Neuro Notes 63 Pages

Neural Axis
May-12-10 9:00 AM
Neuraxis/Neural axis (from bottom to top) 1. Spinal cord 2. Brain stem a. Medulla b. Pons c. Midbrain 3. Cerebellum 4. Diencephalon ( Thalamus & Hypothalamus) 5. Cerebrum ( Cortex)
Spinal Cord (Spina Medullaris)

May-13-10 9:00 AM
Responsible for simple reflex motor actions (ie: removing hand from hot plate) Spinal cord i s 45 cm l ong i nside vertebral column (60-75 cm) Cont'n of brain stem ( medulla oblongata) at the l evel of C1 (atlas) thru the for magnum Spinal cord e nds at o Adults: L1/L2 intervertebral disc (ie: occupies upper 2/3 of vertebral column due to the differential growth of the column) o Infants: L3 o In utero = e ntire l ength of the vertebral column Conus medullaris: the l ower e dge of the spinal cord (from L1/L2 for adults and L3 in i nfants) Neuromere = region of the spinal cord that gives off a pair of spinal nerves (31 segments) o Rootlets attach to the spinal cord o Posterior (Dorsal) root --> Dorsal root (Spinal) ganglion o Anterior (Ventral) root o Mixed Nerve o Posterior (Dorsal) ramus o Anterior (Ventral) ramus Spinal segment: C8, T12, L5, S5, Cx1 (total = 31) Vertebrae: C7, T12, L5, S5, Cx3 ( the coccygeal vertebrae are fused hence total = 30; unfused total = 33) Segmental (regional) anesthesia in epidural space at specific dermatome Laminectomy: removal of l amina of vertebra to release pressure on spinal cord from tumors Bony vertebral prominences: o C7 end of the neck o L4 - at the l evel of the i liac crest Rules for determining location of the spinal segment (go down!!): o Cervical spine + 1 (ie: 5th spinal segment i s opposite to 4th cervical spine) o Upper thoracic (T6) + 2 (ie: 5th upper thoracic segment is across 3rd T3 spine) o Lower thoracic (T7-T10) + 3 o T11 + 4 (L3 spinal segment) o T12 + 6 (S1 spinal segment) o After L1 add requisite spinal spines 2 e nlargements of the spinal cord (to accommodate i ncreased number of neurons) o Cervical enlargement (C5-T1) --> to accommodate the brachial plexus o Lumbar enlargement (L1-L4) --> to accommodate the l umbo-sacral plexus Longitudinal fissures: o Anterior median fissure (AMF) o Anterolateral sulcus (ALS) o Posterior median sulcus (PMS) o Posteriorlateral sulcus (PLS) The spinal cord has been divided i nto two e qual halves by the AMF and the two halves are connected by the white commissure and grey commissure (nerve fibres) Cerebral Dura Mater covers the brain o The periosteum of the cranium i s replaced by the pericranium (5 th layer of scalp) o Cerebral Dura Mater: 2 layers separated by dural venous sinuses Outer e ndosteal layer Inner meningeal layer --> forms tentorium cerebri, tentorium cerebelli, e tc. o NO e pidural space bc outer e ndosteal i s part of pericranium (potential space) o Epidural hematoma needs to be resolved within 24 hrs otherwise death will result Meninges of the spinal cord Spinal Dura Mater (only one l ayer) & considerable e pidural space Arachnoid mater Spinal Pia mater
Spinal Cord Cont'd

May-14-10 9:00 AM
Spinal Dura Mater Extends from the margin of the foramen magnum to the S2 vertebra Epidural space o Fat o Vertebral venous plexus of Baton (Valveless --> hence blood can flow i n both directions): Normal changes i n the abdominal or i ntrathoracic pressure ( -3 to -4 mmHg) does not alter flow i n these veins however coughing, sneezing does Communicates with the: Radicals of veins Caval system of veins Azygous system of veins (not paired with arteries slow ) Thyroid gland veins Prostrate veins Breast veins Due to the vertebral venous plexus, there can be metastasis from different organs to the spinal cord, hence causing compression of the spinal cord 4 possible routes of metastasis (in order): Lymphatics Venous system Arterial system Organ to organ o Roots of the spinal nerve (hence segmental/regional/epidural anesthesia can be achieved via the e pidural space) Epidural anesthesia o Most common procedure: Childbirth o Through the sacral hiatus Subdural space: between dura mater & arachnoid mater Arachnoid Mater (avascular) Extends from the margin of the foramen magnum to the S2 vertebra Subarachnoid space: bt arachnoid mater and spinal pia mater Cerebral Cysterms: e nlarged subarachnoid space at base of brain; contains CSF Spinal Cysterns: e nlarged subarachnoid space w/ CSF from L1-S2 of spinal cord o Function: Protection of cauda equina Spinal Pia Mater (Vascular layer) The pia mater e nds at the dorsum of the coccyx Modifications of the spinal pia mater o Ligamentum Denticulatum (21 pairs): extensions from pia mater that att to i nner surf of dura mater = anchorage Selective Risotomy: cutting some of the rootlets i n the sensory dorsal root This l igament = partition bt dorsal & ventral roots (helps i dentification) o Linea Splendence: Thickened part of the pia mater i n the region of the anterior median fissure (no clinical significance) o Filum Terminale (not very vascular) Thread-like e xtension of pia mater from tip of the conus medullaris S2 --> pierces arachnoid & dura mater and attaches to dorsum of coccyx Anchoring capacity to the spinal cord during e xtreme flexion Filum terminale internum (Up to S2) Filum terminale externum (after piercing the 2 meninges past the l evel of S2) Cauda Equina o Tip of spinal cord has appearance of a horse tail since the spinal cord e nds at L1/L2 o Lower 4 Lumbar nerves, Sacral, Coccgeal nerves and the filum terminale ( non- nervous part of the cauda equina)
nervous part of the cauda equina)

Lumbar Puncture (Spinal Tap) Performed at the l evel of L3-L4 preferably (or between L2-L3) Purpose: Spinal anesthesia, sampling of the CSF ( microbiological, pathological analysis) Position: Extreme flexion/Lateral decubitus (so that the spinal cord moves up) Layers pierced before reaching the subarachnoid space ( from outside to i nside): o Skin o Connective tissue (superficial/deep fascia) o Supraspinous l igament o Interspinous l igament o Ligamentum flavum o Dura Mater o Arachnoid mater When blood seen i n needle = reached e pidural space ( due to venous plexus), go further i n Rate of collection of CSF: 1 drop/min Contraindications for LP o Increased ICP (Normal ~ 0-20 mmHg i n supine and -10mmHg i n the vertical position) = herniation of cerebellar tonsils and medulla (resp & CVS center) thru for magnum Normal CSF P: Supine = 80-100 mmH2O; Standing = 300-400 mmH2O i n Spinal Cystern Complications after LP: o Severe headache --> specific cause unknown If there i s cont'd l eakage of CSF which can't be replenished fast e nough = brain -sensitive structures. Dilation (widening) of the veins i n the brain after procedure o Severe lower limb pain --> Damage to nerves (peripheral nerves) i n the cauda e quine (lower l umbar, sacral, coccygeal), but they can regenerate bc peripheral nature
Dorsal Column - Medial Lemniscus Pathway

May-17-10 9:00 AM
Discriminative G eneral Senses --> carried by dorsal column Discriminative touch, vibration, stereognosis, conscious proprioception Input from: Paccinian & Meissner's corpuscles, joint receptors, muscle spindle & GTO Anterior spinothalamic pathway --> l ight touch, pressure, tickle, i tch Lateral spinothalamic pathway --> pain, temperature Spinocerebellar pathway --> proprioceptors to cerebellum Anterior --> have crossed & uncrossed fibers Posterior --> uncrossed fibers only Cuneocerebellar pathway --> unconscious proprioception Every sensation has to reach the thalamus before reaching the higher center (except Olfactory) Dorsal Root Ganglion (DRG) --> SPINAL CORD FIRST ORDER Fasciculus gracilis ( medial) carries sensory from LOWER LIMB Fasciculus cuneatus (lateral) carries sensory from UPPER LIMB & THORAX
Medulla Oblongata SECOND ORDER F gracilis synapses at GRACILE NUCLEUS F cuneatus synapses at CUNEATE NUCLEUS
2ND ORDER NEURONS CROSS TO OPPOSITE SIDE (CONTRALATERAL) SIDE OF BRAIN AT MIDLINE OF MEDULLA = Internal Arcuate Fibers From pons onward = "Medial Lemniscus Pathway" Thalamus 2nd order neurons synapse at VENTRAL POSTEROLATERAL (VPL) NUCLEUS OF THALAMUS THIRD ORDER Project to postcentral gyrus via post limb of internal capsule --> SOMESTHETIC SENSORY AREA (AREAS 3, 1, 2) in cortex
TOUCH ON LEFT SIDE G OES TO RIGHT SIDE OF BRAIN Clinical Scenarios Tumor at C5 --> affects dorsal column tract = loss of discriminative general senses at & below C5 on IPSILATERAL side Lesion at Fasciculus G racilis --> flaccid paralysis in l ower trunk & l ower l imb Lesion at Fasciculus Cuneatus --> spastic paralysis (weakness i n muscle tone) In upper If RIGHT MEDIAL LEMNISCUS is damaged = l oss of discriminative sensation on LEFT side If damage on RIGHT SIDE OF T11 = lose sensation on SAME side below T11 Astereogenesis: inability to discriminate bt objects of different shapes, textures, weight & size based on just touch Damaged sensory nerve pathways ( posterior funiculus) Lesions i n parietal l obe = astereogenesis on CONTRALATERAL side DDx: ask patient to close their e yes and i dentify a familiar object i n their hand Romberg sign: neurological test used to assess dorsal columns of spinal cord - essential for
Romberg sign: neurological test used to assess dorsal columns of spinal cord - essential for proprioception & vibration +ve = sensory ataxia ( ie: l oss of proprioception) Loss of balance when person i s standing straight w/ feet together Conditions affecting dorsal columns of spinal cord Conditions affecting sensory nerves (CN V II) -ve = cerebellar ataxia ( ie: l ocalized cerebellar dysfunction); vestibular disorder Can't use test bc e ven when e yes are open, these patients can't stand straight
Spinothalamic Tract
May-18-10 9:09 AM
Spinothala mic Tract Lateral Spinothalamic Tract located i n l ateral column carries PAIN & TEMPERATURE sensations Pain: noxious stimuli or unpleasant sensation; protective mechanism Caused by cell i njury or potential cell i njury ( ie: i ncreased prostaglandins) Indicates i f there i s something wrong with specific organ (ie: i nternal i njuries) Pain receptors: free nerve e ndings - NEVER adapts Fast Pain carried by G roup III (A ) fibers Gray Matter of the Spinal Cord Thickly myelinated fibers Anterior, Post & Lateral Horn cells Sharp & pricking pain Divided i nto many 10 laminas Latency period i s very short --> NOT blocked by morphine Each l amina corresp to cells Very well localized Lateral Spinothalamic Tract Less e motional = pain i s not i nhibited = pain pathway Neospinothalamic Tract Slow Pain carried by Group IV (C) fibers Dull, burning sensation Slow onset --> CAN be blocked by morphine before pain reaches maximum Diffuse (poor l ocalization) Emotional, autonomic response = can i nhibit pain Paleospinothalamic Tract Pain i s i nhibited by the body We don't take pain killers for small pains Analgesic System w/in body to maintain pain Rubbing painful area will give temporary relief of pain sensation When e motions are running high, pain systems are i nhibited
Audio recording started: 9:18 A M May-18-10
Gate Control Theory of Pain Sensation (Melzak, 1965) You have to stop the pain sensation before i t reaches the cortex Lamina 2: Substantia Gelatinosa Rolando (SGR) "Gate" i s l ocated i n the posterior horn cell of the SPINAL CORD Rubbing painful area relieves pain bc the collaterals of the thickly-myelinated, touch fibers stimulate SG cells & T cells T cells releases SUBSTANCE P - allows pain sensation to ascend If release of substance P is blocked = inhibition of pain system SG cells inhibit T-cells --> can't release Substance P --> pain can't ascend Thinly-myelinated fibers inhibit SG cells and stimulate the T-cells Transection of lateral spinothalamic tract = CONTRALATERAL loss of pain & temp below lesion (pain i sn't completely l ost bc spinoreticular pathway also carries pain)
Descending Pain Inhibiting System

