerve which are interposed by nasociliary
nerve (Fig. 19.38). Selective lesion of abducent nerve is rare. If it occ-
urs, it will cause medial strabismus (squint) due to
nonfunction of lateral rectus leading to unopposed
Extracranial distribution (in the orbit)
action of medial rectus.
Reaching the orbit, abducent nerve runs forwards
and laterally between optic nerve and lateral rectus FACIAL NERVE
muscle. It ends by supplying the only muscle, lateral
rectus, through its ocular (medial) surface (Fig. 19.38).
Introduction
Hypophysis cerebri Cavernous sinus Facial nerve is the VIIth cranial nerve.
Oculomotor nerve (sup div)
l It is the nerve which supplies muscles developed
from mesoderm of 2nd branchial arch. These are
a) Muscles of scalp, auricle and of facial expr-
ession with platysma
b) Stapedius muscle of middle ear
Oculomotor
nerve (inf div) c) Posterior belly of digastric and stylohyoid.
Trochlear l It supplies secretomotor fibers to submandibular
nerve and sublingual salivary glands, lacrimal gland,
Ophthalmic mucous glands of pharynx, palate and nasal cavity.
Internal carotid artery nerve l It carries taste sensation from anterior two-thirds
of tongue and form palate.
l It carries proprioceptive sensation from muscles of
Meningeal facial expression.
Abducent nerve
dura
Endosteal dura Maxillary nerve Type
Fig. 19.37 Abducent nerve in relation to cavernous sinus and It is a mixed nerve with multiple motor and sensory
internal carotid artery components.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Motor nucleus
Nuclei of facial
nerve
{ Superior
salivatory nucleus
Nucleus tractus
solitarius
Medulla oblongata
Fig. 19.39 Nuclei of facial nerve with its intraneural course and exit from brainstem
Functional Components
1. Special visceral efferent fibers: Supply muscles
developed from mesoderm of second branchial
arch as mentioned above.
2. General visceral efferent fibers: Supply secret-
omotor fibers to submandibular and sublingual
salivary glands, lacrimal glands and mucous glan-
ds of palate, pharynx and nasal cavity.
3. Special visceral afferent fibers: Carries taste
fibers from anterior two-thirds of tongue and form
palate.
4. General somatic afferent fibers:
a) Carries proprioceptive sensation from muscles
of facial expression through communication
of terminal branches of facial nerve with ter-
minal branches of trigeminal nerve in face.
These fibers end in mesencephalic nucleus of
trigeminal nerve.
b) Carries general somatic exteroceptive sensa-
tion from auricle via auricular branch of vagus
nerve which communicates with terminal
branches of facial nerve. These fibers entering
the brainstem end in spinal nucleus and supe-
rior sensory nucleus of trigeminal nerve.
n Nuclei (Fig. 19.39):
1. Motor nucleus of facial nerve: It is the special
visceral efferent nucleus of facial nerve which is
known as motor nucleus of facial nerve. It is situa-
ted in lower half of pons.
2. General visceral efferent nucleus: It is the
parasympathetic nucleus of facial nerve. This
nucleus is also situated in lower part of pons
adjacent to motor nucleus. This nucleus is called
superior salivatory nucleus.
320
Facial colliculus
Abducent nerve nucleus
Cross section of pons
Vestibulocochlear nerve
Sensory root of facial nerve
(nervus intemedius)
Motor root of facial nerve
3. Nucleus tractus solitarius: This nucleus is
situated in medulla oblongata. It is a composite
special visceral afferent nucleus whose upper
part is the nucleus of facial nerve.
Supranuclear Connection (Fig. 19.40)
It is the motor nucleus (branchial efferent nucleus) of
facial nerve which is divided into dorsal and ventral
parts. Motor fibers of facial nerve arising from dorsal
part of nucleus supply muscles of upper part of face
and those from ventral part of the nucleus supply
muscles of lower half of face.
Corticobulbar or corticonuclear fibers from contra-
lateral motor area of cerebral cortex project in both
dorsal as well as ventral parts of nucleus. In addition,
dorsal part of the nucleus receives supranuclear
connections from motor area of cerebral cortex of
same side.
n Clinical significance: In case of supranuclear
lesion, i.e. lesion of corticonuclear fibers of one side
projecting on opposite sided motor nucleus, dorsal part
of the nucleus still receive supranuclear connection
from same side which is thereby spared. Therefore,
supranuclear lesion causes paralysis of muscles of
lower half of face and upper half is not affected.
Intraneural Course (Fig. 19.39)
Three different types of fibers of facial nerve arising
from three different nuclei follow their independent
intraneural course.
Among these, efferent fibers from motor nucleus
and superior salivatory nucleus first wind round
abducent nerve nucleus on floor of fourth ventricle to
from facial colliculus at the level of lower half of pons
 Cranial Nerves

Contralateral
Ipsilateral corticonuclear fibers corticonuclear fibers

Dorsal part
Facial nerve
nucleus
{ Ventral part

Facial nerve

Facial nerve fiber for

upper half of face

Facial nerve fiber for

lower half of face

Fig. 19.40 Supranuclear connection of facial nerve

and ultimately extend forwards and laterally through
tegmentum and basilar part of pons to come out
from ventral surface of brainstem at pontomedullary
junction.
Afferent fibers from nucleus tractus solitarius
initially ascend from the level of medulla oblongata to
reach pontomedullary junction where they come close
to emerging fibers of motor and superior salivatory
nuclei. These fibers form lateral sensory root of the
nerve.
Exit from Brainstem (Fig. 19.39)
Both the motor as well as sensory fibers of the nerve
converge at pontomedullary junction but motor and
sensory roots come out of brainstem separately like
those of trigeminal nerve. Like trigeminal nerve,
motor root is medial. Both the roots emerge from
pontomedullary junction lateral to olive. Further
laterally emerges vestibulocochlear (VIIIth) cranial
nerve.
Intracranial Course
Coming out of brainstem both motor and sensory
roots of facial nerve run forwards and laterally in
the posterior cranial fossa for a very short course to
reach internal acoustic (auditory) meatus on posterior
surface of petrous part of temporal bone.
n Entry through the meatus: Facial nerve (motor
and sensory roots still separate) enters through
internal auditory meatus along with vestibulocochlear
nerve and internal auditory (labyrinthine) artery, a
branch of basilar artery.
Intrapetrous Part of Facial Nerve (Fig. 19.41)
Inside the petrous part of temporal bone facial nerve
has a complicated course which is briefed in a simple
manner as follows.
1. Passing through internal auditory meatus, sepa-
rate roots of facial nerve pass laterally above the
level of vestibule of labyrinth or internal ear.
2. Then it reaches medial wall of middle ear cavity to
enter a bony canal called facial canal.
3. At the commencement of facial canal on the medial
wall of middle ear cavity two roots of the nerve
unite where it shows two changes
i. The canal transmitting the nerve changes its
direction to pass backwards forming a bend or
genu.
ii. At the site of bend or genu, the nerve presents
a ganglion called geniculate ganglion.
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Geniculate ganglion
Greater superficial petrosal
nerve
Promontary
Medial wall of middle ear
Chorda tympani nerve
Fig. 19.41 Intrapetrous part of facial nerve with its branches
Geniculate ganglion is the peripheral sensory gan-
glion of facial nerve. Being homologous to posterior
root ganglion of spinal nerve, it is composed of cell
bodies of 1st order of neuron of sensory pathway
through facial nerve.
4. During its course horizontally backwards through
the facial canal, the nerve passes above promontory
on medial wall of middle ear cavity (tympanic
cavity).
5. At the junction of medial wall and posterior wall
of middle ear cavity, the facial canal lodging the
nerve presents a second bend to pass vertically
downwards.
6. Vertical part of facial canal, in the posterior wall
of tympanic cavity, is related in front to conical
elevation called pyramid which lodges stapedius,
a tiny muscle of tympanic cavity.
7. Apex of pyramid present a small aperture through
which stapedius muscle comes out forwards to be
inserted at neck of stapes.
8. Vertical part of facial canal ends at stylomastoid
foramen of temporal bone.
9. So intrapetrous part of facial nerve is in between
internal auditory meatus and stylomastoid fora-
men.
322
Motor and sensory roots of facial nerve
Internal auditory meatus
Vestibule of internal ear
Facial nerve in facial
canal
Nerve to stapedius
Stapedius muscle
through pyramid
Posterior wall of
middle ear
Stylomastoid foramen
Branches of Intrapetrous (Intracranial) Part of
Facial Nerve
1. Greater superficial petrosal nerve: This
nerve arises from geniculate ganglion of facial
nerve. It comes out through hiatus for greater
superficial petrosal nerve on anterosuperior surf-
ace of petrous part of temporal bone and run
over foramen lacerum where it is joined by deep
petrosal nerve (sympathetic fibers from internal
carotid plexus) to form nerve of pterygoid canal.
Via nerve of pterygoid canal, fibers of greater
superficial petrosal nerve end in sphenopalatine
(pterygopalatine) ganglion. Postganglionic secret-
omotor fibers (general visceral efferent) are distri-
buted to lacrimal gland and mucous glands of
pharynx, palate and nasal cavity.
Greater superficial petrosal nerve also contains
special visceral afferent fibers carrying taste sensation
from palate and upper part of pharyngeal wall to
upper part of nucleus tractus solitarius. Cell bodies
of 1st order of this neuronal pathway are situated in
geniculate ganglion.
2. Nerve to stapedius: It is short branch arising
from facial nerve in vertical part of facial canal. It
enters the muscle lodged in pyramid.

Contraction of stapedius pulls the neck of stapes
backwards and this damps down the conduction of
sound wave passing through solid medium formed by
chain of ear oscicles. So lesion of nerve to stapedius,
leading to release of damping down effect, makes the
sound audible more loudly in the affected ear. This
defect is called hyperacusis.
3. Chorda tympani nerve: This branch arises from
facial nerve 6 mm above stylomastoid foramen
(Fig.19.41).
From posterior wall of tympanic cavity, the nerve
passes through the lateral wall formed by tympanic
membrane.
Chorda tympani nerve runs forwards through the
plane between fibrous and mucous layers of trilaminar
tympanic membrane.
The nerve comes out through petrotympanic
fissure.
It passes medial to spine of sphenoid bone to join
lingual nerve at an acute angle at infratemporal fossa.
Distribution of Chorda Tympani Nerve (Fig.
19.42)
Fibers of chorda tympani nerve are distributed thro-
ugh lingual nerve.
The nerve contains following functional compo-
nents of fibers.
1. Special visceral afferent: These fibers are
the peripheral processes of geniculate ganglion
Lingual nerve
Sublingual gland
Lingual nerve hooking
round submandibular duct Hyoglossus muscle
Fig. 19.42 Components and distribution of chorda tympani nerve
Cranial Nerves
carrying taste sensation from anterior two-thirds
of tongue. Central processes reach upper part of
nucleus tractus solitarius.
2. General visceral efferent: These are pregang-
lionic secretomotor parasympathetic fibers of
the nerve, which arise from superior salivatory
nucleus. Postganglionic fibers are distributed from
submandibular ganglion to submandibular and
sublingual salivary glands.
Exit of Facial Nerve from Cranium
Facial nerve comes out through stylomastoid foramen,
crosses lateral aspect of styloid process of temporal
bone and immediately enters parotid gland through
upper part of its posteromedial surface.
Extracranial Part of Facial Nerve (Fig. 19.43)
Emerging through stylomastoid foramen, facial
nerve runs forwards crossing lateral aspect of styloid
process of temporal bone. Before it enters parotid
gland through upper part of posteromedial surface,
facial nerve gives following branches
1. Posterior auricular nerve: It gives auricular
and occipital branches. Auricular branch send
branches to the extrinsic as well as intrinsic
muscles of medial or cranial surface of auricle which
includes auricularis posterior muscle. Occipital
branch supplies occipital belly of occipitofrontalis.
Superior salivatory nucleus
Nucleus tractus
solitarius
Chorda tympani
nerve
Submandibular ganglion
Deep part of submandibular gland
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Z
UB
LB
M styloid process
C
Fig. 19.43 Extracranial part of facial nerve with its terminal branches: TTemporal, Z Zygomatic, UBUpper buccal, LB Lower
buccal, MMarginal mandibular, and CCervical
2. Nerve to digastric and stylohyoid: This bra-
nch arises near stylomastoid foramen. It sends
branches to stylohyoid and posterior belly of
digastric muscles which form posterior boundary
of digastric triangle.
Facial Nerve in Parotid Gland (Fig. 19.44)
Entering through upper part of posteromedial surface
of parotid gland facial nerve divides into terminal
branches. These branches pass from behind forwards
through a plane between superficial and deep parts of
the gland.
Terminal Branches of Facial Nerve (Figs 19.43
and 19.44)
These are five in number.
These branches come out of the gland piercing
anteromedial surface very close to anterior border of
parotid gland.
They run in temporofrontal region and face to
supply muscles of those areas.
1. Temporal branch: Supplies frontalis, corrugator
supercilii, muscles on external surface of auricle,
upper part of orbicularis oculi.
2. Zygomatic branch: Supplies lower part of orbic-
ularis oculi, zygomaticus major and minor.
3. Buccal branches: Upper and lower, running
above and below parotid duct respectively.
324
Posterior auricular nerve
Facial nerve
emerges through
stylomastoid foramen
crosses lateral aspect of
enters parotid gland through
posteromedial surface
Nerve to stylohyoid and
posterior belly of digastric
a) Upper buccal branch: Supplies muscles of
external nose and upper lip.
b) Lower buccal branch: Supplies buccinator and
orbicularis oris.
4. Marginal mandibular branch: Supplies mus-
cles of lower lip and chin.
5. Cervical branch: It comes through apex of parotid
gland and supplies platysma on the subcutaneous
plane of neck.
CLINICAL ANATOMY
Clinical Test to Judge Function of
Facial Nerve
1. Frowning: Appearance of small parallel vertical
creases on root of nose by corrugator supercilii and
transverse creases on forehead by frontalis.
2. Tight closure of eyelids: By contraction of
orbicularis oculi.
3. Smiling: It is associated with bilateral symme-
trical contraction of levator anguli oris of both side.
In paralysis of one side, there will be asymmetrical
elevation of angle of mouth on the normal side.
4. Blowing of mouth: The person is asked to fill up
the mouth cavity with air with tight closure of lips.
Then finger pressure is applied over the cheeck to
feel resistance offered by buccinator.