May-19-10 Audio recording started: 9:11 A M May -19-10 9:09 AM
Audio Recording
Pain perceived i n area #43 1970 - endogenous morphine-l ike substances found (ie: e nkephalin & e ndorphins) Magnus Raphae Nucleus i n pons Very rich i n SEROTONIN Substantia G elatinosa Rolando i n spinal cord Opiate-binding receptor substances found i n Periaqueductal G rey Matter in MIDBRAIN Collaterals given from pain system to periaqueductal grey matter as system ascends which i s connected to Magnus Raphae Nucleus --> SGR --> release Serotonin (Descending Pain Inhibiting System) Magnus Raphae Tract bt MRN & SGR = release of Serotonin from MRT & release of ENKEPHALIN from SG cells = i nhibits release of P -substance from Tcells When e motions are very high, stimulates Periaqueductal G rey Matter --> stimulates MRN --> releases Serotonin --> SGR --> release Enkephalin --> block P-substance Insufficient blockage of P substance i n normal conditions, but when e motions are very very high, the whole pain system i s blocked Analgesics stimulate the Periaqueductal G rey Matter Enkephalins INHIBIT P-substance If pain system doesn't reach the cortex --> don't feel pain at all Pain killers not needed for e very l ittle thing bc body will take care of i tself Taking pain killers all the time decreases the sensitivity of the nuclei Somatic Pain felt i n affected organ Visceral Pain felt i n superficial somatic structure (referred pain) Referred Pain: Pain i n deeper diseased viscera i s felt i n the superficial somatic structure Diaphragm pain i s felt i n neck region (Dermatome C3, C4) Gall Bladder pain i s felt i n back Heart pain felt i n shoulder region 3 Theories: A combination of these theories explain Referred Pain 1. Dermatomal Rule: during devl't, the deeper diseased viscera (ie: septum transversum) has carried its i nhibition from the higher region (ie: septum transversum descends from neck region) Deeper diseased viscera & superficial somatic structure are derived from same dermatome Every organ does NOT present referred pain (this theory doesn't completely e xplain) 2. Convergence: pain from superficial somatic structure & deeper diseased viscera synapse i n spinal cord next to e ach other ( synapses converge in same segment) then ascend via pain system Higher brain center perceives pain i n superficial somatic structure i nstead of viscera ( is not explained completely e ither) 3. Facilitation: pain from superficial somatic structure gives off a collateral i n spinal cord which facilitates stimulation so that the higher brain perceives pain from superficial (but still doesn't explain why brain doesn't perceive visceral pain) If you damage Area #43 on one side, you DO NOT lose pain & temperature sensation! Damage to area #43 doesn't affect sensation because there i s BILATERAL INPUT Phantom Limb Pain Pain comes from amputated l imbs Selective Risotomy: take out few fibers of dorsal nerve root --> pain doesn't reach spinal cord Performed i f pain killers aren't helping If this still presents i n pain, must amputate l imb (ie: i n diabetic patients) Sensory Projection Law Each part of the body i s received by i ts specific segment i n Area 43 of cortex That part of the cortex has l earned where i t i s receiving pain sensation from If l imb has been amputated, the cut e nds of the nerves get e ntangled = Neuromass Compression of neuromasses l eads to stimulation i n cortex = perceives pain i n that region
Spinocerebellar Tract
May-20-10 9:14 AM
Audio recording started: 9:21 A M May -20-10
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Carry unconscious proprioception for Lower Limb & Lower part of the Trunk Ascend to Cerebellum These tracts conduct i mpulses at a faster rate than any other tract i n the body ( 125 m/s) Has to be faster so that body can prepare for mov't Receptors are proprioceptors/stretch receptors i n muscle fibers ( ie: Golgi Tendon) Dorsocerebellar (DSCT): unconscious proprioception from spinldles via Group Ia & II First order neurons in DRG First order touch fibers give off collaterals to Lamina 7 in Clark's Column of Cells ( Nucleus Dorsalis) Clark's Column of Cells only present from T1-L2 Also receives fibers from Group Ia & II from muscle spindle 2nd order fibers collaterals of touch pthwy from Nucleus Dorsalis become Spinocerebellar Tract Fibers cross on the same side of the spinal cord & ascend up through l ength of spinal cord
Ventrocerebellar
Cuneocerebellar Pathway
May-25-10 11:08 AM
Audio recording started: 11:15 A M May-25-10 Audio recording started: 11:22 A M May-25-10
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Spinocerebellar Tract carries unconscious proprioception from l ower l imb Anterior --> carries e fferent copy T1-L2 go to Clark's column of cells (Nucleus Dorsalis) Above C8there i s NO Clarke's column of cells From upper limb fasciculus cuneatus ascends up to medulla oblongata and give collaterals to accessory cuneate nucleus (behaves l ike Clark's column) Follow ICP to cerebellum Cuneocerebellar Pathway (homologous to spinocerebellar pthwy) OTHER ASCENDING TRACTS Ventral Spinothalamic Tract (light touch, pressure) 1st ORDER: free nerve e ndings (Merkel's disk); i n DRG --> Tcells 2nd ORDER: dorsal horn i n Lamina 4-6, cross via Ant grey commissure & travel up as Ant STT 3rd ORDER: from thalamus to Areas 3, 1, 2 i n cortex This pthwy allows for maintainance of l ight touch & pressure sensation
Spinotectal: visual reflexes Fibers from visual pthwy reach Superior Colliculus of tectum of midbrain Fibers from sound pthwy & cutaneous sensations also carried via this pthwy When you pinch the skin on the neck (or squeeze trapezius) = slight dilation of ipsilateral pupil Spinoreticular: diffused pthwy, carries PAIN = e motional response Cell bodies l ocated i n DRG & ascend i n brain stem --> go IPSI or CONTRA and then ascend to thalamus & hypothalamus then diffuses If lateral spinothalamic pthwy is damaged; this pthwy still maintains pain sensation Spinoolivary Reflexes Upper motor neurons: from cortex or brainstem to spinal cord Once a reflex gets conditioned (ie: withdrawal reflex), depending on how strong the stimuli i s If someone gets any noxious stimuli = WITHDRAWAL & COUNTEREXTENSION REFLEXES Reflexes are due to plasticity of nerve fibers (we have l earned and kept the reflex) Anterior Column/Grey Matter/Horn cells: contains LOWER MOTOR NEURONS Lower motor neurons Alpha-motor neurons = Final Common Pathway of Sherrington Each measures about 25 m, thickly myelinated fibers Conduct i mpulses at rate of 115-120 m/s Supply striated muscle fibers at motor end plate Motor unit: single alpha-motor neuron divides to supply many striated muscle fibers (ie: a single alpha-motor neuron can supply
striated muscle fibers (ie: a single alpha-motor neuron can supply 100s of e xtrafusal muscle fibers) = mass contraction or skilled activity Larger motor unit: supplies 100s Smaller motor unit: supplies ~5 muscle fibers Phasic alpha-motor neurons: heavy l ifting (mass contraction) supplies many muscle fibers Sometimes becomes purposeless because don't contract to prerequisite l ength; contraction depends on muscle spindles Tonic alpha-motor neurons: skilled activity only supplies few muscle fibers Contract to prerequisite length of muscle contraction Monosynaptic reflex loop from Group Ia fibers from muscle spindle and influence from higher center (suppression or i nhibition) Gamma-motor neurons Beta-motor neurons Brown-Sequerd Syndrome: hemisection of spinal cord Ex: 32 yo male stabbed i n the back at T7; no 2-point discrimination & no pain i n right l ower l imb. Which pathway was damaged? PAIN At level of Lesion (T7) Bilateral loss of pain sensation Ipsilateral l oss of discriminative general senses (DGS) Lower motor neuron paralysis alpha motor neuron damage = flaccid paralysis Gamma motor neuron damage = atrophy Ipsilateral l oss of unconscious proprioception (DSCT) Below lesion Contralateral l oss of pain sensation Ipsilateral l oss of DGS Ipsilateral l oss of unconscious proprioception (DSCT) Above lesion Normal pain sensation Normal DGS
Anterior Horn Cells

May-26-10 Audio recording started: 11:10 AM May-26-10 11:10 AM
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Alpha-motor neurons Monosynaptic reflex loop from G roup Ia fibers of muscle spindle As they supply striated muscle fibers, give collaterals to interneurons (many i n grey matter) Renshaw cells --> INHIBIT adj alpha-motor neurons = inhibit the antagonistic muscles When you are flexing, you need to have i nhibition of the e xtensors Prevents excessive alpha-firing & may be antagonists Strichnine (plant poison) i nhibits these i nterneurons ( Renshaw cells) = person will die of convulsions Final common Sherrington Pathway Gama-motor neurons: l ess thickly-myelinated (10-25 m) fibers; conduction = 10-45 m/s supply intrafusal fibers (Nuclear bag & chain fibers) of muscle spindle (2-5 mm bundles) = stretch receptors --> maintain muscle tone
Muscle spindles = 2-5mm i nside muscle fibers = stretch receptors Nuclear Bag Fibers Nuclear Chain Fibers
Muscle tone: sustained muscle contraction ( partial state of a muscle contraction) Determined by muscle spindle
Anterior Horn Cells

5-10 m ins of recording is m issing Audio recording started: 11:46 A M May-26-10
Gamma motor neurons Thinly - myelinated Dynamic ( 1): supply polar region of nuclear bag fibers --> Trail Endings Detect motion of muscle Stimulation of 1 = stimulate polar regions of nuclear bag fibers = stretch Nuclear bag surr by Annulo-spiral nerve endings = Group Ia fibers where i t e nds Annulospiral nerve endings are non-contactile; when bag stretches, nerve endings stimulated and i nfo sent via Group Ia fibers to alpha-motor neurons --> skeletal muscle fibers Determines rate of change of contraction of muscle fibers 1 damage = lead-pipe rigidity Parkinson's: 2 hyperactivity = cog-wheel rigidity Static ( 2): supply polar region of nuclear chain fibers --> non-contractile
Adaptation of change after contraction has happened Group II fibers --> monosynaptic reflex l oop to alpha fibers (extrafusal) Gamma Reflex Loop Constantly i nfluenced by upper motor neurons Lower motor neuron paralysis = ATROPHY bc intrafusal spindle becomes flaccid hyperactivity --> Clasp-knife rigidity = i nitial resistance followed by sudden release Upper motor neuron paralysis = no atrophy
Descending Tracts
May-27-10 Audio recording started: 11:05 AM May -27-10 11:04 AM
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Areflexia: paralysis caused by damage to l ower motor neurons

Motor system Pyramidal system: originate from giant pyramidal cells i n 3rd l ayer of cortex Supplementary motor cortex (area 4 & 6) Area 3,1,2 contributes Fibers descend thru corona radiata Extra-pyramidal system
Pyramidal System Corticospinal Lateral corticospinal Tract Anterior corticospinal Tract Giant cells of Bertz: found i n precentral gyrus and i n anterior paracentral l obule Bell's Palsy: paralysis of contralateral l ower side of face (along l ip) Test for CNVII damage: ask patient to smile & check i f l ips are aligned Ask patient to close e yes & resist while you try to open i t --> i f patient can't resist = paralysis of obicularis oculi (CN III) If patient can wrinkle forehead = CN VII damage Damage to area above brain stem --> Upper motor neuron damage Damage in brain stem --> Upper & Lower motor neuron damage Damage below brain stem --> lower motor neuron damage Transection = spastic hemiparesis w/ Babinski sign Corticobulbar Corticonuclear fibers pass thru genu of i nternal capsule after corona radiata Some fibers synapse i n cranial nerve nuclei (lower motor neurons) of brain stem & descend downward Most fibers synapse on contralateral cranial nerve nuclei of brain stem
Extra-pyramidal System Not from cortex, other parts of the brain i nstead Vestibulospinal Tract --> e xtensor tone Standing e rect ctrld by this system Olivospinal --> compares skilled activity Tectospinal Tract --> vision Responsible for cutaneous stimulation Reticulospinal --> activity Rubrospinal --> flexor tone
Brain Stem Houses cranionuclei, EXCEPT Olfactory & Optic N Cardiovascular & Respiratory Centers i n LOWER MEDULLA OBLONGATA Reticular System Ascending Reticular Activating System (ARAS): i mportant for arousal from sleep and from wakefulness to AWAREness Constantly charging NTs to be awake Sometimes you are so tired and unaware of surroundings bc l ess active Must check cross symptoms Lesions always l ead to crossed systems ( ie: l oss of pain & temperature on RIGHT side of face, but LEFT side of body) If there i s a l ower motor neuron paralysis on l eft side of tongue and upper motor neuron paralysis on right side of body Stroke: i schemia i n brain ( different classifications); neurological symptoms l ast greater than 24 hours Vertigo: nausea & dizziness Transient Ischemic Attack (TIA): symptoms l ast <24 hrs 3 Segments --> connected to cerebellum Medulla Oblongata connected to cerebellum via ICP (Restiform body) Pons connected to cerebellum via MCP (Brachium pontis) Midbrain connected to cerebellum via SCP (Brachium conjunctivum)
Medulla Oblongata
May-28-10 Audio recording started: 11:25 AM May -28-10 11:21 AM
Medul l a Obl onga ta
Capital punishment --> when you break the atlantoaxial joint = crushes odontoid process of axis & cardiovascular centers i n medulla obl Medulla Oblongata Contains cranial nerve nuclei Motor derived from basal l amina Sensory derived from alar l amina Piriform-shaped structure; l ength ~3cm & max transverse diam i n cranial part ~2cm Upward continuation of spinal cord at Spinomedullary junction: Junction bt medulla & spinal cord Horizontal l ine just above att of 1st pair of cervical nerves; approximately crosses middle of odontoid process of axis (C2) Cranial nerves that e merge from horizontal line (medial to lateral): CN VI, VII, VIII
Pons
Ponto-medullary junction: horizontal sulcus bt medulla & pons Nerves e merge out from medial to l ateral from horizontal sulcus: Abducens (VI) bt medial part of sulcus & pons Facial (VII), & Vestibulocochlear (VIII) bt olive & l ower part of pons motor part of Facial i s more medial than sensory (Nervous intermedius) Striae Medullare: separates pons from medulla oblongata on posterior side Internal Structure of Medulla Oblongata
Internal Structure of Medulla Oblongata
Crossed motor paralysis: Inferior Superior Alternating Hemiplasia: i psilateral /contralat presentation i n diff parts of the body Unilateral l esion i n brainstem affecting UMN & LMN Affects majority of l imb & trunk muscles on contra side due to UMN decussation Cause i psilat paralysis of cranial nerve due to l ack of decussation ( ie: 3, 6, 12 --> facial muscles on i psi side) Inferior: Medial Medullary Syndrome (Dejeune syndrome) Infarction of medial part of medulla Ipsilateral = hypoglossal nerve damage = deviation of tongue on same side Contralateral = l imb weakness (corticospinal tract damage) Loss of discrete touch, conscious proprioception, vibration ( damage to medial lemniscus) Superior: Weber's syndrome= occulomotor nerve palsy Manifestation of decompression syndrome Dmg to paramedian branches of post cerebral art or perforating arteries Ipsilateral: occulomotor nerve palsy w/ drooping e yelid Contralateral: corticospinal & corticobulbar tracts damage (UMN dmg & l ower facial muscles & tongue Substantia nigra: contralateral parkinsonism
Pyramidal (Motor) Decussation of Medulla

May-31-10 11:12 AM
Audio recording started: 11:15 A M May-31-10
Brain Stem Cont'd
Pyramidal Decussation Supraspinal Nucleus: part of central grey matter that i s detached; descends down to C5 Lamina 2 of post grey column of spinal cord corresp to Substantia Gelatinoso Rolando (SGR) Spinal Nucleus of Trigeminal Nerve: i n continuation with SGR; e nds at Ponto-medullary Junc'n then continues with principle sensory nucleus of Pons Extended across e ntire l ength of medulla oblongata Separated from surface of medulla obl by Spinal Tract of Trigeminal Nerve
Clinical Scenarios If spinal nucleus of damaged = l oss of pain & temp from IPSILATERAL side If trigeminal lemniscus damaged = l oss of pain & temp from CONTRALATERAL If spinal lemniscus & trigeminal lemniscus damaged i n medulla Alternating hemianesthesia --> l oss of pain & temp i psilaterally from head/neck & contralaterally from body Sensory Decussation Pyramids i n ventral part --> corticospinal fibers (few corticobulbar) White matter --> ascending & descending tracts Grey matter --> Gracile Nucleus & Cuneate Nucleus Fibers from both cross = Internal Arcuate Fibers and then ascend as Medial Lemniscus Sensory fibers are decussating Cranial Nerve Nuclei appears here Hypoglossal Nucleus: belongs to general somatic efferent (GSE) column Fibers to all muscles of tongue except Palatoglossus & Styloglossus Main bulk of tongue ctrld by Genioglossus ("life-saving" muscle bc protrudes tongue to open airway) Paralysis of genioglossus = tongue falls back --> closes oropharynx = death by suffocation Injury to hypoglossal nerve = Lower motor neuron paralysis
Injury to hypoglossal nerve = Lower motor neuron paralysis To test, ask patient to protrude tongue --> deviates to affected side Upper motor neuron lesions --> contralateral
Sensory Decussation of Medulla

June-01-10 11:21 AM
Audio recording started: 11:21 A M J une-01-10
Sens ory Decus s a t...
Medial Zone supplied by Anterior Spinal A. --> 4th part of Vertebral A Clinical Scenarios Strokes in vicinity of Brain stem = devastating effects Medial Medullary syndrome = blockage of Ant spinal A Medial zone of medulla damaged = INFERIOR CROSSED MOTOR PARALYSIS (aka: Inferior Alternating Hemiplasia) Damage to corticospinal fibers from pyramid = UPPER MOTOR NEURON PARALYSIS, contralateral No atrophy Hyperreflexia Rigidity Positive Babinsky Sign If right side of pyramid damaged --> e ntire LEFT side of body paralyzed Damage to Hypoglossal Nucleus = damage to IPSILATERAL tongue muscles Hypoglossal Palsy: fasciculus, atrophy, flaccid paralysis If you see tongue muscle involvement + effects on contralateral side of body = MEDIAL MEDULLARY SYNDROME Damage of Medial Lemniscus --> l ose CONTRALATERAL touch, vibration, pressure, stereognosis
Medulla Oblongata at Level of Olive