Anteromedial surface of
parotid gland
Base of parotid gland
Facial nerve
Posteromedial surface of
parotid gland
Fig. 19.44 Facial nerve enters through upper part of posteromedial surface of parotid gland. Its terminal branches emerge close to
anterior border. (Medial view of the gland)
Facial Nerve Lesion
Lesion of facial nerve is very common. This lesion
may be intraneural, intracranial or extracranial.
But as per the site of lesion of the nerve, it is
classified into following types
l Nuclear
l Supranuclear
l Infranuclear.
Nuclear lesion
It is intraneural, at the level of pons where motor
nuclei of facial nerve are situated. It is vascular in
origin due to ischemic change of branches of basilar
artery supplying basilar part of pons. It leads to lesion
of nuclei of pons with emerging nerve fiber and fibers
of corticospinal tract passing through basilar part of
pons. The lesion is called Millard Gubler syndrome
which is characterized grossly by contralateral hemi-
plegia and ipsilateral total facial paralysis.
Supranuclear lesion (Fig. 19.40)
(this lesion is also intraneural)
Fibers from dorsal part of facial nerve nucleus
supply muscles of upper half of face, whereas those
from ventral part of nucleus supply lower half facial
muscles. Both the parts of nucleus receive cortico-
bulbar (corticonuclear) fibers from opposite cerebral
cortex. In addition, dorsal part of nucleus also
receives projection from motor area of same sided
Cranial Nerves
Temporal
Terminal
Zygomatic
branches of
facial nerve
Upper buccal
Parotid duct
Lower buccal
Mandibular
Terminal
branches of
facial nerve
Cervical
cerebral cortex. So, understanding the above note and
consulting the (Fig. 19.40), it is clear that lesion of
corticonuclear fibers of one side will lead to paralysis
of muscles of lower half of face of opposite side sparing
upper half as it has supranuclear control from the
same side in addition.
Infranuclear lesion (Fig. 19.45)
n It is extraneural, but may be intracranial or
extracranial: Infranuclear lesion means lesion of
facial nerve anywhere after its exit from the brain-
stem. It may be at different level with different
manifestations as mentioned below. The level of
lesion is to be correlated with the (Fig. 19.45).
1. Lesion beyond stylomastoid foramen: It is
called Bells paralysis. Cause of this lesion is
compression of the nerve within stylomastoid
foramen. Very often it results due to inflammation
of the neural sheath following exposure to cold.
Effect is temporary.
Clinical manifestation of Bells palsy is due to
paralysis of all muscles of facial expression on
the affected side. The affected side seems to be
motionless with abolition of emotional expression.
There is widening of palpebral fissure between
two eyelids. If attempted, tight closure of eyelids
will be failed. Nasolabial furrow will be less prom-
inent. Patient will complain of accumulation
of masticated food in vestibule of mouth due to
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4
Geniculate ganglion
Nerve to stapedius
Greater superficial petrosal
nerve
Chorda tympani nerve
Temporal
Terminal Zygomatic
branches of facial
Upper buccal
nerve
Lower buccal
Marginal mandibular
Cervical
Fig. 19.45 Sites of lesion of facial nerve of various level
paralysis of buccinator muscle. Due to paralysis
of lacrimal part of orbicularis oculi, action of
lacrimal puncta fails to drain lacrimal fluid into
lacrimal sac, so lacrimal fluid may dribble from
inner canthus of eye. Due to paralysis of frontalis,
abolition of transverse creases on forehead will
be noted. If patient is asked to show teeth or in
case of attempt for smiling, angle of mouth will
be asymmetrically raised on normal side due to
unilateral contraction of elevators of upper lip and
angle of mouth.
2. Lesion above origin of chorda tympani
branch: In addition to disabilities due to Bells
paralysis, there will be loss of taste sensation from
anterior two-thirds of tongue and salivation will
be impaired due to lesion of secretomotor fibers to
submandibular and sublingual salivary gland.
3. Lesion above the origin of nerve to stapedius:
In addition to above disfunctions, patient will
suffer from hemihyperacusis due to loss of dam-
ping down effect in conduction of sound wave
through stapes of the chain of middle ear ossicles.
4. Lesion proximal to origin of greater supe-
rficial petrosal nerve: This branch of facial nerve
carries secretomotor fibers for lacrimal gland and
taste fibers of soft palate. So lesion proximal to
origin of this nerve will cause loss of lacrimation
and loss of taste sensation from soft palate.
VESTIBULOCOCHLEAR NERVE
Vestibulocochlear nerve is VIIIth cranial nerve and it
is a purely sensory nerve made up of two components,
vestibular and cochlear.
326
Internal auditory meatus
3
2
Stylomastoid foramen
Posterior auricular nerve
1
Nerve to stylohyoid and
posterior belly of digastric
Vestibular component of the nerve carries impulses
required for maintenance of equilibrium or balance of
body.
Cochlear component carries impulse for perception
of hearing.
For both the components, receptor or peripheral
sensory end organs are situated in specialized part of
internal ear (membranous labyrinth) (Fig. 19.46).
Vestibulocochlear nerve is commonly known as
auditory nerve.
As both the components of the nerve form the
parts of respective sensory pathways, the nerve is
to be studied alongwith description of the sensory
pathways.
VESTIBULAR PATHWAYS
It is the special somatic afferent pathway which fun-
ctions for maintenance of equilibrium or balance of
body.
Composition of Pathway (Fig. 19.47)
1. Receptor: It is the peripheral sensory end organ
called vestibular receptor which is situated in
specialized area of wall of membranous labyrinth
(Fig. 19.46).
2. First order of neurons: These are bipolar cells
(not pseudounipolar) whose peripheral processes
are carried from receptors and central processes
enter brainstem. The collection of cell bodies form
vestibular ganglion. The processes from vestibular
nerve.
3. Second order of neurons: Vestibular nuclei at
pontomedullary junctions.

Macular of saccule
Cochlear duct
Fig. 19.46 Membranous labyrinth showing positions of receptors for balance
Efferent from vestibular nuclei project to
i. Flocculonodular lobe of cerebellum.
ii. Interconnect nuclei of IIIrd, IVth, VIth and
XIth cranial nerves
iii. Spinal cord.
4. Third order of neurons: Thalamus.
5. Sensory area of cerebral cortex: Postcentral
gyrus.
Vestibular receptors
These are end organs for balance which are specialized
areas of some selective parts of wall of membranous
labyrinth.
These are of two functional types.
n Organ of static balance is called static labyrinth.
These are situated in anterior wall of saccule and
utricle. The specialized areas are called macula.
Static labyrinth is for recognition of position of head
in reference to gravity. It also maintains the balance
of head during the acceleration or decelaration phase
of momentum, for example for detection of position of
head when a moving vehicle increase or decrease the
speed.
n Maculae (Fig. 19.48): Maculae are the specialized
area in the anterior walls of saccule and utricle.
These areas of the labyrinth are lined by specialized
cells. The receptor cells are hair cells. Hair cells are
interlaced with tall columnar supporting cells resting
on basement membrane. Free surface of the hair cells
which are actual receptor cells presents numerous
stereocilia (nonmotile) and one motile kinocilium.
Free ciliary surface of hair cells are embedded into
a thick pad of gelatinous material which consists
of irregular particles of calcium carbonate. These
irregular particles of calcium carbonate are called
otolith for which the membrane is named otolithic
Cranial Nerves
Macula of utricle
Ampullary crest
Posterior semicircular duct
Endolymphatic duct with sac
membrane. Gelatinous mass of the membrane moves
in case of movements of head which stretches the
microvilli of hair cells, generating action potential.
n Organ of kinetic balance: It is called kinetic
receptor. It is stimulated during movements of head
and coordinates movements of eyeball and neck
with head movements. Receptors for kinetic balance
are situated in the wall of ampulla of all the three
semicircular ducts of membranous labyrinth. These
are called ampullary crests.
n Ampullary crest (Fig. 19.50): This end organ for
kinetic balance is present in the form of specialized
area of epithelial lining of ampulla of semicircular
ducts.
Structure of Ampullary Crest (Fig. 19.49)
Surface epithelium from the wall of ampulla of
each of the three semicircular ducts of membranous
labyrinth forms ridge or crest-like elevation, which
is called ampullary crest. In each ampullary wall
crest arise from opposite pole giving the appearance
of lumen like figure of eight (Fig. 19.50). Surface of
the crest present hair cells which are the receptors
for kinetic balance. Free surface of these cells present
stereocilia. From the basal surface free endings of
vestibular nerve start. The hair cells are supported
by tall columnar cells (supporting cells). A dome of
gelatinous material covers the free surface of hair
cells. It is known as cupola (Fig. 19.49). Cupola differs
from otolithic membrane of macula, as it does not
contain particles of calcium carbonate.
n Generation of action potential: For both the
cases of vestibular receptors, vibration of endolymph
causes oscillation of gelatinous membrane (otolithic
membrane and cupola) on the stereocilia of free
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Medial longitudinal fasciculus
Spinal nucleus of accessory
nerve
Fig. 19.47 Vestibular pathway
surface of hair cell receptors. Stretching of hair cells
stimulates vestibular nerve endings at the basal
surface of hair cells which generate action potential.
Vestibular Ganglion and Vestibular Nerve
Vestibular ganglion is made up of cell bodies of
bipolar neurons which are the first order of neurons
in the vestibular pathway. The ganglion is located at
the bottom (fundus) of internal auditory meatus. The
bipolar neurons of vestibular ganglion are homologous
to pseudounipolar neurons of posterior root ganglion
of a spinal nerve. Peripheral processes of the bipolar
neurons of vestibular ganglion are in contact with
base of hair cells. Central processes continue as
vestibular nerve.
328
Postcentral gyrus
Ventroposterior nucleus of thalamus
III nerve nucleus
IV nerve nucleus
VI nerve nucleus
Vestibulocerebellar fibers
Vestibular nuclei
Vestibular nerve
Vestibular ganglia
End organs of macula
End organs of ampullary crest
Entry of Vestibular Nerve in Brainstem
Entry of this sensory nerve in the brainstem is
at the site of surface attachment of the nerve at
pontomedullary junction lateral to olive of medulla
oblongata. It is one of the two components of vestibu-
locochlear nerve, attached just lateral to exit of facial
nerve, fibers of vestibular nerve are lateral to those of
cochlear nerve.
It is clinically important to note that both vestibu-
locochlear nerve as well as facial nerve are related
to cerebellopontine angle (CP angle) in the posterior
cranial fossa after coming out from internal auditory
meatus and before entering brainstem. So, the nerves
may be affected in CP angle tumors of brain.
 Cranial Nerves
Otolith Gelatinous otolithic membrane

Hair cells Stereocilia

Peripheral processes of neurons

Supporting cells
of vestibular ganglion

Fig. 19.48 Structure of macula

Vestibular Nucleus Further Components of Vestibular Pathway

Vestibular nucleus is made up of second order of
neurons in vestibular pathway. The nucleus is
situated beneath the ependyma of lateral angle of
floor of fourth ventricle which is called vestibular area
(triangle). The nucleus is made up of four components,
superior, inferior, lateral and medial.
n Awareness of balance: From vestibular nucleus
fibers ascend through central tegmental core of
pons and midbrain to the ventroposterior nucleus of
thalamus which represents the third order of neurons.
From thalamus impulse reach postcentral gyrus of
cerebral cortex via thalamocortical fibers of superior
thalamic radiation.

Stereocilia
Gelatinous mass of cupola
with no otolith

Supporting cells
Hair cells

Peripheral processes of
neurons of vestibular ganglion

Fig. 19.49 Structure of ampullary crest

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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Outline of ampulla of
semicircular duct
Ampullary crest
Fig. 19.50 Outline of ampulla of semicircular ducts showing
ampullary crest
n For stereotyped postural adjustment: Inputs
are carried from vestibular nucleus to flocculo-
nodular lobe of cerebellum (archicerebellum) via
vestibulocerebellar fibers which pass through infer-
ior cerebellar peduncle. Cerebellum, receiving the
inputs, analyses these and command is given through
cerebellovestibulospinal pathway to anterior horn
cells of spinal cord. Functioning of this pathway
helps in coordination of muscular movements in
maintenance of upright posture.
n For reflex movements of eyeball and head
and neck during change of equilibrium: In conn-
ection with change of position of head, there occur
reflex movement of eyeball head and neck. This is
due to functioning of neural pathway called medial
longitudinal fasciculus. It passes through central core
of brainstem to interconnect vestibular nucleus with
nuclei of oculomotor, trochlear and abducent nerve
supplying extraocular muscles and spinal nucleus
of accessory nerve supplying sternomastoid and
trapezius muscles.
COCHLEAR COMPONENT OF VESTIBULOCOCH-
LEAR NERVE
Cochlear nerve is the part of cochlear pathway which
is one special somatic sensory pathway concerned with
perception of hearing. Like any sensory pathway, it is
made up of receptors, chain of neurons and specific
sensory area of cerebral cortex.
Fundamental components of cochlear pathway are
following for the purpose of hearing.
1. Receptors or sensory end organs: Called organ
of Corti which is stimulated by sound waves and
330
located in cochlear duct of membranous labyrinth
of internal ear.
2. Chain of neurons:
a) First order of neurons: In internal ear. Cells
are bipolar in nature.
b) Second order of neurons: In the pontomedullary
junction of brainstem Dorsal and ventral
cochlear nucleus.
c) Third order of neurons: Nucleus of Trapezoid
body Where relay second order of neurons of
both side, thus proving bilateral influence of
the pathway.
d) Fourth order of neurons: At thalamic level. It
is the medial geniculate body of metathalamus.
3. Sensory (auditory) area of cerebral cortex: It
is the transverse gyrus of superior temporal gyrus
of cerebral cortex (area 41 and 42 of Brodmann).
Organ of Corti (Fig. 19.51)
(Sensory End Organ for Hearing)
It is a composite cellular structure located inside inte-
rnal ear. Throughout the whole length of spiral turn
of bony cochlear canal, similar turn of a membranous
duct, much narrower in diameter, follows the total
length of bony canal. It is called cochlear duct, which
is triangular in cross section. Its outer (peripheral)
wall is bony formed by part of wall of bony cochlear
canal, other two layers are membranous formed by
two membranes called basilar membrane and vesti-
bular membrane which extend to the bony wall
from tympanic lip (lower) and vestibular lip (upper)
of osseous spiral lamina. Osseous spiral lamina is a
spiral turn of bony lip, like threads of a screw proje-
cting from modiolus which is a conical bony pillar at
the central axis around which cochlear canal turns
spirally.
Inside the cochlear duct (membranous labyrinth),
on the surface of basilar membrane rest the spiral
organ of Corti.
n Organ of Corti: This is the end organ for hearing
made up various kinds of cells which are made up of
two fundamental types.
l Supporting cells of various kinds
l Receptor cells (Hair cells).
Architecture of organ of Corti is made up of two
rows of pillar cells which are known as outer and
inner rods of Corti. Cells of both of the rows, resting
on basilar membrane show inclination towards each
other for which their free ends meet forming tunnel of
Corti. The tunnel contains a fluid called cortilymph.
Hair cells are also present in the form of rows on
outer and inner side of rods of Corti. These cells
are present in the form of one inner row and three
 Cranial Nerves
Modiolus

Scela vestibuli

Vestibular membrane

Membrana tectoria

Hair cells

Cells of Hensen

Cells of Claudius

Interphalangeal
cells of Deiters

Rod cell of Corti

Basilar membrane

Peripheral processes of
bipolar cells

Scela tympani

Central processes of bipolar

neurons of spiral ganglion Spiral canal containing spiral
forming cochlear nerve ganglion

Fig. 19.51 Organ of Corti (cochlear receptor) and origin of cochlear nerve

outer rows. Basal aspect of the hair cells present two
characteristics. They are received or supported by
cups of columnar supporting cells whose free ends
present finger-like projection in between hair cells
for which they are called interphalangeal cells of
Deiters. Secondly, basal aspect of hair cells present
contact with synaptic knobs of bipolar type 1st order
of neurons which form spiral ganglion located in
modiolus. Free surface of hair cells also present two
characteristics. One cell is covered by about 100
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
numbers of stereocilia. Stereocilia of hair cells pass
through pores of a net-like membrane called reticular
membrane to come in contact with thick pad-like
gelatinous membrane which is attached medially
to the limbus of osseous spiral lamina. It is called
membrana tectoria. Peripheral to outer row of hair
cells, supporting cells are typical columnar called
cells of Hensen. Most laterally, adjacent to bony wall
of cochlear duct, cells are shorter in height, called
cells of Claudius.
First Order of Neuron and Cochlear Nerve
Cochlear nerve is the central process of first order of
neuron in cochlear pathway. These neurons are bipolar
cells. Cell bodies of these bipolar neurons are present
in the form of cluster called spiral ganglion (Fig. 19.51).
Spiral ganglion with adjacent part of their process
are present in the bony canals of modiolus which are
called spiral canal. Peripheral process of cells of spiral
ganglion form contact with basal aspect of hair cells.
Central processes form cochlear nerve which finally
comes out of petrous part of temporal bone through
internal auditory meatus along with vestibular comp-
onent of eight cranial (auditory) nerve. The nerve
Lentiform nucleus
Auditory radiation
Medial geniculate body
Inferior cerebellar peduncle
Trapezoid body
Fig. 19.52 Cochlear pathway
332
enters brainstem through anterolateral aspect of
pontomedullary junction. Entering brainstem, fibers
of cochlear nerve divides into two groups to end in
ventral and dorsal cochlear nuclei, ventral and dorsal
to inferior cerebellar peduncle (Fig. 19.52).
Second Order of Neurons Cochlear Nuclei
(Fig. 19.52)
Axons of both ventral and dorsal cochlear nuclei pass
horizontally and, forwards and medially through
central tegmental part of pons.
n Decussation of fibers to form trapezoid body:
In central tegmental part of pons of this level, fibers
of both cochlear nuclei partly run in the same side
and partly decussate to pass to other side and relay in
a nucleus. As the fibers of both side partly decussate
and partly run ipsilateral, these give the appearance
of a trapezium, for which called trapezoid body. So
the nucleus is called nucleus of trapezoid body (Fig.
19.52).
So, it is clear that nucleus of trapezoid body of one
side receives fibers from ventral and dorsal cochlear
of both sides. It proves that, impulse from one ear,
via trapezoid nuclei of both sides ascends to higher
sensory centers of both sides.
Auditory cortex of superior
temporal gyrus (area 41, 42)
Inferior colliculus
Nucleus of lateral lemniscus
Lateral lemniscus
Dorsal cochlear nucleus
Cochlear nerve
Spiral ganglion
Ventral cochlear nucleus
Nucleus of trapezoid body

Third Order of Neurons Nucleus of
Trapezoid Body (Fig. 19.52)
This nucleus is situated at the tegmentum of lower
end of pons. Axons of this nucleus form a compact
bundle which ascend through pons to dorsal part
of lower end of midbrain. This compact bundle
on either side forming a part of cochlear pathway
is called lateral lemniscus. The term lemnisci
(pl) mean compact bundle of afferent fiber tracts
passing through central core of brainstem. It is so
called because, it is lateralmost in position among
four lemnisci. Medial to lateral they are medial
lemniscus, trigeminal lemniscus, spinal lemniscus
and lateral lemniscus.
Fourth Order of Neurons Medial Geniculate
Body (Fig. 19.52)
In the cochlear pathway, the ascending route for
perception of hearing, fourth order of neurons lie
in thalamic level. This cell station is the medial
geniculate body of metathalamus.
n Other cell stations in this path: While asce-
nding, some fibers of lateral lemniscus show a
diversion while passing through inferior colliculus of
midbrain to medial geniculate body. Following points
are to note in connection with the fibers passing to
inferior colliculus.
1. These fibers from afferent part of a reflex pathway
called spinoauditory reflex, efferent component of
which is formed by tectospinal tract. This reflex
pathway in concerned with reflex movement of
head, neck and trunk in response to an audible
sound.
2. Fibers from inferior colliculus passing to medial
geniculate body form inferior brachium.
3. Before relaying in cells of inferior colliculus
(tectum), some fibers of lateral lemniscus relay
in intermediate cell stations known as nucleus of
lateral lemniscus.
Termination of Cochlear Pathway (Fig. 19.52)
From thalamus level (medial geniculate body) coch-
lear pathway pass to auditory cortex at temporal lobe
of cerebrum through inferior thalamic radiation. It
forms sublentiform part of internal capsule, as these
fibers are related to inferior aspect of lentiform
nucleus. It is called auditory radiation. Fibers end
in auditory cortex which is the transverse gyrus on
upper surface of superior temporal gyrus, at the
lower lip of stem of lateral sulcus (area 41 and 42 of
Brodmann).
Cranial Nerves
CLINICAL ANATOMY
Mnires Syndrome
This is a clinical condition which occurs due to
increase of endolymphatic volume in membranous
labyrinth due to imbalance between synthesis and
absorption of endolymph. Rise of endolymphatic
pressure leads to ballooning of cochlear duct, saccule
and utricle. Patient complains of recurrent attacks
of vertigo and tinnitus. Vertigo may be associated
with nausea. Patient suffers from progressive loss of
hearing due to pressure degeneration of receptors.
Further complication may be sense of pressure in the
ear, sensitivity to noise and distortion of sound.
Hearing Loss (Deafness)
Injury of the peripheral vestibulocochlear system
causes hearing loss (deafness). This disability is
associated with following two conditions.
1. Vertigo (dizziness): This symptom is due to invo-
lvement of semicircular ducts containing receptors
for kinetic balance.
2. Tinnitus: It is the feeling of buzzing or ringing
sound which is due to lesion in cochlear duct.
Hearing loss (deafness) may occur due to lesions
anywhere in peripheral or central cochlear path-
way. Following are the two types of hearing loss.
n Conductive hearing loss: It results from any
pathology in external or middle ear which interferes
with conduction of sound waves through air medium
and solid medium of chain of oscicles respectively.
Patient with this type of hearing loss speaks with a
low voice because his/her own voice is audible louder
than the surrounding sounds.
This type of hearing loss is corrected surgically or
through use of mechanical hearing aid.
n Neural hearing loss: This condition occurs due
to lesion of cochlear neuronal pathway anywhere from
cochlear receptor in internal ear to cochlear center
in brain. Usually defect may be in organ of Corti,
cochlear neuronal pathway, brainstem or cortical
area for hearing.
Motion Sickness
When a person is moving through a running vehicle, a
coordination is maintained between sense of position
of head and visual sensation of moving objects. Patient
suffering from motion sickness experiences vertigo,
nausea and vomiting due to incoordination between
vestibular and visual stimulation.
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LAST FOUR CRANIAL NERVES
Last four cranial nerves are
IX Glossopharyngeal nerve
X Vagus nerve
XI Accessory nerve
XII Hypoglossal nerve.
Before each of these four cranial nerves are
discussed separately, following points are to be noted.
1. Four cranial nerves come out of the cranium thro-
ugh two bony apertures, jugular foramen and
hypoglossal canal.
2. Intermediate component of jugular foramen tran-
smits IXth, Xth and XIth nerves. Hypoglossal
(XIIth) nerve comes out through hypoglossal canal.
3. Coming out of cranial cavity, in the base of skull
they are initially closely related to each other
where they lie in between internal carotid artery
and internal jugular vein.
4. IXth and Xth cranial nerves being mixed in
nature, present at the base of skull superior and
inferior ganglia for their sensory component of
fibers. Superior as well as inferior ganglia of both
the nerves are homologous to dorsal root ganglia of
spinal nerves or semilunar ganglion of trigeminal
nerve.
5. Accessory (XI) and hypoglossal nerve (XII) are
motor nerves.
Accessory nerve
Hypoglossal nerve
Spinal accessory nerve
Vagus nerve
Internal jugular vein
Fig. 19.53 Last four cranial nerves related to great vessels of neck
334
6. At the site of base of skull, in between great artery
and vein of neck, cranial root of accessory joins
the vagus losing its own identity. The spinal root
courses thereafter independently as accessory
nerve.
7. From the gap between internal carotid artery and
internal jugular vein, finally four cranial nerves
follow different course as follows (Fig. 19.53)
Glossopharyngeal (IX) nerve runs downwards,
forwards and medially passing superficial to internal
carotid artery and deep to external carotid artery, i.e.
between two arteries to reach tongue and pharynx.
Vagus (X) nerve descends vertically downward
between carotid artery and internal jugular vein.
Accessory (XI) nerve (spinal root) passes down-
wards and backwards either superficial or deep to
internal jugular vein.
Hypoglossal (XII) nerve runs downwards, forwards
and medially superficial to both internal and external
carotid artery to reach the tongue.
GLOSSOPHARYNGEAL NERVE
Introduction
Glossopharyngeal nerve is ninth (IXth) cranial nerve.
It is the nerve to supply muscle developed from third
branchial arch.
Vagus nerve
Glossopharyngeal nerve
Internal carotid artery
External carotid artery
Glossopharyngeal nerve
Hypoglossal nerve
Lingual artery
Common carotid artery