June-02-10 11:22 AM
Medul l a Obl onga t...
Section of Medulla at Level of Olive 3 zones --> Medial, Lateral, Intermediate Olive produced by Inferior Olivary Nuclear Complex --> corticoolivary & spinoolivary fibers Efferents --> cerebellum = climbing fibers --> synapse w/ purkinje cells Stereotypic skilled activity Medial Zone Medial l emniscus Tectospinal tract Medial Longitudinal Fasciculus (MLF): l esion can cause nystagmus CN XII nuclei (efferent column i n Hypoglossal column) --> anterior-l ateral sulcus Intermediate Zone Afferents: sensory motor cortex (corticoolivary fibers), red nucleus (rubroolivary fibers), spinal cord from anterior & l ateral column (Spinoolivary fibers) Efferents: Inferior cerebellar peduncle --> cerebellum --> climbing fibers (on purkinje cells) Nucleus Ambigus: gives bronchomotor fibers to cranial parts of CN IX, X, XI --> e fferent column Supplies soft palate, vocal cords Dorsal Nucleus of Vagus: gives preganglionic PS fibers to heart, sm muscles of resp & alimentary canal & glandular e pith; l ocated l ateral to hypoglossal nucleus Nucleus of Tractus Solitarus: belongs to visceral afferent column (SVA) Receives taste sensation from V II, IX, X ( sensory nerves of tongue) Inferior Salivatory Nucleus: belongs to visceral e fferent column Preganglionic PS fibers to parotid gland via CN IX Lateral Zone --> Anything that l ies beneath ICP
Other Structures in Lateral Zone Ventral & Dorsal Spinocerebellar Tracts Lateral Spino-thalamic Tract ( Spinal Lemniscus begins at Pont-medullary junc'n) Supplied by Posterior Inferior Cerebellar Artery (PICA) Lateral Medullary Syndrome (Wallenberg's Syndrome): most common brain stem syndromes; caused by hemorrhagic stroke, embolic stroke, tumors Alternating Hemianesthesia: ipsilateral loss of pain & temp from face & contralateral loss of pain & temp from rest of body Damage to LEFT Spinal Nucleus of Trigeminal N --> loss of pain & temp from LEFT side of face & RIGHT side of body Damage to Spinal Lemniscus Ipsilateral Horner's Syndrome
Partial ptosis: partial drooping of upper e yelid --> due to damage to descending autonomic fibers Hypothalamus = head ganglion of autonomic sys Lateral horn cell of spinal cord only from T1-L2 = preganglionic fibers of sympathetic ( White rami communicantes) Myosis: constriction of pupil resulting from paralysis of dilator muscle of i ris Anhydrosis: no sweating from affected side (ipsilateral) Enopthalmus: sunken e yeballs bc fat l oculi i n orbit are supplied by post- ganglionic sympathetic fibers Vasodilation = i ncreased blood flow i n face & neck (flushing) Dysphagia: difficulty swallowing bc damage to Nucleus Ambigus --> all pharyngeal muscles paralyzed Hoarseness of voice: paralysis of Recurrent Laryngeal ( Vagus) --> Nucleus Ambigus Ipsilateral Ataxia because of damage to i nferior cerebellar peduncle Decreased sensitivity to l ight touch due to damage to spinal nucleus of trigeminal
Pons
June-03-10 Audio recording started: 11:20 A M J une-03-10 11:17 AM
Audio Rec...
Pons: bridge bt midbrain, medulla & cerebellum External Features (Ventral)
Basilar Part of the Pons

June-07-10 11:11 AM
Pons Cont'd
Pons at level of Facial Colliculus

June-08-10 11:14 AM
Pons Cont'd
Basilar Part of Pons at level of Facial Colliculus Verticle fibers Horizontal fibers Ponti nuclei Neurobiotaxis phenomenon --> Facial N l oops around abducens nucleus Dorsal to trapezoid body i n tegmentum = chain of l emniscus system
Pons at level of Trigeminal Nuclei

June-10-10 11:09 AM
TEST 1 ON MONDAY JUNE 14
Pons at level of Tri...
Pons at the Level of Trigeminal Nuclei Just above the facial colliculus Medial lemniscus (cell bodies i n medulla) Spinal lemniscus (cell bodies i n dorsal horn of spinal cord --> Laminas 4-6 Trigeminal lemniscus Lateral lemniscus (cell bodies i n superior olivary nuclear complex (2 o) & cochlear nuclei (3o)) Bronchomotor fibers: from motor nucleus of trigeminal N --> joins the l ateral thicker sensory part of nerve --> trigeminal ganglion; supplies muscles derived from 1st pharyngeal arch Muscles of mastication; Masseter, temporalis, med & l at pterygoids, tensor tympani, tensor veli palati, anterior belly of digastric
If Trigeminal N i s i ntact, but can't feel touch sensation during corneal reflex = lesion i n principal nucleus of pons i n brainstem
Pontine Syndromes Medial Pontine Syndrome: results when short circumferential branches of Basilar A i n pons are damaged Symptoms Usually unilateral damage Damage to corticospinal tract = contralateral hemiparesis of body (UPPER MOTOR NEURON TYPE OF PARALYSIS) Hyporeflexia (NO ATROPHY) Rigidity Spasticity Raymond's Syndrome (aka Alternating Abducens Hemiplasia): damage to Abducens nucleus Lower motor neuron type of Lateral Rectus paralysis --> medial strabismus (eye will move to medial side) Upper motor neuron type of paralysis on contralateral side of body --> l oss of proprioception & tactile pressure Miller-Gubler Syndrome (aka Alternating Facial Hemiplasia): ipsilateral LOWER MOTOR NEURON PARALYSIS of facial musculature Contralateral UPPER MOTOR NEURON PARALYSIS of body Lateral Pontine Syndrome: damage to l ong circumferential branches of Basilar A Ipsilateral l imb ataxia ( due to damage to ICP) Ipsilateral Horner's syndrome ( due to damage of descending autonomic fibers) Partial Ptosis Myosis Anhydrosis Enopthalmus Contralateral l oss of pain & temp from body ( damage to spinal l emniscus) Ipsilateral l oss of pain & temp from face ( damage to spinal nucleus of trigeminal) Alternating Trigeminal Hemiplasia: paralysis of muscles of mastication How to differentiate bt Lat Medullary & Pontine Syndromes Lateral Pontine Syndrome Hearing loss due to i nvolvement of cochlear component of vestibulocochlear N Ipsilateral Facial paralysis due to i nvolvement of Facial Nerve (not nucleus) Lateral Medullary Syndrome: Dysphagia, hoarseness of voice
Midbrain
Midbrain
Midbrain Shortest segment of the brainstem Cerebral aqueduct of Sylvius: i n center of midbrain, communicates the 3rd ventricle to 4th ventricle; CSF flows through Cerebral peduncles (2)diverge Interpeduncular fossa: between 2 peduncles Mamillary bodies w/in fossa Tectum (dorsal) = 4 e levations Quadrigeminal bodies (Corpura quadrigemina) 2 pairs of colliculi (Inferior & Superior) inferior brachium connects i nferior colligate to MGB Tegmentum Crus cerebri (ventral): crossed f rom above, downwards by optic tract Occulomotor N (CN III) emerges from medial side Trochlear N (CN IV) emerges from l ateral surface of crus cerebri Section of Midbrain at level of Inferior Colliculus
Midbrain Cont'd
June-16-10 11:10 AM
Audio recording started: 11:10 A M J une -16-10
Midbrain Cont'd
Section at Level of Inferior Colliculus
Midbrain @ Superior Colliculus

June-17-10 11:09 AM
Midbrain ...
Quadrigeminal bodies Pair of Inferior & Superior Colliculi Tectum of Midbrain Inferior Colliculi: responsible for auditory reflexes Afferents from Lateral Lemniscus and from the opposite side of i nferior colliculus, MGB via Inferior Brachium
Syndromes of the Midbrain Weber's Syndrome (Ventromedial Superior Midbrain Syndrome) Paramedian perforators of terminal Basilar A Peduncular perforating branches of posterior cerebral A Lesion of crus cerebri of midbrain & Occulomotor Nuclear Complex Damage of crus cerebri --> corticospinal & corticobulbar fibers CONTRALATERAL HEMIPARESIS OF BODY ( UMN paralysis of corticospinal) CONTRALATERAL HEMIPARESIS OF FACE ( UMN paralysis of corticobulbar)
Cranial Nerve Nuclei in Brainstem Midbrain Occulomotor Nerve (III) Nucleus: i ndirectly innervated by corticobulbar tract Signs of l esion: fixed dilated pupil doesn't accommodate, ptosis devl'ps f ollowed by a complete i nternal ophthalmoplegia (masked ptosis); unopposed l ateral rectus = outward deviation of the e ye Trochlear Nerve (IV) Nucleus: i ndirectly innervated by corticobulbar tract Signs of l esion: diplopia due to weakness of downward & i nward mov't, vertical diplopia Edinger-Wespal Nucleus Pons Trigeminal (V) Nucleus: directly innervated by corticobulbar tract Signs of l esion: weakness of jaw clenching & side to side mov't LMN --> jaw deviates to weak side when mouth opened; fasciculation of temporalis & masseter Mesencephalic
Principal Spinal Abducens (VI) Nucleus: i ndirectly innervated by corticobulbar tract Can't l ook l aterally; e ye i s deviated medially bc unopposed action of medial rectus Facial (VII) Nucleus: directly innervated by corticobulbar tract Signs of l esion: facial weakness LMN --> forehead paralyzed; due to Bell's palsy, otitis media, skull fracture, cerebello-pontine angle tumors, parotid tumors, Herpes Zoster ( Ramsay-Hunt syndrome), Lyme disease UMN --> spares the forehead, stroke, tumor Cochlear Nucleus Vestibular Nucleus Medulla Nucleus of Vagus (X) Signs: palatal weakness, nasal regurgitation, palate moves asymmetrically when patient says 'ah'; recurrent nerve palsy = hoarsness, l oss of volume ( bovine cough) Hypoglossal (XII) Nucleus: directly innervated by corticobulbar tract LMN --> wasting of ipsilateral side of tongue, with fasciculation; on protrusion, deviates to affected side ( but away from the side of a central lesion)` Spinal nucleus of Trigeminal (V) Nucleus Ambigus Solitary Nucleus
Midbrain Syndromes
June-18-10 Audio recording started: 11:09 AM June-18-10 11:09 AM
Midbrain S ...
Corticobulbar Fibers "corticonuclear" fibers (from cortex to cranial nerve nuclei) UMN -- LMN --> begins i n neural axis (ie: brain stem, spinal cord) and supplies target cells Not all of the cranial nerves have LMNs Olfactory, Optic, V estibulocochlear are purely sensory nerves (no motor component) Recall: Weber's Syndrome Contralateral facial palsy Motor nucleus of facial nerve supplies face; l ower part of nucleus supplies l ower part of the face, upper supplies upper part of face
Benedict's Syndrome (Paracentral Tegmental Superior Midbrain Syndrome) Involvement of CN III Hemichorea due to i nvolvement of red nucleus & subthalamic nucleus Ataxia & tremor due to i nvolvement of red nucleus Ipsilateral CN III fascicular palsy Paramedian perforators of terminal Basilar A, Interpeduncular branches of Posterior cerebral A Paineras syndrome?
External Features
June-21-10 11:13 AM
External F ...
Cerebellum Part of hindbrain; situated i n the posterior cranial fossa w/ pons & medulla oblongata 4th ventricle cavity bt pons & cerebellum "silent" area of the brain bc upon e lectrical stimulation, no conscious response Responsible for Timing of an action; if timing i s off (ie: dysmetria) will overshoot or fall short when reaching Ex: flexion has to be stopped before e xtension can start Smooth progression bt mov'ts --> Compares actual mov't & intended mov't Intensity/velocity of muscle contraction Learns from mistakes (ie: playing a piano) Plasticity of neuronal pools: ability to l earn skills (ie: swimming, riding bike) Receives sensory i nfo from periphery (ie: via spinocerebellar pthwy) and from motor cortex Motor cortex = plan of action to cerebellum Dysdidakhokinesia (Adidakhokinesia): absence of 2 alternating mov'ts "organ of balance" Cerebellum connected to 3 parts of brain stem via cerebellar peduncle ICP (Restiform body) --> Medulla MCP (Brachium pontis) --> Pons SCP (Brachium conjunctiva) --> midbrain Vermis: anatomical midline worm-l ike structure Hemisphere: e xtend from vermis
Divisions of Vermis Lingula Central Lobule Culmen Declive Folium Tuber Pyramid Uvula Nodule
Internal Features
June-22-10 11:14 AM
Cerebellum Cont'd
Internal Features of the Cerebellum All i nputs i nto cerebellum can be classified i nto 2 types = e xcitation of cerebellum Mossy fibers - -> all other afferents Climbing fibers - -> All of the afferents f rom Inferior Olivary Nuclear Complex Deep Cerebellar Nuclei Festigial Nucleus derives f ibers f rom V ermis Nucleus Interpositus Globus Emboliformis Dentate Nucleus Cerebellar Cortex = 3 layers Outer = Molecular layer Middle = Purkinje cell layer Deep = Granular cell layer
Synaptic Glomerulus Afferent terminals on GRANULAR LAYER Mossy fiber Rosette Afferent fibers e xcept inferior olivary i nput 2/3 of medullary center Granular Cell Dendrite --> main afferent i nput Golgi cell Axon Synapse on granule cell dendrite; (GABA --> i nhibitory) Surrounded by astrocyte foot process
Cerebellum Cont'd
June-23-10 11:15 AM
Cerebellu... Cerebellu...
Functional Unit Surrounded around 1 purkinje cell; 30 million functional units Purkinje fibers are the only output of cerebellar cortex
Effect of Alcohol on Purkinje cells Efferents of Cerebellum (MAILY FROM SCP) SCP Cerebellothalamic fibers from 3 deep nuclei to V PLo, V Lc, CL Cerebeloorubral fiber predominantly from Dentate nucleus & nucleus globusus ICP Fastigiovestibular fiber
Connections of the Cerebellum

June-24-10 11:15 AM
Connection s of the C...
Main Connections of the Vestibulocerebellum
Main connections of Paleocerebellum
Main connections of Neocerebellum
Pyramidal Tract & Associated Circuits
Cerebellum & Automatic Motor Control
Functions of Cerebellum Maintenance of Equilibrium --> balance, posture, e ye mov't
Maintenance of Equilibrium --> balance, posture, e ye mov't Coordination of automatic mov't of walking & posture maintenance --> posture, gait Motor learning = motor skills Cognitive Function
Disorders Ataxia: i ncoordination of mov't; gait ataxia, truncal ataxia, titubation Decomposition of mov't --> breaking down a smooth muscle act i nto a number of j erky awkward component parts Dysmetria(past-pointing): inability to arrest muscular mov't at desired point Dysdiadochokinesia (Adidydakokinesia):inability to perform rapid alternating mov'ts ( rapid supination & pronation of hands) Rebound phenomenon of Holmes Normally, when flexors are working, we need to have a gradual release of e xtensors If e xtensors stop i mmediately = jerky mov't If flexors are not inhibited upon extension = rebound phenomenon Intention tremor: dysmetria that occurs during a voluntary action Nystagmus: form of dystaxia consisting of to-and-fro e ye mov'ts (ocular dysmetria) Archicerebellar lesion --> medulloblastoma Malignant; most common i n vermis; originate from granular l ayer of cereb cortex Obstruct passage of CSF = hydrocephalus Paleocerebellar Lesion --> gait disturbance Neocerebellar Lesion --> hypotonia, ataxia, tremor MUST KNOW FOR TEST TOMORROW Cerebellum If there is a lesion in vermis = truncal ataxia Paravertebral lesion = gait ataxia Lateral zone lesion = incoordination = tremor Herniation of cerebellar tonsils --> chiari malformation Arnold Chari Malformation: tonsils are e longated & pushed down thru foramen magnum --> blocks flow of CSF Action/intention tremor: dysmetria that occurs during a voluntary mov't Lesions of each division of cerebellum Anterior vermis syndrome: l eg region of anterior l obe Caused by alcohol abuse = atrophy of rostral vermis Gait, trunk, & l eg dystaxia Posterior vermis syndrome: flocculonodular l obe Result of brain tumors i n children; caused by medulloblastomas or ependymomas Truncal dystaxia Hemispheric syndrome: from brain tumor or abscess Arm, l eg, trunk & gait dystaxia Cerebellar signs are ipsilateral to l esion Midbrain Weber's Syndrome: occlusion of posterior cerebellar A & aneurysm of circle of Willis Intra-axial fibers of Oculomotor nerve roots Corticobulbar tracts --> contralat weakness of l ower face (VII), tongue (XII), palate (X) Corticospinal tracts --> contralat hemiparesis of trunk & e xtremities Benedikt Syndrome: occlusion or hemorrhage of paramedian midbrain br of post cerebral A Occulomotor nerve roots (intra-axial) Complete ipsilateral oculomotor nerve paralysis Eye abduction & depression bc unopposed action of LR ( CN V I) & SO ( CN IV) Paralysis of l evator palpebrae = severe ptosis Complete i nternal ophthalmoplegia = i psilateral fixed & dilated pupil Red nucleus & dentatorubrothalamic tract Contralateral cerebellar dystaxia w/ i ntention tremor Medial lemniscus Contralateral l oss of proprioception, discriminative tactile sensation & vibration sensation from trunk & e xtremities Complete Occulomotor palsy --> direct & indirect light reflex Have to have alternating syndromes for it to be midbrain lesion Pons Internuclear opthalmoplegia (INO) aka MLF syndrome Results from l esions of MLF i n dorsomedial pontine tegmentum; affect 1 or both MLFs Sign of MS Medial rectus palsy on attempted l ateral gaze monocular nystagmus i n abducting e ye w/ normal convergence Lesions of CN V I = all MLF signs & l ateral rectus paralysis w/ i nternal strabismus Spinocerebellar pathway Dorsal Tract --> unconscious proprioception from lower e xtremities via ICP Ventral tract --> unconscious proprioception from lower e xtremities via SCP Rhomberg's sign: l oss of balance when subject stands w/ feet together & closes the e yes +ve --> sensory ataxia = l oss of proprioception -ve --> cerebellar ataxia = vestibular disorder
Test 2
June-29-10 11:14 AM
Test 2
1. Purkinje cells are only output from cerebellar cortex (A) 2. Left l ower l id drooping , l eft angle of mouth sagging & saliva dripping; patient can't close e yes & difficulty e xposing teeth on l eft side; l esion i nvolves? Facial nerve; Lower motor neuron paralysis (B) 3. How cerebellum controls balance (which i s NOT correct) a. Flocculus & nodules = balance b. Cerebellum ctrls balance by controlling vestibular nuceli c. d. Juxtarestiform body is an important link in this pathway 4. Spastic paralysis on l eft upper & l ower l imbs, l oss of fine touch & proprio i n upper & l ower body on l eft, flaccid paralysis of l ateral rectus. Where i s l esion? Right side of pons 5. Lesion i n flocculonodular l obe & festigial nucleus does NOT produce none of the above Tremor i s i nvolved with lateral zone not cerebellum 6. Inability to close right e ye, weakness i n right orbicularis oculi (facial nerve), other symptoms? a. Blurred vision b. Hyperacusis (paralysis of stapedius - facial nerve) c. Inability to chew (muscles of mastication) d. Inability to feel face (trigeminal) e. Inability to shrug shoulder (spinal part of accessory) 7. Sudden onset of headache at night, complete ptosis on l eft, e ye l ies down and out with fixed dilated pupil; which cranial nerve i nvolvement a. III b. IV c. V d. VI 8.
Basal Ganglia
June-29-10 11:07 AM
Basal Ganglia
Basal Nuclei Subcortical masses of gray matter ( inner core) Corpus Striatum: l argest component of the basal nuclei Internal capsule divides corpus striatum i nto 2 components Medially --> Caudate nucleus, Lentiform nucleus Lentiform nucleus = biconvex mass of gray matter i n concavity of i nternal capsule Caudate Nucleus = C-shaped grey matter Clostrum Subthalamic Nucleus Amygdaloid complex Stereotyped activity Subcortical center for extra-pyramidal pathway Influences LMN of brainstem & spinal cord via Reticulospinal Tectospinal Vestibulospinal Olivospinal Rubrospinal Pyramidal pathway (corticospinal, corticobulbar) --> skillful voluntary act of distal musculature of distal part of l imbs (ie: hands, feet) Area #6 = cortical center for e xtra-pyramidal pathway; Supplementary Motor Area Extra-pyramidal pathway are multineuronal & multisynaptic pathways --> proximal part of limb --> responsible for i nitiating action (ie: when writing, your shoulder needs to move first) Basalganglia disease --> l ose i nitiation of skilled voluntary act of proximal distal musulature Classified i nto 2 types: Hypokinetic, Hyperkinetic Hypokinetic Akinesia --> no mov'ts Bradykinesia Hyperkinetic Parkinson's disease: also falls i n hypokinetic category (worse) Choreas --> Huntington's, Syndenham's Hemiballism Athetosis Direct & Indirect Pathway of Basal Ganglia
Basal Ganglia Cont'd