Type
It is a mixed cranial nerve.
Nuclei
n Motor nucleus: It is special visceral efferent
nucleus called nucleus ambiguous. Nucleus ambig-
uous is a composite nucleus of IXth, Xth and XIth
cranial nerves. Upper part of nucleus is part for
glossopharyngeal nerve. Fibers pass to supply stylop-
haryngeus which is the muscle developed from meso-
derm of third branchial arch.
n Inferior salivatory nucleus: It is also the motor
nucleus of general visceral efferent group. This is one
of the four parasympathetic nuclei of cranial nerves.
n Nucleus tractus solitarius: It is also a composite
nucleus for VIIth, IXth and Xth cranial nerve of
special visceral afferent group.
All the three nuclei of glossopharyngeal nerve are
situated in medulla oblongata.
Functional Components
Motor
1. Special visceral efferent: These fiber component
is made up of axons arising from nucleus amb-
iguous to supply only one muscle developed
from third branchial arch mesoderm which is
stylopharyngeus.
2. General visceral efferent: These are prega-
nglionic parasympathetic secretomotor fibers of
the nerve, which arise from inferior salivatory
nucleus, for parotid gland.
Sensory
1. Special visceral afferent: This fiber component
is made up sensory fibers of the nerve which
carries taste (gustatory) sensation from posterior
Nucleus tractus
solitarius (IX)
Inferior salivatory nucleus (IX)
Nucleus ambiguous (IX)
Glossopharyngeal
nerve (IX)
Fig. 19.54 Intraneural course of glossopharyngeal nerve
Cranial Nerves
one-third of tongue and also same sensation from
circumvallate papillae of anterior two-thirds. The
fibers are carried to nucleus tractus solitarius.
2. General visceral afferent: These fibers carry
general sensation from viscera like pharynx,
carotid body and carotid sinus. Fibers carry general
sensory impulse to nucleus tractus solitarius.
3. General somatic afferent: These fibers of
glossopharyngeal nerve carry general somatic
sensation, e.g. touch, pain and temperature from
posterior one-third of tongue, palate, tonsil and
pharynx. Having no general somatic afferent
nucleus of its own, these fibers of glossopharyngeal
nerve, after entering brainstem end in nucleus of
spinal tract of trigeminal nerve.
Intraneural Course (Fig. 19.54)
All the nuclei of glossopharyngeal nerve are situated
more close to the dorsal aspect of medulla oblongata.
Fibers from all the nuclei converge and run forwards
and laterally through the tegmental core of medulla.
During ventrolateral course, the emerging nerve
fibers are related medially to medial lemniscus and
spinothalamic tracts and laterally to nucleus of
spinal tract of trigeminal nerve. The nerve traverses
reticular formation of medulla oblongata.
Exit from Brainstem (Fig. 19.54)
Glossopharyngeal nerve comes out through the upper
end of a vertical sulcus between olive and inferior
cerebellar peduncle. It lies in a vertical row with roots
of vagus and accessory nerves arranged serially from
above downwards.
Intracranial Course
In the posterior cranial fossa it runs forwards and
laterally to approach jugular foramen. Intracranial
course of the nerve is short and insignificant.
Inferior cerebellar
peduncle
Nucleus of spinal tract of
trigeminal nerve
Glossopharyngeal nerve
Lateral spinothalamic tract
Medial lemniscus
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Postganglionic fibers
to parotid gland
Soft palate
Tonsillar and palatal
branches
Lingual branch to
posterior 1/3 rd of tongue
Middle constrictor muscle of
pharynx
Common carotid artery
Fig. 19.55 Extracranial course and distribution of glossopharyngeal nerve
Exit from Cranium
Glossopharyngeal nerve along with vagus and acce-
ssory nerves leaves the cranium through intermediate
component of jugular foramen. The nerve is covered
by separate (independent) dural sheath. Anterior and
posterior compartments of jugular foramen are venous
compartments transmitting inferior petrosal sinus
and beginning of internal jugular vein respectively.
Extracranial Course and Distribution (Fig.
19.55)
Beyond jugular foramen the nerve lies in relation
to base of skull between internal jugular vein and
internal carotid artery. Here it presents two ganglia,
superior and inferior.
Superior ganglion is smaller and considered to be
the detached portion of inferior ganglion.
Both these ganglia, being homologous to posterior
root ganglia of spinal nerve, present cell bodies of
sensory fibers (both special as well as general visceral
afferent) of glossopharyngeal nerve.
336
Otic ganglion
Preganglionic fibers from
tympanic plexus to otic ganglion
Tympanic plexus
Glossopharyngeal
nerve
Jugular foramen
Superior ganglion
Tympanic branch
arising from inferior
ganglion
Internal carotid artery
Carotid branch
Muscular branch to
stylopharyngeus
Pharyngeal branch
Internal jugular vein
A slender tympanic branch arises from inferior
ganglion. It ascends through a slit on jugular fossa
(tympanic cavity floor) to enter tympanic cavity.
The branch forms tympanic plexus on promontory
of medial wall of the cavity along with sympathetic
fibers (caroticotympanic branches) from internal
carotid plexus. Tympanic branch carries preganglionic
parasympathetic secretomotor fibers for the parotid
gland. From tympanic plexus fibers are carried throu-
gh lesser superficial petrosal nerve to relay in otic
ganglion. Postganglionic fibers reach parotid gland
through auriculotemporal nerve.
Beyond inferior ganglion, glossopharyngeal nerve
changes direction to pass downwards, forwards and
medially deep to styloid process of temporal bone.
It crosses superficial to internal carotid artery but
deep to external carotid artery. While in between two
arteries, it sends a carotid branch which descends to
supply carotid body and carotid sinus.
The nerve while passing in relation to wall of
pharynx it sends following two branches.
n Muscular branch: This is the only motor (bran-
chiomotor) branch of the nerve which supplies stylo-

pharyngeus developed from mesoderm of third phar-
yngeal arch.
n Pharyngeal branch: This carries sensory fibers
for the wall of pharynx through formation of phary-
ngeal plexus of nerves on the surface of middle
constrictor muscle of pharynx. Pharyngeal plexus is
formed by
1. Pharyngeal branch of glossopharyngeal nerve
Sensory in nature.
2. Pharyngeal branch of vagus nerve Motor for all
muscles of pharynx except stylopharyngeus. These
fibers are actually from cranial root of accessory
nerve carried through vagus nerve.
3. Laryngopharyngeal branch of sympathetic which
is vasomotor in nature.
After giving above two branches, glossopharyngeal
nerve changes direction further to pass upwards,
forwards and medially deep to stylohyoid ligament
and ends by giving following terminal branches.
1. Tonsillar branch: It carries general somatic sen-
sory fibers to the tonsillar fossa.
2. Palatal branch: This branch forms a plexus with
lesser palatine nerve. It is general somatic sensory
to the soft palate.
3. Lingual branch: It carries both general somatic
afferent and special visceral afferent fibers for
posterior one-third of tongue.
General somatic afferent fibers carry touch, pain
and temperature sensation from posterior one-third
of tongue.
Special visceral afferent fibers carry taste (gust-
atory) sensation from not only posterior one-third of
tongue but also circumvallate papillae which are in
front of and parallel to sulcus terminalis.
Lesion of Glossopharyngeal Nerve
Isolated lesion of glossopharyngeal nerve or its
nuclei are uncommon and no perceptible disability
is observed. If there occurs lesions at all, patient
suffers from loss of taste sensation on the posterior
one-third of tongue. Gag reflex will be absent on the
side of lesion. Due to paralysis of stylopharyngeus,
ipsilateral weakness in swallowing may be noticed.
n Jugular foramen syndrome: It is the effect of
infection or tumor in the vicinity of jugular foramen.
Because of close relation of IX, X and XI cranial nerve
at this site, this syndrome will present features of
multiple cranial nerve palsies.
In case of tumor in the neck adjacent to route of
glossopharyngeal nerve, pain may be felt along the
line of distribution of nerve.
Cranial Nerves
VAGUS NERVE
Introduction
Vagus nerve is the Xth cranial nerve. It is so called
because it is vagarant or wandering in nature.
Distribution of vagus nerve is extensive for head,
neck, thorax and abdomen.
Vagus nerve receives whole of the fiber component
of cranial root of accessory which is made up of special
visceral efferent fibers to supply muscles developed
from mesoderm of VIth branchial arch.
Widespread distribution of vagus nerve is for follo-
wing two reasons
1. Vagus nerve supplies smooth muscles of whole
tracheobronchial tree and, foregut and midgut.
2. It gives secretomotor fibers for mucous glands of
whole of the above mentioned areas of respiratory
and alimentary tracts.
Functional Component
1. Special visceral efferent: Special visceral
efferent fibers of vagus nerve of its own are to
supply muscle developed from mesoderm of IVth
branchial arch which is cricothyroid.
Besides, vagus also carries special visceral effer-
ent fibers which are borrowed through joining
of cranial root of accessory nerve. These fibers
supply muscles developed from mesoderm of VIth
branchial arch which are
l All muscles of palate except tensor palati
l All muscles of pharynx except stylopharyngeus
l All muscles of larynx except cricothyroid.
2. General visceral efferent: These are parasy-
mpathetic, preganglionic secretomotor fibers to
supply smooth muscle and mucous glands of trach-
eobronchial tree, foregut and midgut.
3. General visceral afferent: This component of
fibers of vagus nerve carries general sensations
from above mentioned areas of respiratory and
alimentary tracts. Visceral sensations are sense of
compression, distension and pain due to ischemia.
4. Special visceral afferent: These fibers carry
taste (gustatory) sensations from posteriormost
part of tongue, vallecula and epiglottis.
Cell bodies of first order of neurons of above
mentioned two sensory pathways through vagus
are situated in inferior ganglion of vagus nerve.
5. General somatic afferent: This component of
fibers of vagus nerve carries general somatic sen-
sation from skin of conchal area of external ear.
Cell bodies of first order of neurons of this pathway
are situated in superior ganglion of vagus nerve.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nuclei
All the following nuclei of vagus nerve are situated in
medulla oblongata.
1. Nucleus ambiguous (IX, X, XI): This is a comp-
osite nucleus for IXth, Xth and XIth cranial nerve.
Its lower end is continued as spinal part upto Vth
cervical segment of spinal cord.
Special visceral efferent fibers of vagus nerve
arising from this nucleus supply cricothyroid
which is the only muscles developed from IVth
branchial arch mesoderm.
2. Dorsal nucleus of vagus: Unlike nucleus ambi-
guous, it is the nucleus for vagus nerve only. But
it is also considered to be a composite nucleus as
dorsal nucleus of vagus is made up of a motor and
a sensory component.
Motor component gives out general visceral
efferent fibers of the nerve while sensory component
of the nucleus receives general sensations from
the viscera.
3. Nucleus tractus solitarius (VII, IX, X): Like
nucleus ambiguous, this is also a composite
nucleus made up of components for VIIth, IXth
and Xth cranial nerve. Fibers carrying taste
(gustatory) sensation from posteriormost part of
tongue, vallecula and epiglottis, carried through
special visceral afferent fibers of vagus end in this
nucleus.
Dorsal nucleus of vagus
Nucleus tractus solitarius
Nucleus of spinal tract of
trigeminal nerve receives
general somatic sensory
fibers of vagus
Inferior cerebellar
peduncle
Nucleus ambiguous
Vagus nerve
Spinothalamic tract
Hypoglossal nerve
Fig. 19.56 Intraneural course of vagus nerve
338
Nucleus tractus solitarius is also considered to
share with sensory component of dorsal nucleus of
vagus to receive general sensation from viscera.
4. Nucleus of spinal tract of trigeminal nerve:
Though it is the nucleus of Vth cranial nerve,
this nucleus is well known for its cordial nature
to receive general somatic sensory fibers carried
through many cranial nerve. General somatic
afferent fibers carried through vagus nerve from
external ear end in nucleus of spinal tract of
trigeminal nerve.
Intraneural Course (Fig. 19.56)
All the nuclei of vagus nerve are situated in dorsal
part of tegmentum of medulla oblongata. Fibers from
nuclei converge and course inside medulla forwards
and laterally. While proceeding through the substance
of medulla oblongata, fibers are related medially to
medial lemnicus, intraneural part of hypoglossal
nerve, medullary reticular formation, spinothalamic
tract and inferior olivary nucleus. Laterally the
nerve fibers are related to nucleus of spinal tract of
trigeminal nerve and inferior cerebellar peduncle.
Exit from Brainstem
Vagus nerve comes out from brainstem in the form of
multiple roots. These roots exit through the vertical
sulcus between olive and inferior cerebellar peduncle.
Hypoglossal nerve nucleus
Medial longitudinal bundle
Tectospinal tract
Reticular formation
Medial lemniscus
Pyramid
Arcuate nucleus