Connections to Striatum Principal afferents from 3 sources Corticostriate fibers from CORTEX Thalamostriatal fibers from V enteroanterior, V enterolateral THALAMUS Nigrostrial fibers from SUBSTANTIA NIGRA Amygdalostrial fibers from AMYGDALOID Connections FROM Striatum Striopallidal fibers: Most of e fferents go to Globus pallidus e xternum Strionigral fibers: Some go back to Substantia Nigra
Basal Ganglia C...
Hyperkinetic Disorders Syndenham's Chorea Lesion i n CORPUS STRIATUM (probably i n Putamen) Complication of Rheumatic fever; usually recovers spontaneously i n 1-4 mo Fine, disorganzined, random mov'ts of tongue, face & e xtremities Accompanied by muscular hypotonia Exaggeration of assoc mov'ts Common i n children Huntington's Chorea Lesion i n Corpus Striatum (esp CAUDATE NUCLEUS) & Cerebral Cortex Autosomal dominant ( chromo 4); fatal Insidious onset: usually 30-50 yrs Choreic mov'ts assoc w/ e motional disturbances Grotesque gait & severe .. Dementia only results i f there i s i nvolvement w/ cerebral cortex Hemiballism Lesion i n SUBTHALAMIC NUCLEUS Commonly as a result of cerebrovascular accidents (ie: stroke) Mov'ts are cont's & e xhausting, but cease during sleep Can be fatal due to e xhaustion Can be ctrld by phenothiazines & sterotaxic surgery Parkinson's Disease (Paralysis Agitans) Lesion i n SUBSTANTIA NIGRA (pars compacta) Difficult to stop mov'ts once activity i nitiated Can't e xpress feelings i n face (masked face) Resting tremor Cog-wheel rigidity
Cerebrum
July-05-10 11:21 AM
Audio recording started: 11:21 A M J uly-05-10
Cerebrum
Frontal Lobe
July-06-10 9:05 AM
Audio recording started: 9:06 A M July -06-10
Lobes of the Cereb...
Frontal Lobe Primary Motor Cortex (Area 4) Lesions of motor cortex = contralateral spasatic paralysis of the body Afferents from Area 3,1,2 via commissural fibers (association fibers) Efferents = corticospinal & corticobulbar fibers Premotor Cortex (Area 6)
Lesion of prefrontal cortex = l ose i nitiative, carelessness, e uphoria, vulgarity Mental i llness treated w/ bilateral prefrontal l acotomy (not as common today) = behavioral changes Excessive blood flow to prefrontal cortex also produces same problems (unknown reason)
Parietal Lobe
July-07-10 11:15 AM
Parietal Lobe
Features Over 1/5 of total cortex Primary somatosensory Secondary somatosensory Gustatory Association
Cognition: ability to pay attention to i dentify & plan meaningful responses to e xternal stimuli or i nternal motivations Involves association areas of cerebral cortex Association areas are responsible for i nfo processing bt sensory i nput & motor output Parietal (Contralateral) neglect syndrome: i f l esion on right side, can't recognize anything on the l eft (ie: neglect anything that i s on the l eft of patient) If vigorously ask i f the l imb i s there, then they will admit i t Frequent consequence of stroke on right side of brain = neglect e verything on l eft NOT blindness --> Patients can recognize & name objects Doctor wiggles a finger --> patient sees the finger, but i f the doctor doesn't move the finger, patient i s oblivious --> they don't pay attention to l eft side If there i s damage to l eft side, you will never have neglect to right side bc paying attention i s function of dominant hemisphere (right brain) Association Cortex Parietal Association Cortex: paying attention to complex stimuli Temporal Association Cortex: i dentification of stimuli Frontal Association Cortex: planning responses Inputs are different from the rest of cerebral cortex does NOT receive direct i nputs from sensory organs Inputs reflect highly processed sensory i nfo from other areas of the cortex Area 22: Sensory Speech Area (Wernicke's speech area): forms words & sentences, comprehension of spoken word
comprehension of spoken word Ability to speak via fibers connected to Areas 44 & 45 --> Motor Speech Area ( Broca's) Area 41 & 42: hear the words and sends stimuli to Area 22
Language Areas
July-08-10 11:20 AM
Cerebrum Cont'd
Language Areas of the Brain Broca's area (44 & 45): motor speech center ( located i n i nferior gyrus) Motor programs for speech production Projects to motor cortex areas controlling vocal cords, tongue & l ips Lesion causes e xpressive aphasia w/ poor articulation, short sentences, slow speech "nonfluent", "motor", "Boca's" aphasia --> agrammatical, nonfluent speech. Hemisphere w/ l anguage = dominant hemisphere ( most commonly l eft hemisphere)
Global Aphasia --> damage to dominant hemisphere If damage dominant hemisphere before 6years old = transfer of language to NON-DOMINANT
Test 3 Key
July-13-10 11:16 AM
Test 3 Key
Test 3 Key
Answers 1. Parkinson's disease 2. Cog-wheel rigidity 3. Lateral pontine doesn't i nclude tongue paralysis 4. Efferent fibers from cerebellar to deep nuclei are axons from purkinje cells 5. Transverse section has E-W and red nucleus 6. Muscles of mastication are paralyzed ( damage to motor nucleus of trigeminal) and can't feel texture of f ood will also have l oss of tactile pressure on right face 7. Proprioceptive i nfo from l ower body i s NOT mainly carried by SCP (b) 8. Parkinson's 9. Bradykinesia, rigidity, resting tremor ( all of the above) 10. Substantia nigra 11. c 12. GABA e verywhere e xcept corticostriate ( glutamate) D 13. Lentiform nucleus = putamen & globus pallidus 14. Left neglect = l esion i n Parietal l obe 15. Left neglect = Right parietal cortex 16. c 17. Given 18. e 19. All deficits are NOT contralateral to l esion ( D) 20. Ventral spinocerebellar pthwy i n SCP 21. Impaired comprehension & repetition = Wernicke's ( B) 22. Normal f luency, comprehension, i mpaired repetition = conduction aphasia ( D) 23. Impaired fluency, comprehension & repetition = global 24. Impaired fluency, repetition, comprehension i ntact = broca's ( A) 25. Chromosome 4 for Huntingtons
Occipital Lobe
July-13-10 11:46 AM
Occipital Lobe
Visual Lobe Area 17: Primary Visual Cortex Extended along calcaranean sulcus Lunate sulcus posteriorly Receives temporal half of same side of vision & nasal half of opposite side Afferent from LGN Lacks ability to analyze and discriminate Anterior part --> Peripheral vision Posterior part --> Macular vision Lesion = homonymous hemianopsia Occlusion of posterior cerebral artery Macular vision spared due to presence of collateral blood supply from middle cerebral A Association cortex: storage of past visual i mages Analyzes & discriminates new i mages vs past i mages Occipital Eye Field Area 18: Parastriate cortex Area 19: Peristriate cortex Superior longitudinal bundle between area Area 18 & 19 connected to Superior Colliculus for scanning mov'ts and protective measures via Tectobulbar pathway Corticotectal fibers from Area 18 & 19 Area 18 & 19 receives i nfo from bilateral Area 17 (can analyze & discrimination) Processing of color, mov't direction (scanning mov'ts), visual i nterpretation Area 18 & 19 efferent to Area 39 (higher association visual cortex) Lesion to Area 39 = visual agnosia (can't i dentify i mages that have been seen before) Can't recognize a face you have already met Vision i s normal Alzheimer's --> l ose ability to recognize familiar faces (no facial recognition)
Vestibuloccular Reflex We always move body parts opposite to mov't of e yeball Ex: flinching i f something thrown towards you
White Matter
July-14-10 11:36 AM
Audio recording started: 11:36 A M J uly -14-10
Cerebrum Cont'd
White Matter Fibers are predominantly from pyramidal cells and stellate cells of cortex Association fibers: comm w/ adjacent gyri (ie: bt Area 3,1,2 & Area 4) Enables us to react to sensory i nput Short association fibers (aka cortical U-shaped fibers) --> connect adjacent gyri Long association fibers Superior longitudinal bundle: connects frontal e ye field ( Area 8) to occipital e ye field ( Area 18 & 19) w/in same hemisphere Arcuate fasciculus: between Area 22 ( Wernicke's) & Area 44, 45 (Broca's) Cingulum: bundle which becomes most i mportant part of Papez Circuit ( memories) Projection fibers: project beyond the cerebrum ( afferents & e fferents) Neo-cortical: from neocortex Corona radiata: project from vicinity of corpus striatum Intermingle w/ commissural fibers (anterior commissure & corpus callosum) Cont's w/ i nternal capsule, downwards Internal capsule: highway for afferents & e fferents of cerebral cortex Corticopetal fibers: fibers that go INTO cerebral cortex Corticofugal fibers: fibers that go OUT of cerebral cortex Continuous upwards with corona radiata Continuous downwards with crus cerebri of midbrain Anterior Limb Genu Posterior Limb Sublentiform part & Retrolentiform part Allo-cortical: from old cortex Fimbria derived from hippocampus Commissural fibers
Cortical Connections Cont'd