Through this sulcus IXth, Xth and XIth cranial
nerves come out in vertical row sequentially from
above downwards.
Intracranial Course
Intracranial course of the nerve is short. Multiple
rootlets of the nerve unite to form a large trunk
which runs forwards and laterally across the jugular
tubercle towards jugular foramen.
Exit from the Cranium
Vagus nerve leaves the cranium passing through
middle compartment of jugular foramen along with
glossopharyngeal and accessory nerve. Here the
nerves are related to inferior petrosal sinus in front
and sigmoid sinus continued as internal jugular vein
behind which pass through anterior and posterior
compartments of jugular foramen respectively.
While passing through jugular foramen, vagus
nerve is enclosed by a common dural sheath with
accessory nerve.
Cranial root of accessory nerve joins vagus nerve
at the level of jugular foramen or just beyond it at
base of skull.
Common dural sheath
Cranial Nerves
Immediately beyond jugular foramen, at the base
of skull, vagus nerve presents a small round superior
and a long fusiform inferior ganglia. Superior ganglion
is considered to be the detached part of inferior one.
Extracranial Course and Distribution
Extracranial course is divided into three segments, in
head and neck, thorax and abdomen.
Vagus Nerve in Head and Neck (Fig. 19.57)
It is the part of the nerve extending from base of skull
to root of neck. This part is enclosed by carotid sheath
where it presents a vertical course between internal
jugular vein laterally and carotid arteries medially.
The nerve lies in a more posterior plane than the
great vessels inside carotid sheath.
Branches in Head and Neck
From superior ganglion, following two branches of
vagus take origin.
n Meningeal branch: It reenters cranial cavity
through jugular foramen and supplies meninges of
posterior cranial fossa.
Jugular foramen
Meningeal branch

Vagus nerve

Auricular branch of vagus arising from

superior ganglion of vagus
Accessory nerve (both roots)
Inferior ganglion of vagus nerve

Spinal accessory nerve

Pharyngeal branch

Superior laryngeal branch

Carotid (sinus branch)

Internal laryngeal branch

Vagus nerve
External laryngeal branch supplying
cricothyroid muscle

Cervical part of vagus nerve Right recurrent laryngeal nerve

approaching tracheoesophageal groove
Right recurrent laryngeal nerve

Cardiac branches

Fig. 19.57 Course and distribution of cervical part of vagus nerve

339
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
n Auricular branch: A reader should not bother
for its complicated course. But its distribution is
important to note. It gives branches to
i. Concha and root of auricle
ii. Posterior half of external auditory meatus
iii. Posterior half of outer surface of tympanic
membrane.
Branches from inferior ganglion of vagus are the
following:
n Pharyngeal branch: This branch arising from
vagus carries fibers of cranial root of accessory nerve.
Pharyngeal branch topographically arising from upper
part of inferior ganglion of vagus runs downwards,
forwards and medially superficial to internal caro-
tid artery and deep to external carotid artery. It
then runs on middle constrictor of pharynx close
to its upper border. One branch ascends as palatal
branch to supply all muscles of soft palate except
tensor palati which is supplied by mandibular nerve.
Pharyngeal branch finally forms a plexus on middle
constrictor muscle of pharynx called pharyngeal
plexus. The plexus is contributed by pharyngeal
branch of glossopharyngeal nerve (sensory) and
laryngopharyngeal branch of sympathetic chain
(vasomotor). Pharyngeal branch of vagus carries
special visceral efferent fibers to supply all muscles of
pharynx except stylopharyngeus.
n Carotid branch: It is a long descending branch
from inferior ganglion of vagus running between
carotid arteries to supply carotid body and carotid
sinus at the site of bifurcation of commom carotid
artery.
n Superior laryngeal nerve: It arises from lower
part of inferior ganglion of vagus. It runs downwards,
forwards and medially deep to both internal carotid
as well as external carotid arteries. First it lies on
superior constrictor and finally on middle constrictor
of pharynx where it divides into internal and external
laryngeal branches.
Internal laryngeal nerve is the upper and thicker
branch accompanied by superior laryngeal artery.
It pierces thyrohyoid membrane to supply mucous
membrane of upper part of larynx upto level of vocal
cord.
External laryngeal nerve is the lower division of
superior laryngeal nerve. It accompanies superior
thyroid artery and pierces middle constrictor muscle
to supply cricothyroid muscle. It also supplies cricoph-
aryngeus portion of inferior constrictor muscle of
pharynx. External laryngeal nerve may also have
contribution to pharyngeal plexus.
Other Branches from Cervical Part of Vagus
n Right recurrent laryngeal nerve: It arises
from the right vagus nerve while the nerve crosses in
340
front of subclavian artery. This branch of vagus winds
round the inferior aspect of subclavian artery to pass
backwards and finally run upwards and medially to
approach tracheoesophageal groove. Here it is related
to inferior thyroid artery.
The recurrent laryngeal nerve, while approaching
tracheoesophageal groove has some important
relation of clinical significance. The nerve may be
superficial or deep to the artery. Branches of inferior
thyroid artery may be intermingled in tracheoesop-
hageal groove, while the nerve is passing through
ligament of Berry or suspensory ligament of thyroid
gland. While performing thyroid surgery, the surgeon
is to take into consideration of these important rela-
tions of recurrent laryngeal nerve.
Branches of recurrent laryngeal nerve are following:
1. All muscles of larynx except cricothyroid.
2. Inferior constrictor muscle of pharynx (cricopha-
ryngeus component).
The above mentioned fibers are borrowed from
cranial root of accessory nerve.
3. Cardiac branch: To deep cardiac plexus.
4. Sensory branches to mucous membrane of larynx
below vocal cord.
5. Sensory branches to trachea and esophagus.
Cardiac Branches of Cervical Part of Vagus
From cervical part of vagus nerve, two cardiac bran-
ches take origin, superior and inferior. Thoracic part
of vagus also gives rise to cardiac branches.
All cardiac branches carry parasympathetic fibers
which are cardioinhibitory in nature.
Out of cervical cardiac branches, left inferior
cervical cardiac branch takes part in formation of
superficial cardiac plexus. All other branches join
deep cardiac plexus. Cardiac plexuses are located in
middle mediastinum of thorax.
On the right side, out of two cardiac branches, one
may arise from right recurrent laryngeal nerve.
Vagus Nerve in the Thorax (Fig. 19.58)
At the root of neck right vagus nerve enters the thorax
crossing in front of 1st part of right subclavian artery.
Then it runs downwards and medially behind right
brachiocephalic vein to reach right side of trachea.
Left vagus enters thorax passing between left common
carotid artery and left subclavian artery, behind left
brachiocephalic vein.
Further downwards vagus nerve passes behind root
of lung of respective side in the middle mediastinum
of thorax.
 Cranial Nerves

Right recurrent laryngeal nerve Left recurrent laryngeal nerve hooks

hooks round right subclavian artery round ligamentum arteriosum
Right vagus nerve enters Left vagus nerve enters
thorax crossing in front of thorax crossing in front of
right subclavian artery arch of aorta

Posterior pulmonary plexus

Right bronchus
Anterior pulmonary plexus

Cardiac branches

Esophageal orifice of diaphragm

through which both vagi enter
abdomen from thorax

Anterior gastric nerve

Loop of small intestine

Both vagi supply parasympathetic
fibers upto right two-thirds of
transverse colon

Fig. 19.58 Distribution of vagus nerve in thorax and abdomen

Distribution in the thorax It is the time for a reader to recapitulate that

any branch of vagus going to the target organ reach
In the thorax, vagus nerve of both sides, gives follo- as preganglionic parasympathetic fiber. They relay
wing branches close to the wall (surface) of the organ from where
1. Cardiac branches postganglionic fibers are distributed.
2. Pulmonary branches In the thorax, postganglionic fibers of vagus, along
3. Esophageal branches. with the sympathetic fibers form plexuses for the
341
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
respective organs which are named as cardiac plexus,
pulmonary plexus and esophageal plexus.
Cardiac plexus
Cardiac plexus is formed by cervical and thoracic
cardiac branches of vagus along with sympathetic
fibers from upper four or five thoracic sympathetic
ganglia.
Vagal fibers are cardioinhibitory to slow down
the heart rate and diminish the force of contraction
of myocardium whereas sympathetic being cardioac-
celeratory in function, increases heart rate and force
of contraction with coronary vasodilation.
Cardiac plexus is made up of two components,
superficial and deep.
Superficial cardiac plexus is the smaller component
and considered to be detached portion of main (deep)
cardiac plexus. It is situated below arch of aorta and
in front of right pulmonary artery. Deep cardiac
plexus, being more prominent, is situated behind
arch of aorta and in front of bifurcation of trachea.
Superficial cardiac plexus is formed by superior
cervical cardiac branch of left sympathetic trunk
and inferior cervical cardiac branch of left vagus. All
other vagal and sympathetic contributions take part
in formation of deep cardiac plexus.
From cardiac plexuses postganglionic fibers are
distributed along the course of coronary artery.
Pulmonary plexus
Pulmonary plexus is formed by branches of vagus
nerve (parasympathetic) and also sympathetic fibers
from T2 T5 sympathetic ganglia. Nerve fibers from
both sympathetic and parasympathetic (vagal) contr-
ibutions form anterior and posterior pulmonary
plexuses which are situated in front and behind root
of lung respectively. From these plexuses branches
follow the course of tracheobronchial tree as post-
ganglionic fibers.
Vagal (parasympathetic) fibers of pulmonary
plexuses possess following functions.
i. Excitatory to the muscles of tracheobronchial
tree. Their stimulation causes bronchocons-
triction.
ii. Secretomotor to mucous glands of whole respi-
ratory tract.
iii. Sensory in nature for mucous membrane of
respiratory tree. It responds to stretch or
cough reflex.
Sympathetic fibers exert inhibitory effect on
musculature and mucous gland. So, it results bronch-
odilatation and diminished secretion of mucous
glands.
342
Esophageal plexus
It is the lower half of esophagus which receives
esophageal branches from vagal trunk of both sides.
Upper half is supplied by esophageal branch of both
recurrent laryngeal nerve while they run upwards
along the tracheoesophageal groove of corresponding
sides. Sympathetic fibers for upper half of esophagus
come from middle cervical sympathetic ganglion.
Lower half receives fibers from first four thoracic (T1
T4) ganglia.
Vagal (parasympathetic) fibers are motor, secret-
omotor and sensory for the esophagus. Sympathetic
fibers are vasomotor.
Left Recurrent Laryngeal Nerve
Left recurrent laryngeal nerve arises from vagus in
the thorax while the vagus nerve crosses in front of
left (anterior and left) side of arch of aorta. It hooks
round the ligamentum arteriosum and finally reaches
the tracheoesophageal groove. Its distributions are
similar to the right nerve.
Vagus Nerve in Abdomen (Fig. 19.58)
In the abdomen vagus nerve is concerned with para-
sympathetic innervation of foregut and midgut with
associated structure like liver, gallbladder, pancreas.
Parasympathetic fibers of vagus are for following
functions to gastrointestinal tract.
1. Excitatory to smooth muscles of the gut for which
it promotes peristalsis.
2. Inhibitory to all sphincters of gut which get
relaxed.
3. Secretomotor for mucous glands in the wall of gut
upto right two-thirds of transverse colon.
4. Sensory to the wall of the gut due to compression,
distension or ischemic change.
Both the vagi enter abdomen through esophageal
orifice of diaphragm. Because of rotation of foregut to
the right, left and right vagi lie in relation to anterior
and posterior aspects of stomach respectively. After
anterior and posterior gastric nerves are distributed
to the stomach, vagus nerve fibers are continued
further distally to supply successive part of gut.
The fibers of both vagi proceed to the viscera of
upper abdomen with foregut and midgut through
corresponding vascular plexus related to the artery
supplying that particular organ. But in these vas-
cular plexuses, parasympathetic vagal fibers are still
preganglionic until they reach the wall of gut. These
preganglionic fibers are axons of connecter neurons
which are the cells of dorsal nucleus of vagus in
medulla oblongata.

Reaching the wall of gut these preganglionic fibers
relay in effector neurons in two levels to form
following two plexus from where postganglionic fibers
are distributed.
1. Myenteric (Auerbach) plexus: It is placed
in between of muscular coats of the gut. From
this plexus postganglionic fibers of vagus are
distributed to muscles of the gut. Stimulation
of these fibers increases peristalsis and relaxes
sphincters.
2. Submucosal (Meissner) plexus: This forms the
relay stations in submucous coat of the concerned
portions of gut. Postganglionic fibers promotes
secretion of glands.
Parasympathetic fibers derived from vagus are
motor fibers for smooth muscles of wall of gallbladder
and biliary tree and inhibitory to the musculature of
sphincter of Oddi.
For kidney, postganglionic parasympathetic fibers
of vagus form renal plexus along with sympathetic.
Vagal fibers for the kidney are vasodilator in
function.
CLINICAL ANATOMY
Isolated lesion of vagus nerve is uncommon. Injury
to individual branch may occur independently or
together. Injury to pharyngeal branch produces diffi-
culty in swallowing (dysphagia). Injury to superior
laryngeal branch produces loss of sensation (ane-
sthesia) of upper-half (supraglottic part) of mucous
membrane of larynx. Due to paralysis of cricothyroid,
voice becomes weak and tires easily.
Lesions of Recurrent Laryngeal Branch
Lesions of recurrent laryngeal nerve may occur due
to cancer of larynx or thyroid, or from injury of the
nerve following surgical operation in thyroid gland,
esophagus, heart and lungs. Due to longer course, left
nerve is more prone to be lesioned than right. Paralysis
of recurrent laryngeal nerve will cause hoarseness of
voice and dysphonia (difficulty in speech) due to loss
of function of vocal cord. Paralysis of both recurrent
laryngeal nerve cause aphonia (loss of voice) and
inspiratory stridor which is characterized by harsh,
high pitched respiratory sound.
Central lesion of vagus nerve may occur in a
condition called lateral (posterior) medullary syndr-
ome due to occlusive disorder of posterior inferior
cerebellar artery. In this case disorder of swallowing
and speech will be associated with manifestations of
cerebellar ataxia.
Cranial Nerves
ACCESSORY NERVE
Introduction
Accessory nerve is the XIth cranial nerve. It is made
up of two roots, cranial and spinal. Cranial root arises
from brainstem and spinal root arises from upper five
(C1C5) segments of spinal cord. Accessory nerve is
so called as it is considered to be accessory to vagus
nerve, because its cranial root totally joins with vagus
through which fibers are distributed.
Type
Accessory nerve is a purely motor nerve to supply
muscles developed from sixth branchial arch along
with sternomastoid and trapezius.
Functional Components
The nerve (both cranial and spinal roots) is made up
of only special visceral efferent fibers which supply
muscles developed from mesoderm of sixth branchial
arch.
These muscles are
1. All muscles of soft palate except tensor palati
2. All muscles of pharynx except stylopharyngeus
3. All muscles of larynx except cricothyroid
4. Sternomastoid and trapezius.
Muscles of 1st three groups are supplied by cranial
root of accessory nerve through vagus. Spinal root
supplies sternomastoid and trapezius which are also
considered to be of VIth branchial arch origin.
Fibers of spinal root supplying sternomastoid and
trapezius are sometimes considered to be somatic
efferent in nature.
Nucleus
Nucleus of accessory nerve is single and composite
called nucleus ambiguous. It is the nucleus of special
visceral efferent column and present in lower two-
thirds or lower three-fourths of medulla oblongata.
Its upper part belong to the nuclei of IXth and
Xth cranial nerve. Lower part being the nucleus of
accessory nerve is known as nucleus for cranial root.
It is continuous below with central group of anterior
horn cells of spinal cord of upper five (C1 C5) cervical
segments of spinal cord. It is known as spinal nucleus
of accessory nerve.
Spinal nucleus of accessory nerve is also altern-
atively considered to be of somatic efferent group.
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Nucleus ambiguous (II) Hypoglossal Dorsal nerve root Central group of anterior horn
nucleus cells from C1C5 segments forming
spinal nucleus accessory nerve
Medial longitudinal
bundle

Inferior cerebellar
peduncle

Nucl. of sp. tr. of

V nerve Tectospinal
tract Spinal
nerve
Cranial root of
accessory nerve Ventral
nerve roots

Inferior olivary
nucleus Spinothalamic
tract Spinal root of accessory
Pyramid nerve ascends to join
Medial lemniscus cranial root

Fig. 19.59 Intraneural course of cranial root of accessory nerve Fig. 19.60 Intraneural course of spinal root of accessory nerve

Intraneural Course nerves. Rootlets of cranial accessory nerve unite to

Cranial root (Fig. 19.59)
Cranial root of accessory nerve arises from nucleus
ambiguous. The fibers run ventrolaterally through
tegmental portion of medulla oblongata being flan-
ked medially by medullary reticular formation, spin-
othalamic tract, medial lemniscus, and laterally
by nucleus of spinal tract of trigeminal nerve and
inferior cerebellar peduncle to reach posterolateral
sulcus between olive and inferior cerebellar peduncle
(Fig. 19.59).
Spinal root (Fig. 19.60)
Spinal root is formed by multiple branch of fibers
which arise from central group of anterior horn cell
neurons present from C1C5 segments of spinal cord.
These fibers come out from lateral surface of spinal
cord as five roots between ventral and dorsal roots of
spinal nerve. The five roots ascend and converge to
meet together to form single spinal root of the nerve.
Spinal root finally enter cranium through foramen
magnum to join cranial root, thus forming composite
accessory nerve, that is of course for a shorter length.
Surface Attachment of Nerve Roots
Cranial root (Fig. 19.61)
Multiple rootlets come out from posterolateral sulcus
of medulla oblongata between olive and inferior
cerebellar peduncle. These fibers are in the same
vertical plane with glossopharyngeal and vagus
344
form single nerve trunk as they approach jugular
foramen.
Spinal root (Figs 19.60 and 19.61)
Spinal roots are five pairs in origin, each arising
from lateral surface of spinal cord in between sites
of attachments of ventral and dorsal roots of spinal
nerve. The nerve roots ascend vertically and join
successively with adjacent one to form a single trunk
which enter cranium through foramen magnum.
Intracranial Course (Fig. 19.61)
Intracranial course of both the roots are very short
and join together to approach jugular foramen.
Exit from cranium (Fig. 19.61)
Couple of cranial and spinal accessory nerve
starts the journey together to come out through
intermediate compartment of jugular foramen along
with glossopharyngeal and vagus nerve. Accessory
nerve is enclosed with vagus nerve here in a common
dural sheath.
Extracranial Course and Distribution
Cranial root
While studying, and particularly while asked in
examination the course and distribution of whole
accessory nerve, a learner must not forget or ignore
the course and distribution of cranial root.
Cranial root of accessory nerve joins the vagus
nerve immediately after the nerve comes out of
jugular foramen. It joins proximal to inferior ganglion

Combined cranial and spinal roots
of accessory nerve
Cranial root of
accessory nerve joining
vagus nerve
Spinal root of
accessory nerve
entering through
foramen magnum
Right recurrent laryngeal
nerve
Right vagus
nerve
Fig. 19.61 Surface attachment, intracranial course and exit from cranium of accessory nerve and its relation with vagus nerve
of vagus. Beyond this, cranial root does not possess
its own identity. Its fibers are distributed through
following two branches of vagus.
1. Pharyngeal branch of vagus: Though topogr-
aphically it is a branch of vagus, it contains
special visceral efferent fibers of accessory nerve
to supply
a) All muscles of palate except tensor palati.
b) All muscles of pharynx except stylopharyngeus.
2. Recurrent laryngeal nerve: This branch of
vagus is a mixed nerve. Special visceral efferent
fibers are contributed by cranial root of accessory
which supply all muscles of larynx except crico-
thyroid. Sensory component of the nerve are the
fibers of vagus which supplies infraglottic part of
mucous membrane of larynx.
Spinal root (spinal accessory nerve) (Fig. 19.62)
Being separated from cranial root, it descends
vertically between internal carotid artery and inte-
Cranial Nerves
Rootlets of vagus nerve
Rootlets of cranial
accessory nerve
Jugular foramen
Sup. ganglion of vagus
Inf. ganglion of vagus
Spinal accessory
nerve
Pharyngeal branch of
vagus nerve
Left recurrent
laryngeal nerve
Left vagus nerve
rnal jugular vein, deep to parotid gland and styloid
process. Here it lies in the point midway between
angle of mandible and mastoid process. Next it
changes its direction to pass downwards, backwards
and laterally, superficial to internal jugular vein and
deep to sternocleidomastoid. Here it is related to
number of lymph nodes.
The nerve pierces or passes deep to anterior border
of sternocleidomastoid at its junction of upper one-
fourth and lower three-fourths. Here it communicates
(forms a network) with IInd and IIIrd cervical nerves.
The nerve appears in posterior triangle of neck
coming out of posterior border of sternocleidomastoid
at the junction of upper one-third and lower two-
thirds of the muscle. Here also the nerve is related to
a group of lymph nodes.
In the posterior triangle of neck, spinal accessory
nerve runs downwards, backwards and laterally over
levator scapulae, being embedded in the investing
layer of deep cervical fascia forming the roof of
345
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Levator scapulae
Sternocleidomastoid
Fig. 19.62 Course and distribution of spinal accessory nerve
posterior triangle. The nerve leaves posterior triangle
of neck passing deep to anterior border of trapezius
muscle 5 cm above the level of lateral end of clavicle.
Here spinal accessory nerve forms a network with
fibers of IIIrd and IVth cervical nerves.
Muscular branches of spinal accessory nerve
supply sternocleidomastoid and trapezius.
Proprioceptive supply to these muscles are derived
from IInd, IIIrd and IVth cervical nerves.
CLINICAL ANATOMY
Central lesion of accessory nerve (jointly both the
roots) may occur due to two reasons
l Lateral medullary syndrome
l Jugular foramen syndrome.
In these cases common manifestations of the lesion
of IX, X and XI cranial nerve are observed.
Independent lesion of spinal accessory nerve
may occur due to local cause in posterior triangle of
neck. Usually the spinal accessory nerve, instead of
being damaged, gets irritated causing reflex spasm of
sternocleidomastoid (with trapezius). The condition
is known as torticollis (wry-neck)
346
Lymph nodes
Lymph nodes
IInd and IIIrd cervical nerves
Spinal accessory nerve
IIIrd and IVth cervical nerves
Trapezius
Congenital Torticollis
The term torticollis means a clinical condition that is
characterized by contraction or shortening of cervical
muscles which presents twisting of neck and slanting
of head. Congenital torticollis occurs due to fibrous
tissue tumor in sternocleidomastoid (fibromatosis
colli). It causes head to tilt towards and face to turn
away from affected side. However, it is not related to
lesion of spinal accessory nerve.
n Spasmodic (acquired) torticollis: It gives rise
to similar kind of muscular disability which results
due to irritation of spinal accessory nerve because of
inflamed cervical lymph nodes lying in the vicinity of
the nerve.
Clinical Test for Competence of Spinal
Accessory Nerve
Action of sternocleidomastoid is tested by asking
the patient to turn the face and head to the opposite
side against the resistance applied. Functioning of
trapezius is tested by asking the patient to shrug
(elevate) the shoulders upwards against resistance by
application of pressure with both hands of examiner
over both shoulders of the patient. Weakness of the

muscle of the affected side can be comfirmed when
compared with normal side.
HYPOGLOSSAL NERVE
Introduction
It is the XIIth cranial nerve supplying muscles of
tongue.
Type
Hypoglossal nerve is a purely motor nerve.
Functional Components
Hypoglossal nerve consists of only somatic efferent
fibers which supply muscles developed from occipital
myotome of para-axial mesoderm. These are all
extrinsic as well as intrinsic muscles of tongue except
palatoglossus.
Cranial Nerves
Intraneural Course (Fig. 19.63)
Somatic efferent fibers of hypoglossal nerve arises
from its nucleus in the posterior part of medulla
oblongata. The fibers run forwards traversing central
core of medulla oblongata. While passing forwards
the fibers are flanked medially by medial lemniscus
and pyramid and laterally by spinothalamic tract and
inferior olivary nucleus.
n Exit from brainstem: The nerve comes out in
the form of multiple rootlets through anterolateral
sulcus between pyramid and olive.
Intracranial Course
Intracranial course of the nerve is very short in
posterior cranial fossa. The multiple rootlets unite to
form two trunks which join to form a single nerve at
hypoglossal (anterior condylar) canal.
n Exit from the cranium: Hypoglossal nerve leav-
es cranium through hypoglossal or anterior condylar
canal.

Nucleus Extracranial Course and Distribution (Fig.

Hypoglossal nucleus is elongated of about 2 cm
length. It is subependymal in position in the lower
part of medial eminence of floor of fourth ventricle
corresponding to hypoglossal triangle.
Connections of nucleus
Hypoglossal nucleus possesses connections with follo-
wing areas of brain.
1. Supranuclear connections: Motor area of opposite
cerebral hemisphere.
2. Sensory nuclei of trigeminal nerve.
3. Nucleus tracts solitarius.
4. Reticular formation.
5. Cerebellum.
19.64)
Only following points are to be remembered for
extracranial course.
First it lies behind internal jugular vein from
where it appears in the interval between upper ends
of the vein and internal carotid artery.
The nerve descends for a while crossing in front of
vagus nerve and joined by fibers from C1 nerve.
At the lower border of posterior belly of digastric
and stylohyoid, the nerve turns its direction up-
wards, forwards and medially hooking round lower
sternocleidomastoid branch of occipital artery. The
nerve crosses superficial to internal carotid, external
carotid and loop of lingual arteries to run forwards
over hyoglossus muscle.