July-15-10 11:11 AM
Cortical Connectio...
Internal Capsule Posterior Limb Anterior 2/3 Corticospinal fibers (upper l imb, trunk, l ower l imb) Corticobulbar fibers Lesion = contralateral hemiparesis of body Posterior 1/3 Corticorubral fibers If these fibers are i ntact does NOT = complete paralysis Superior thalamic radiation fibers From ventral anterior & midline nucleus of thalamus to Area 4 & 6 Corticostriate fibers Fasciculus thalamicus Commissural Fibers Connect i dentical area of one hemi to the opposite hemi across midline (most are homotopical, but few are heterotopical - go to diff areas) 5 sets of commissural fibers Anterior Commissure Posterior Commissure Hippocampal Commissure Hebelunar Commissure Corpus Callosum ( ~300 million fibers) Connects almost ALL the i dentical areas to opposite hemisphere EXCEPT primary somasthetic sensory area of hand (3,1,2) & primary visual area (Area 17) 95% of population i s l eft hemisphere dominant Language, analytical, clinical thinking, i ntellectual ability, calculations Non-dominant hemisphere (right) Spatial arrangements, artistic skills, musical abilities, non-verbal abilities Language areas: Broca's (44, 45), Wernicke's (22), Area 29, 40 These areas are also i n opposite hemisphere, so i nfo i s sent via corpus callosum, but one side i s still dominant Learned e xpression --> l eft hand will know what right hand i s doing Writing = upper part of Area 6 (Supplementary Motor Area) Cut corpus callosum to prevent series of traffic between hemispheres (ie: severe epilepsy) --> split brain preparations
Thalamus
July-16-10 11:16 AM
Thalamus
Diencephalon Mass of gray matter split i n between 3rd ventricle 3rd ventricle: cavity i n midline Sagittal section Hypothalamic sulcus: runs i n middle of diencephalon extends from inter-ventricular foramen ( of Monroe) to upper e nd of cerebral aqueduct Divides i nto 2 parts: hypothalamus (below) & (epi)thalamus (above) Thalamus All sensory modalities integrated in thalamus EXCEPT Olfaction If thalamus doesn`t function a pin-prick sensation becomes a highly unbearable pain sensation; music that you normally l ike becomes highly unbearable
Diencephalon Cont'd
July-20-10 11:14 AM
Diencephalo n Cont'd
Thalamus
Specific Relay Nuclei --> receive specific sensations MGB --> auditory fibers LGB --> l ight VA & VL --> motor function VPL/VMP --> somatosensory (ie: V PL receives pain & temp) Association Nuclei --> no specific projections, associated w/ e motions Pulvinar/Lateral Posterior Complex Lateral Dorsal (LD) Dorsal medial (DM) --> e motions; depth of e motions/tone of feelings Connected to pre-frontal cortex & amygdaloid complex Non-specific --> no specific function, but i s associated (ie: DM related to prefrontal cortex) Part of V A Intralaminar --> Important for ARA system Cenromedian nucleus Reticular nucleus Parafollicular nucleus
3rd & 4th Ventricles

July-21-10 11:19 AM
Ventricles
4th Ventricle Ependymal-lined (columnar e pith l ining) cavities where produc'n of CSF occurs 4th ventricle = cavity of hindbrain Posteriorly --> cerebellum Ventrally --> upper part of medulla & pons Diamond-shaped space Superior angle --> comm w/ 3rd ventricle via cerebral aqueduct Inferior angle --> cont's w/ central canal 2 lateral angles Run venteromedially --> cerebellar peduncle Foramen of Luschka --> CSF to pontine cistern
Roof Tent-shaped Extends dorsally --> Dorsal Recess of 4th Ventricle (at the midline), e xtends i nto white core of the cerebellum Divides roof i nto upper & l ower parts Upper part: nervous part Formed by converging fibers of SCP = superior medullary velum Lower part: non-nervous part Ependyma Tela-choroidae of 4th ventricle: double-layer of the pia mater Foramen of Mazendie: aperture i n midline of roof Cerebello-medullary cistern (aka cysterna magna) Floor Diamond-shaped Upper part --> Pons Lower part --> Medulla Striae medullarae fibers i n between pons & medulla Median sulcus divides the floor i nto 2 halves; vertically Sulcus limitans divides e ach half of the ventricle Extends from Superior fovea (surface depression) caudally to another surface depression --> Inferior fovea (depression on l ower half) Medially --> Medial eminence Facial colliculus e levation that i s opposite to superior fovea Laterally --> Vestibular Area
Area Postrema: 2 small subependymal oval areas on e ither side of 4th ventricle Contains modified neurons & astrocyte-like cells surr by fenestrated capillaries Chemoreceptor Trigger Zone (CTZ): triggers vomiting i n response to circulating e metic substances Plays a role i n food i ntake & cardiovascular regulation 3rd Ventricle Inter-thalamic space (in midline) Comm w/ l ateral ventricle via interventricular foramen of Monroe Comm w/ 4th ventricle via cerebral aqueduct Roof Formed by Tela choroideae of 3rd ventricle = double l ayer of pia mater Fornix (choroid fissure bt thalamus and fornix) Choroid plexus from l ateral ventricle e xtends i nto 3rd ventricle via choroid fissure Floor Optic chiasma (most anterior) Tuber cenarium Infundibulum Mamillary body Posterior perforated substance Pituitary gland Anterior Wall Lamina Terminalis invaded by anterior commisssure Primitive cranial e nd of neural tube Anterior commissure: connects 2 olfactory areas Uvula: Small e xtension of 3rd ventricle beyond i ts space bt diverging columns of fornix Body of Fornix divides i nto 2 columns Sloping area & 2nd column can't be seen (uvula between these columns) Posterior Wall Pineal gland att to wall via Pineal stalk (ventricle e xtends i nto stalk, dividing i t i nto 2 parts) Upper part of stalk Hebelunar Commissure: thickening connecting 2 hebelunar nuclei Lower part of stalk Posterior commissure --> pretectal fibers for i ndirect l ight reflex If dmgd (ie: due to e nlarged 3rd ventricle) --> no i ndirect light response Partially formed by tectum of midbrain Lateral Wall (2)
Lateral Ventricle & CSF Circulation

July-26-10 11:04 AM
Audio recording started: 11:11 A M J uly -26-10
Ventri cl es Cont'd
Lateral Ventricle Cavity of forebrain (Telencephalon) --> i nverted C-shaped Body: extends from i nterventricular foramen of Monroe to splenium of corpus callosum Anterior Horn (frontal l obe) --> body projects forwards and l ateral Roof: corpus callosum Medial Wall: septum pallucidum Floor: Laterally --> head of caudate nucleus Medially --> rostrum of corpus callosum Posterior Horn (occipital l obe) --> tail-like e xtension of body Roof & Lateral Wall: retrolentiform part of i nternal capsule --> fibers of optic radiation & tapetal fibers (don't interdigitate w/ corona radiata) Floor & Medial Wall: Bulb: e levation formed by Forceps major fibers from splenium of corpus callosum Inferior Horn (temporal l obe) --> l argest projection of body Calcaralis e levation at junc'n bt posterior & i nferior horns Roof: covers medial & l ateral side tail of caudate nucleus --> continuous w/ amygdaloid complex Striae terminalis fibers Floor: covers medial & l ateral side hippocampus Albius: white matter covering the hippocampus; has dentate gyrus Collateral eminence: e levation produced by collateral sulcus i n i nferior surface of brain (classified as complete sulcus) Bilaminar Septum Pallucidum: between both sides of l at ventricles; e xtends from i nferior surface of corpus callosum to body of fornix pleasured area = part of l imbic system "5th ventricle of the brain" bt 2 layers of septum pellucidum but NOT really a ventricle bc no e pendymal l ining --> only has tissue fluid Roof: formed by undersurface of body of corpus callosum Floor: thalamus i n medial aspect & body of caudate nucleus i n l ateral aspect Striae terminalis --> bundle of fibers = only e fferent out of amygdaloid complex i n groove between thalamus & caudate nucleus Thalamostriate vein also present i n groove Medial Wall: formed by septum pallucidum Hydrocephalus --> e xtension of body of l ateral ventricle May affect body of caudate nucleus -- CSF Circulation Very clear, colorless, odorless, water-like fluid (ultrafiltrate of plasma) pH = 7.35, specific gravity = 1007, [protein] = 25 mg/dL (vs 1025 mg/dL i n plasma) very high [Na] & [Cl], low [K] & [Ca] Formed by choroid plexus --> mainly i n lateral ventricles, but also i n 3rd & 4th ventricles Lateral ventricle --> interventricular foramen of Monroe --> 3rd ventricle 3rd ventricle --> cerebral aqueduct --> 4th ventricle 4th ventricle --> subarachnoid space
Hydrocephalus Impaired circulation & resorption of CSF Obstructive (Non-Communicating): obstruction w/in ventricular system Aqueductal stenosis: most common cause; narrowing of cerebral aqueduct = e nlargement of l ateral & 3rd ventricles bc l ateral communicates with 3rd but comm bt 3rd & 4th i s i mpaired Blockage of interventricular foramen of Monroe Obstruction of cerebral cisterns (superior, cerebromedullary, l umbar, pontine, chiasmatic) Non-Obstructive (Communicating) Increased production of CSF due to choroid plexus papilloma Decreased reabsorption i nto venous system Venous thrombus: occlusion of outflow veins Arachnoid villi inflammation: occlusion of arachnoid granulations Subarachnoid hemorrhage: compression of outflow veins Signs Children Sluggish pupillary reaction Absence of upward gaze Impaired l ateral gaze, nystagmus Paralysis or spasm of convergence Absence of visual fixation Seizures Exopthalmos --> optic disk i s choked --> Optic Nerve (CN II) i s submerged i n subarachnoid space Optic N compressed due to i ncreased CSF Impairment of venous flow = i mpairment of central retinal artery Scleral prominence from downward displacement of orbits UMN signs Adults HA, Lethargy, Malaise, Incoordination, Weakness Ocular nerve palsies Papilledema (choked disk): noninflammatory congestion of optic disk caused by i ncreased i ntracranial P Most commonly caused by brain tumors, subdural hematoma, hydrocephalus Usually doesn`t alter visual acuity or result i n visual field defects Usually asymmetric & greater on side of supratentorial l esion Foster-Kennedy Syndrome: results from meningioma of olfactory groove --> compresses olfactory tract & optic nerve = i psilateral anosmia, optic atrophy & contralateral papilledema Ataxia Corticospinal tract anomalies, UMN signs Causes Lesions or malformations of posterior fossa Chiari malformation Type I: displacement of cerebellar tonsils i nto cervical canal Symptoms i n adolescence or adult l ife --> headache, neck pain NO Hydrocephalus Type II: progressive hydrocephalus & myelomeningocele Elongation of 4th ventricle Displacement of i nferior vermis, pons & medulla i nto cervical canal bc there i s a congenital absence of the roof to the 4th ventricle Dandy-Walker Syndrome: cystic e xpansion of 4th ventricle i n posterior cranial fossa Developmental failure of roof of 4th ventricle during e mbryogenesis 90% have hydrocephalus --> Enlarged occiput Tumors IVH Meningitis: Pneumococcal, TB Intrauterine i nfections Pathology Aqueductal stenosis (congenital stenosis of cerebral aqueduct) Abnormally narrow aqueductus of sylvius Obstruction of cerebral aqueduct = e nlargement of 3rd & l ateral ventricles Endangers body of caudate nucleus Aqueductal gliosis: brisk, glial response of e pendymal l ining
Hydrocephalus Cont`d
July-27-10 11:09 AM
Causes of Hydrocephalus Cont`d Intraventricular Hemorrhage (IVH) Bleeding i n subependymal germinal matrix w/ or w/o e xt i nto ventricles & brain parenchyma (if w/ e xt'n = communicating hydrocephalus) Pathology Intravascular Vascular Extravascular Complications Hydrocephalus (20% i n moderate bleeds, 65-100% i n l arge bleeds) Prevention Avoid prolonged l abor or difficult vaginal delivery Avoid pneumothorax Avoid hypo- or hypertension i n neonate Avoid hypoxic i schemic i nsult Symptoms Children: Irritability, Poor feed, Lethargy, vomiting Older pts: headache, change i n personality, academic deterioration Signs Anterior fontanelle i s wide open & bulging, i ncreased head circumference Dilated scalp veins Sun-setting sign --> downward deviation of the e yes; occurs whenever there is i ncreased volume of head Brisk tendon reflexes, spasticity Clonus, Babinsky sign Macewen sign "cracked-pot" --> e nlargement Prominent occiput ( Dandy-Walker) Imaging studies X-ray plain films Separation of sutures Erosion of posterior clinoids Increased convolutional markings (beaten silver appearance) Ultrasound CT scan MRI Therapy Medical: Acetazolamide, Furosemide Surgical: V -P shunt placement Prognosis Increased risk for developmental disabilities Lower mean IQ compared to general population Memory abnormalities Some patients may show aggressive or delinquent behavior Visual problems Strabismus Visuospatial abnormalities Decreased visual acuity Visual field defects Patients require l ong term follow up (multidisciplinary) Hydrocephalus of ex-vacuo --> i ncreased CSF w/o i ncreasing i ntracranial P ( occurs i n Alzheimer`s patients) = atrophy of brain
Diagnosis of Different Types of Hydrocephalus Glasgow Coma Scale Tool (GCS): quantifies l evel of consciousness after traumatic brain
Hydrocepha lus
Glasgow Coma Scale Tool (GCS): quantifies l evel of consciousness after traumatic brain injuries ( steth not required) Scored from 3 to 15 (3 = worst, 15 = best) 3 Parameters Best e ye response = max score of 4 1 = no e ye opening 2 = painful e ye opening 3 = e ye opening to verbal command 4 = e yes open spontaneously Best verbal response = max score of 5 1 = no verbal response 2 = i ncomprehensible sounds 3 = i nappropriate words 4 = confused 5 = orientated Best motor response = max score of 6 1 = no motor response 2 = painful e xtension 3 = painful flexion 4 = withdrawal from pain 5 = l ocalized pain 6 = obeys command Case 1 With complaints of headache & a history of chronic e ar i nfections, a 43 yo man was diagnosed w/ papilledema, l eft homonymous hemianopia, altered mental status. There were no other significant motor or sensory findings. Abscess i n right occipital l obe
Spinal Cord Lesions