Nucleus of spinal tract of trigeminal nerve

Inf. cerebellar peduncle

Hypoglossal nerve nucleus
Spinothalamic tract
Medial longitudinal bundle
Tectospinal tract

Vagus nerve
Medial lemniscus
Inferior olivary nucleus

Pyramid
Hypoglossal nerve (left) exits through
Arcuate nucleus anterolateral sulcus of medulla oblongata

Fig. 19.63 Intraneural course of hypoglossal nerve

347
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Styloglossus muscle
Fibers of hypoglossal nerve
Hyoglossus muscle
Nerve to geniohyoid (C1
fibers carried through
hypoglossal nerve
Nerve to thyrohyoid (C1
fibers carried through
hypoglossal nerve
Hypoglossal nerve crossing
loop of lingual artery
Fig. 19.64 Extracranial course and distribution of hypoglossal nerve
Beyond anterior border of hyoglossus, the nerve
divides into terminal branches inside the tongue.
Branches
1. Terminal branches: For better understanding,
terminal branches are to be discussed first.
Terminal branches of hypoglossal nerve are the
only fibers of the nerve itself, which supply all the
extrinsic as well as intrinsic muscles of tongue
except palatoglossus.
Others are topographically the branches of hypo-
glossal nerve, but these fibers are contributed by Ist
cervical nerve. These branches are as follows:
2. Recurrent meningeal branch: This branch re-
enters cranial cavity through hypoglossal canal to
supply meninges of posterior cranial fossa.
3. Descendens hypoglossi: This branch, arising
from hypoglossal nerve descends first in front
of carotid arteries, and joins with descendens
cervicalis formed by twigs from C2 and C3 nerve
to form ansa cervicalis. Ansa cervicalis is a loop
of nerve, so formed, which is embedded in the
348
Hypoglossal nerve
Recurrent meningeal branch
C1 nerve root
Fibers from C1 nerve
joining XII nerve
C2 nerve root
C3 nerve root
Descendens cervicalis
Ansa cervicalis to supply
infrahyoid muscles
Descendens hypoglossi
anterior wall of carotid sheath. From the ansa (C1,
C2, C3) infrahyoid muscles are supplied.
4. : Some fibers of C1 nerve are carried further
forwards with hypoglossal nerve and bifurcate to
supply geniohyoid and thyrohyoid muscles.
CLINICAL ANATOMY
Lesion of hypoglossal nerve is central in origin
and it is for vascular cause occurring as a result of
occlusion of medullary (paramedian) branches of
vertebral artery. It causes damage to the ventral
part of medulla oblongata. The clinical condition
is called ventral medullary syndrome. It causes
crossed paralysis characterized by contralateral
hemiplegia and paralysis of muscles of tongue of
same half. If the lesion is extensive, it will cause loss
of sense of position and movement and discriminative
touch of opposite side due to involvement of medial
lemniscus. If spinal lemniscus lateral to emerging
fibers of hypoglossal nerve is affected, it will cause
contralateral hemianesthesia.

A Ataxia 138
Abducent nerve 317
Accessory nerve 343
Accommodation reflex 295
Acetylcholine 14, 264265
Acetylcholinesterase 14
Acoustic neuroma 125126
Action potential 12
Adie tonic pupil syndrome 284
Afferent fibers 181
Agraphia 161
Alexia 161
Alveus 171, 190, 253254
Amygdaloid body 180, 258
Amyotrophic lateral sclerosis 93
Angular gyrus 152, 161
Annulospiral endings 48
Anosmia 291
Ansa lenticularis 182
Anterior cord syndrome 90
Anterograde degeneration 42
Aphasia 160, 161, 242
Appendicular pain 286
Aqueduct of Sylvius 27, 186, 192,
225, 304
Arachnoid granulations 221
Arachnoid mater 35, 62, 215, 221
Arachnoid villi 221
Arbor vitae cerebelli 132
Area postrema 143
Argyll Robertson pupil 283, 298
Arnold-Chiari malformation 125
Arteries of brain 228
Astrocytes 14
Astrocytoma 126
Index
Athetosis 183
Atonic bladder 284
Auditory pathway 10, 34, 120, 252
Automatic bladder 285
Autonomic ganglia 43, 263
Autonomic nervous system 4, 260
Autonomous bladder 285
Axolemma 5455
Axon 7
Axon-hillock 8
Axonal degeneration 18
Axonal transport 1819
Axoplasm 13, 18
Axosomatic synapse 12
B surface features 96
Babinski sign 87
Ballismus 183
Band of Baillarger 156
Basal ganglia 32, 176
amygdaloid body 32
caudate nucleus 32
claustrum 32
lentiform nucleus 32
Basal lamina 65
Basal vein 236238
Basilar artery 229
Bell-Magendies law 58
Bells palsy 325
Benedikt syndrome 127
Betz cells 155
Bipolar neuron 10
Bitemporal hemianopia 214
Blood-brain barrier 240, 244
Blood-cerebrospinal fluid barrier 225
Blood supply 174, 228, 237
arteries 228
of brain 228
of internal capsule 174
of spinal cord 237
Brainsand 200
Brainstem 21, 26, 28, 96, 106, 112
arteries related 99
cavity 95
clinical anatomy 124
cranial nerve nuclei 106
embryological background 100
medulla oblongata 26
midbrain 26
pons 26
Brocas area 159, 164
Brown-Squard syndrome 90
Buerger disease 283
Bulb of posterior horn 188
C
Calcarine sulcus 148
Callosal sulcus 154
Cardiac pain 286
Cardiac plexus 270, 342
Cauda equina 59
Caudate nucleus 178
Cavernous sinus 220
Cells of Martinotti 155
Central canal
of spinal cord 65
Central cord syndrome 90
Central gray matter
of spinal cord 65
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
Central lobe 151
Central lobule 132
Central nervous system 2, 20, 25
Cerebellar afferent fibers 134
Cerebellar arteries 229230
Cerebellar cortex 132, 134
Cerebellar disease 184
Cerebellar hemispheres 129
Cerebellar nuclei 135
Cerebellar peduncles 136
Cerebellar syndrome 137
Cerebral aneurysms 243
Cerebral angiography 244
Cerebral aqueduct 120, 185
Cerebral arteries 229
anterior 232
middle 231
posterior 234
Cerebral artery syndromes 241
Cerebral cortex 145
architecture 161
cortical areas 160
sulci and gyri 147
Cerebral peduncle 120, 237
Cerebrospinal fluid 224
Cerebrum 144
basal ganglia 176
cortical gray matter 144
ventricle 185
white matter 163
Chemoreceptors 51
Chorda tympani nerve 323
Chorea 183
Choroid plexus 190, 214
Chromatolysis 4142
Cingulate gyrus 154, 256
Cingulum 164
Circadian rhythm 210
Circle of Willis 232
Clarkes column 70, 75
Claustrum 180
Climbing fibers 134
Cochlear nuclei 332
Commissures 165
Communicating hydrocephalus 227
Complete cord transection syndrome
89
Cord hemisection syndrome 90
Corneal reflex 296
Corona radiata 172
Corpus callosum 153, 165
Corpus striatum 171
Corticospinal tract 78
Cranial nerves 288
abducent 317
accessory 343
facial 319
glossorpharyngeal 334
hypoglossal 347
mandibular 313
350
maxillary 311 F
oculomotor 299
olfactory 288 Facial colliculus 142
ophthalmic 308 Facial nerve 319
optic 293 Facial nerve lesion 325
trigeminal 305 Facial nerve nucleus 318
trochlear 304 Falx cerebri 216
vagus 337 Fasciculus cuneatus 74
vestibulocochlear 326 Fasciculus gracilis 74
Craniopharyngioma 210 Fasciculus lenticularis 183
Cremesteric reflex 87 Fastigial nucleus 136
Culmen 131 Fibrous astrocytes 15
Cuneate nucleus 114 Filum terminale 58, 63
Cuneate tubercle 98 Fimbria 190
Flaccid paralysis 88
Cuneus 154
Flocculonodular lobe of cerebellum
D 140, 327
Flocculus 131, 140
Deafness 333
Folds of dura mater 215
Declive 131132
Foramen 141, 187, 190, 225
Deep middle cerebral vein 236
of Luschka 141, 187, 190
Deep petrosal nerve 278, 312
of Magendie 141, 187, 190
Dendrite 7
Dentate gyrus 255 of Monro 225
Dentate nucleus 136 Forceps major 168
Dermatome 38, 90, 286 Forceps minor 167
Descendens hypoglossi 348 Fornix 170
Diabetes insipidus 210 Fourth ventricle of brain 140
Diencephalon 33, 192 Frey syndrome 284
Dopamine 181, 183 Frontal eye field 159
Dorsal column 73, 74, 92, 284 Frontal nerve 309
Dorsal nucleus of vagus 110, 116 Frontooccipital fasciculus 164
Dorsal raphe nucleus 246 Frontooccipitotemporal fasciculus
Drug and blood-brain barrier 244 164
Dura mater 35, 61, 215
G
E
Gamma motor neuron 49
EdingerWestphal nucleus 110, 123, Ganglion 200
262 autonomic 261
Effect of increased cerebrospinal fluid cervical sympathetic 235
pressure 226 ciliary 275, 302
otic 313
Effector organ 51
pterygopalatine 312
Emboliform nucleus 136
semilunar 307
Emotion disorder 210
Encapsulated receptors 46 spiral 331
End bulb of Krause 47 submandibular 323
End bulb of Ruffini 46 sympathetic 266
En grappe endings 52 vestibular 328
En plaque endings 52 Globose nucleus 136
Enteric nervous system 281 Globus pallidus 179
Entorhinal area 290 Glossopharyngeal nerve 110, 334
Epidural (extradural) hemorrhage Gracile tubercle 97
243 Gray matter 67, 68, 212, 253
Epineurium 38 of spinal cord 6768
Epithalamus 34, 200 Gray rami 266
External band of Baillarger 156 Great cerebral vein 167, 237
Exteroceptive sensations 160 Greater splanchnic nerve 271
Extrafusal fibers 48, 53 Greater superficial petrosal nerve
Extrapyramidal tract 86, 87 322

H Intrafusal fibers 47
Habenular commissure 169, 201, 202
Habenular nuclei 200, 202
Habenular trigone 169
Head-ganglion 204
Hearing loss 333
Hemiballismus 183
Heschls gyrus 152
Hippocampal commissure 170
Hippocampal formation 253
Hippocampus 189, 253
Hirschsprung disease 284
Homonymous hemianopia 298
Horner syndrome 283
Huntington disease 183
Hydrocephalus
communicating 227
noncommunicating 227
Hyperthermia hypothermia 210
Hypoglossal nerve 347
Hypoglossal triangle 142
Hypokinesia 184
Hypothalamic sulcus 211
Hypothalamic syndrome 214
Hypothalamohypophyseal tract 208
Hypothalamospinal tract 83
Hypothalamus 35, 203, 209
functions of 209
I Linea splendens 63
Impaired function of paleocerebellum
138
Important visceral pain
cardiac pain 286
gallbladder pain 286
pain over tip of right shoulder 286
Indusium griseum 255, 257
Inferior alveolar nerve 315
Inferior colliculus 98, 123
Inferior frontal gyrus 151
Inferior longitudinal fasciculus 165
Inferior medullary velum 141
Inferior olivary nucleus 115
Inferior parietal lobule 152
Inferior sagittal sinus 219
Inferior salivatory nucleus 110
Inferior temporal gyrus 152
Inferior vermis 129
Infundibulum 205
Insula 151
Internal capsule 172
Internal medullary lamina 179
Interpeduncular cistern 223
Interstitial nucleus of Cajal 202
Interthalamic adhesion 212
Interventricular foramen of Monro
185187, 190
Intracranial hemorrhage 243
Index
Meningeal arteries 229
Intrapetrous part of facial nerve 321 Meningeal headache 224
Inverted homunculus 157 Meninges 61, 215
Inverted sensory homunculus 160 of brain 215
Ipsilateral paralysis of tongue 125 of spinal cord 61
Meningioma 224
J Metathalamus 34, 198
Microglia 66
Joint receptor 75, 76
Microsmatic 288
K Midbrain 120, 126
internal structure of 120
Knee jerk 88
neoplastic lesion 126
L traumatic lesion 126
Midline shifting 191
Labyrinthine artery 229 Millard Gubler syndrome 126
Lacrimal nerve 309 Motion sickness 333
Lacrimatory nucleus 110 Motor end organs 51
Lamina terminalis 166
secretomotor effectors 52
Lateral corticospinal tract 78
somatic effectors 51
Lateral gray column 25, 238, 267
visceral effectors 51
Lateral lemniscus 122, 332
Motor end plate 54
Lateral medullary syndrome 346
Motor neurons 68
Lateral spinothalamic tract 76
Motor nucleus of facial nerve 320
Layer of cerebral cortex 156
Lemnisci 122 Motor unit 53
Lentiform nucleus 179 Multiple sclerosis 92
Lesion of glossopharyngeal nerve 337 Muscle tone 86
Ligamentum denticulatum 63, 84 Myasthenia gravis 55
Light reflex 294 Myelin sheath 17
Limbic system 253 Myenteric (Auerbach) plexus 343
Myoneural junction 53
Lingual gyrus 155
N
Lingual nerve 315
Lobes of cerebral hemisphere 149 Nasociliary nerve
Locus coeruleus 142 anterior ethmoidal nerve 309
Lower motor neuron 78, 87
communicating branch to ciliary
Lumbar puncture 63, 84
ganglion 309
M infratrochlear nerve 309
long ciliary nerves 309
Macrosmatic 288 posterior ethmoidal branch 309
Maculae 327 Neocerebellar syndrome 138
Macular vision 294 Neostriatum 177
Magnetic resonance imaging (MRI) Nerve supply of dura mater 218
191 Nerve to geniohyoid and thyrohyoid
Mammillary body 205, 207 348
Mammillothalamic tract 207 Nerve to lateral pterygoid 314
Mandibular nerve 313 Nerve to stapedius 322
Mantle zone 23 Nerves 288, 66
Marcoglia 66 cranial 288
Maxillary nerve 311 spinal 66
Medial eminence 142 Nervus conarii 200
Medial longitudinal fasciculus 304 Neural hearing loss 333
Medial olfactory 290 Neurilemmal sheath 18
Median sulcus 142 Neuroendocrine gland 201
Medulla oblongata 112, 124 Neurofibrils 7
Medullary arteries 229 Neuroglia 14, 18, 201
Megacolon 284 activities of 18
Meissners corpuscles 46 astrocytes 14
Mnires syndrome 333 ependymal cell 14
351
 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
microglia 16 red 123 Parietooccipital sulcus 148
oligodendrocytes 15 reticular 247 Parkinson disease 183
satellite cells 17 sensory nuclei 306 Pathway of Sherrington 78
Schwann cells 16 somatic efferent 109 Peduncle 122
Neurohypophysis 208 special somatic afferent 111 Pendulous knee jark 138
Neuromodulators 14 special visceral afferent 110 Peripheral nerve 38
Neuromuscular spindle special visceral efferent 109 endoneurium 39
nuclear bag fibers 47 superior salivatory nucleus 207, epineurium 38
nuclear chain fibers 47 262, 275 perineurium 38
Neuronal (axonal) transport 8 Nucleus marginalis 69 Peripheral nerve injury 41
Neuronal junction (synapse) 12 Nucleus of Onuf 70 Peripheral nervous system 35
axoaxonic 13 Nucleus of trapezoid body 333 Pes hippocampus 190
axodendritic 13 Nucleus proprius 69 Pharyngeal branch of vagus 345
axosomatic 13 Nucleus tractus solitarius 110, 116, Pia mater 35, 63, 215, 223
Neurons 6, 8 320 Pineal gland 200
bipolar 10 Pinealocytes 201
O
Golgi type 10 Plantar reflex 87
motor 11 Obesity and wasting 210 Pneumoventriculography 191
multipolar 10 Obstruction in flow of cerebrospinal Poliomyelitis 92
pseudounipolar 10 fluid at subarachnoid space 226 Pons 117, 125
sensory 11 Occipital lobe internal structure 117
unipolar 8 occipital pole 152 neoplastic lesion 126
Neurotendinous spindles (Golgi ten- upper and lower occipital lobules vascular lesion 125
don organ) 50 152 Pontine raphe nucleus 247
Neurotransmitters 14, 19, 135 Oculomotor nerve 299 Positive Queckenstedt sign 226
Nissl bodies 7 Olfactory cortex 290 Posterior commissure 201, 202
Nissl granules 7, 18 Olfactory epithelium 289 Posterior communicating artery 231
Nonencapsulated receptors Olfactory nerve and olfactory pathway Posterior horn of spinal cord 113, 251
free nerve endings 45 288 Posterior spinal artery 229
hair follicle receptors 46 Olfactory tract 290 Postganglionic branches of ciliary
Merkel disks 46 Olivospinal tract 83 ganglion 302
Nucleus (nuclei) 69, 74, 136, 247 Operculum 151 Postsynaptic membrane 13
ambiguous 109 Ophthalmic artery 231 Postural disorder 184
amygdaloid 180, 259 Ophthalmic nerve 308 Preoptic nucleus 204
arcuate 115, 117 Optic chiasma 293, 298 Presynaptic membrane 13
basal 176 Optic nerve 293 Primary auditory area 162
caudate 178 Optic nerve and visual pathway 291 Proprioceptive sensations 160
cuneate 74, 114 Optic radiation 174 Prosencephalon 192
dentate 135, 136 Optic tract 293 Pulmonary plexus 271, 342
dorsal nucleus (of vagus) 142 Orbital surface Pulsating exophthalmos 224
emboliform 136 gyrus rectus 155 Purkinje cell layer 134
fastigial 135, 136 orbital gyri 155
Purkinje cells 133
general somatic afferent 110 Organ of Corti 330
Putamen 179
general visceral afferent 110 Otic ganglion 313
Pyramidal tract 86
general visceral efferent 110 Oxytocin 208
globose 136 Q
gracilis 74, 114 P
habenular 202 Quadrantic representation of retina
Pachymeninges 35
hypothalamic 206 Paleostriatum 177 293
inferior salivatory nucleus 335 Pallidofugal fibers 182 Queckenstedt sign 85
lentiform 179 Pallidotegmental fibers 183 R
motor nucleus 306, 335 Parahippocampal gyrus 237, 255
nucleus of spinal tract of trigemi- Paraventricular nuclei 200 Raphe nuclei 246
nal nerve 338 Parietal lobe Raphe nucleus magnus 247
nucleus tractus solitarius 335, 338 postcentral gyrus 151 Raynaud disease 283
of cerebellum 135 subdivisions of inferior parietal Receptors
of cranial nerves 106 lobule 152 exteroceptors 44
of thalamus 195 superior and inferior parietal interoceptors 45
proprius 69 lobule 152 proprioceptors 45
352

Receptors other ways of classifica-
tion
chemoreceptors 51
mechanoreceptors 51
nociceptors 51
photoreceptors 51
thermoreceptors 51
Recesses
of fourth ventricle 140
of third ventricle 213
Recurrent laryngeal nerve 345
Red nucleus 123, 124
Relations of brainstem
with cerebrum and cerebellum 94
with tentorium cerebelli 94
Renal pain 286
Reticular formation 245
Reticular nucleus 196
Reticulospinal tract 83
Rexeds lamination of 71
Rigidity 184
Rubrospinal tract 80, 123
S Submucosal (Meissner) plexus 343
Schizophrenia 259
Schwann cell 18
Secondary auditory area 162
Secretion of exocrine glands 1
Sensory root ganglia 42
Septum pellucidum 153, 185
Sexual disorder 210
Sleep disorder 210
Slurred speech 138
Solitariospinal tract 83
Somatic nervous system 4, 260
Somatic neuromuscular junction 52
Some important cisterns
cerebellomedullary cistern 223
cistern of great cerebral vein 223
cistern of lateral sulcus 223
interpeduncular cistern 223
pontine cistern 223
Some important effects of thalamic
lesion
altered higher function 198
motor dysfunction 198
sensory impairment 198
Spasmodic (acquired) torticollis 346
Sphenopalatine ganglion
parasympathetic root 312
sensory root 313
sympathetic root 313
Spinal accessory nerve 345
Spinal cord 57, 63
Spinal cord injuries 88
Spinal cord syndrome 88
Spinal nerves 66
Spinal shock syndrome 88
Spinovisual reflex (visual body reflex)
296
Stereognosis 161
Stomach pain 286
Stria medullaris 142
Stria medullaris thalami 200, 211
Striopallidal fibers 182
Structure of ampullary crest 327
Study of cerebrospinal fluid in differ-
ent diseases 227
Subarachnoid cisterns 222
Subarachnoid hemorrhage 243
Subarachnoid septum 63
Subdivisions of brain
forebrain (prosencephalon) 20
hindbrain (rhombencephalon) 21
midbrain (mesencephalon) 21
Subdivisions of nervous system 2
functional subdivision 3
topographical subdivision 2
Subdural hemorrhage 223, 243
Substantia ferrugenia 142
Substantia gelatinosa 69
Substantia nigra 120, 121
Subthalamic fasciculus 183
Subthalamus 35, 203
Sulci and gyri of insula 150
Sulcus limitans 142
Superficial abdominal reflex 87
Superior fovea 142
Superior laryngeal nerve 340
Superior longitudinal fasciculus 164
Superior salivatory nucleus 110
Suprarenal medulla 271
Sydenham chorea 183
Sympathetic ganglia 263
Sympathetic part of autonomic nerv-
ous system 264
Sympathetic system 264
effector neuron 265
effector organs 265
spinal center 264
supraspinal center 265
Synaptic cleft 13, 54
Syringomyelia 92
T
Tabes dorsalis 91
Tail of caudate nucleus 178
Tapetum 168, 189
Tectospinal tract 81, 122
Tectum (inferior colliculus) 123
Tectum of midbrain 237
Tegmentum 120, 122
Tela choroidea 188
Index
Tela choroidea choroid plexus 214
Temporal lobe
superior, middle and inferior tem-
poral gyri 152
transverse temporal gyri 152
Terminal branches of facial nerve 324
Thalamic radiation 173
Thalamic syndrome 198
Thalamus 34, 153, 193, 197
functions of 197
Thoracic sympathetic ganglia 269
branches from 269
Thrombosis of dural venous sinus 224
Tinnitus 333
Tract 73, 83, 121
anterior corticospinal 78
anterior spinocerebellar 76
anterior spinothalamic 77
ascendingn (afferent) 72
corticobulbar (corticonuclear) 78
coticopontine 117, 121
descending (efferent) 78
dorsal column 73
dorsal spinocerebellar 75
extrapyramidal 86
hypothalamospinal 83
lateral corticospinal 78
lateral spinothalamic 77
olivospinal 83
pyramidal 78
reticulospinal 83
rubrospinal 80
solitariospinal 83
tectospinal 81
vestibulospinal 82
Tract neurons 68
Trail endings 52
Tremor 184
Trigeminal ganglion 307
Trigeminal nerve 305
Trochlear nerve 304
Tuberoinfundibular tract 208
Tumors adjacent to fourth ventricle
143
Tumors of central nervous system 18
Types of nerve fibers in a peripheral
nerve
somatic afferent (sensory) 39
somatic efferent (motor) 39
special visceral afferent 40
special visceral efferent 40
visceral afferent (sensory) 39
visceral efferent (motor) 39
Types of neurons in cerebral cortex
cells of Martinotti 155
fusiform cells 156
granule cells 155
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 Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
horizontal cells of Cajal 156
pyramidal cells 155
Types of sulcus
axial sulcus 148
complete sulcus 148
limiting sulcus 148
operculated sulcus 149
primary sulcus 148
secondary sulcus 148
U
Uncinate fasciculus 164
Uncus 155
Ureteric pain 287
V of brain 163
Vagus nerve 110, 337
in abdomen 342
in the thorax 340
Variations of circle of Willis 232
Varieties of hydrocephalus 190
Various kinds of loss of visual field
297
circumferential blindness 298
hemianopia 298
total blindness 298
Vascular disorder related to verte-
brobasilar system 242
lateral medullary (Wallenberg)
syndrome 242
Millard Gubler syndrome 242
pontine hemorrhage 242
ventral (medial) medullary syn-
drome 242
Weber syndrome 242
Vasopressin 208
Vein of Galen 201, 223, 237
Venous drainage
of brain 236
of spinal cord 239
Venous sinuses of dura mater 219
cavernous sinus 220
inferior petrosal sinus 220
inferior sagittal sinus 219
occipital sinus 219
sigmoid sinus 220
sphenoparietal sinus 221
straight sinus 219
superior petrosal sinus 220
superior sagittal sinus 219
transverse sinus 220
Ventral spinocerebellar tract 75
Ventricular system 185
Vertebrobasilar arterial system 228
Vertigo 333
Vestibular ganglion vestibular nerve
328
Vestibular nucleus 329
Vestibular pathways 326
Vestibulocochlear nerve 326
Vestibulospinal tracts 82
Vestigial organ 200
Visceral pain 285
Visual reflexes 294
W
Wallenberg syndrome 125
Weber syndrome 127
Wernickes area 161
Wernickes speech area 161
White matter 212, 253
of spinal cord 72
White matter of thalamus
external medullary lamina 194
internal medullary lamina 194
stratum zonale 194
X
Xanthochromia 227
Z
Zygapophyseal joint 85
Zygomatic nerve 277

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