July-28-10 11:09 AM
Spinal Cord Lesions
Case A 23 yo woman complained of pain i n her right breast & progressive weakness of her right l ower l imb for many months; neuro e xam = weakness i n l ower l imb; assoc w/ spasticity ( increased tone), hyperreflexia ( increased deep tendon reflexes) at knee & ankle = clonus; right side = l oss of 2-ot touch vibratory sense & proprio at levels below hip. Left side showed a l oss of pain & temp below dermatome T7 Complete Hemisection of spinal cord (Brown-Sequard Syndrome) Causes: stab/gun shot i njuries, e xtramedullary tumors affecting side of spinal cord; herniation of disc (aka spinal shock) Symptoms Motor deficits Above lesion --> no problems At level of lesion LMN bc Common Pathway of Sherrington damaged Atropy, areflexia, atonia Below lesion UMN --> mainly dmg to l ateral corticospinal tract LCST --> hyperreflexia, spasticity Reticulospinal tract (tone)--> clasp-knife rigidity Sensory deficits Above lesion At level of lesion BILATERAL loss of pain & temperature (syringomyelia) Below lesion --> cdamage to posterior column tracts Ipsilateral loss of touch, pressure, vibration & conscious proprioception --> Rhomburg's sign (+) Contralateral loss of pain & temp
Syringomyelia --> LISTEN TO LECTURE
In cases of Spinal Shock: Injury above level of Phrenic N ( C3,4,5) = DEATH due to resp arrest Anything below C3,4,5 = alive Gunshot i njury below cervical region Urinary i ncontinence (can't ctrl LMN to bladder) = no micturition reflex As bladder i s filled w/ urine until i t reaches max tone, i nternal urethral sphincter opens a l ittle = dribbling ( retention reflex) Retention of feces i n rectum ( retention outflow) Bed sores --> skin ulcers RECOVERY PERIOD AFTER SPINAL SHOCK = 2-4 WEEKS
Syrnix --> cavity (can e nlarge i n any direction = differing symptoms) MRI i s only way to confirm diagnosis along w/ PE Bilateral loss of pain & temperature sensation
Conus medullaris Amyeotropic lateral sclerosis (ALS) Multiple sclerosis Quada Inguina
Limbic System
July-29-10 11:10 AM
Limbic System
Limbic System Series of structures around brain stem; medial side of brain Emotions referred by l ower centers ( ie: hypothalamus) to cortex ( consciousness) 1837 --> R. Owen --> Rhinencephalon ( entire forebrain = olfactory i n macroosmatic animals, i e: dogs) "smell brain" = forebrain Humans are microosmatic bc our forebrain i s responsible for more functions not just smell Smell e nhances GIT motility Enhances sex search (more i mportant i n animals) Enhances fear...
Anatomical Components Papez Circuit --> responsible for recent memories and past e xperiences Olfactory pathway --> not as i mportant i n humans Olfactory nerves pass through cribriform plate --> bipolar cells --> olfactory bulb --> olfactory tract Olfactory mucosa --> i n roof of nasal cavity (bipolar) Peripheral fibers = receptors Central process pierces cribriform plate of e thmoid bone --> bulb Bulb (6 l ayers) Mitral Cells Tufted Cells Tract --> olfactory sulcus Medial Striae --> traverses w/ ant commissure & goes to opposite side Medial olfactory gyrus: gray matter that accompanies striae Few fibers pass through Ant. Commissure --> opposite side of cortex Some f ibers e nd up below/sub-callosum --> paraterminal gyrus Intermediate Striae --> anterior perforated substance Lateral Striae --> primary olfactory complex (gyrus semilunaris , gyrus ambiens, cortico-medial to amygdaloid complex & uncus Pyriform lobe Lateral olfactory gyrus: Band of gray matter that accompanies striae; continuous with gyrus ambience Both gyri continuous with Entorhinal Area (Area 28) --> part of parahippocampal gyrus (part of corticomedial division of amygdaloid complex) Pyriform area Ant perforated substance (gray matter of cortex) Pierced by many arteries (mainly) & veins Paraterminal gyrus --> beside l amina terminalis Amygdaloid complex Situated i n the roof of the i nferior horn of l ateral ventricle Cortico-medial Lateral olfactory striae (afferent) Baso-lateral Parahippocampal gyrus Striae terminalis --> sole EFFERENT of amygdaloid complex Supra-commissural --> Septal Nuclei of septum pellucidum (Pleasure area)
Supra-commissural --> Septal Nuclei of septum pellucidum (Pleasure area) Commissural --> via Ant Commissure to opp side of amygdaloid complex Sub-commissural --> pre-optic & ant nucleus of hypothalamus Functions Agonistic behavior Aggression Fear Bilateral ablation of amygdala: animal e xhibits l oss of aggression Docile; occasional hypersexual behavior Occlusion of the Middle Cerebral Artery Hippocampal formation --> i n floor of i nferior horn of l ateral ventricle Hippocampus Alveus: velvet covering of hippocampus by fibers from pyramidal cells Fimbria: formed by convergence of all the fibers on medial side Fornix: e fferent fibers; connects to adjacent fornix via hippocampal commissural fibers Body of fornix formed by joining of the 2 forni Choroid fissure between body of fornix & thalamus Body divided i nto 2 columns, e a of which are further divided Anterior (post-) commissural fibers --> ant nuc of thalamus, mamillary body & hebenular nuc of striae medularis Posterior (pre-) commissural fibers --> pre-optic & ant hypothalamic nuclei Stimulation of preoptic nucleus of hypoth when amygdala gives fibers to hypoth (releases hormones) Afferents from cingulate gyrus Dentate gyrus (medial to hippocampus) Limbic lobe Septal nuclei Hypothalamus Mammillary bodies Ant Nuc Thalamus Habenular Nu Midbrain
Papez Circuit (1937) Fornix ( hippocampus) --> mamillary body --> mamillo-thalamic tract --> anterior nuc of thalamus --> ant l imb of i nternal capsule --> cingulate gyrus --> cingulum --> hippoc Responsible for recent memories & our normal sexual behavior w/ integration Amygdaloid complex connected to circuit via fornix Stimulation of hypothalamus = release of adrenalin & noradrenalin Smell stored i n secondary association cortex
Blood Supply of the Brain

August-04-10 12:23 PM
Audio recording started: 12:24 PM August-04-10
Audio recording started: 12:24 PM August-04-10
Brain = 2% of body wt Time taken for blood t o travel w/in brain = 7s Needs oxygen --> cannot sustain w/o oxygen for >10s TIA: i schemia before cell undergoes i rreversible damage ( symptoms < 24 hrs) Stroke: symptoms l ast >24 hrs Normal cardiac output = 5L (750 mL goes to brain) Common Carotid A Internal Carotid A --> carotid canal --> Anterior & Middle Cerebral As S-shaped course before going to brain --> decrease P before e nters brain External Carotid A Vertebro-Basilar System Vertebral Arteries from 1st part of Subclavian A --> foramen transversarium --> for Magnum 2 Join to become Basilar A --> runs i n Sulcus Basilaris (pons) --> Post Cerebral A (2) Circle of Willis: arterial anastomosing circle situated i n interpeduncular cistern Anterior Cerebral As --> medial surface of brain --> Ant communicating A Posterior Cerebral A --> Post communicating A Laterally: bifurcation of Internal Carotid Posteriorly: bifurcatoin of Basilar A Usually blood does not mix bt carotid sys and vertebro-basilar sys; Cortex has maximum blood supply bc many cell bodies Short branches --> periphery of cortex Long branches --> white matter & sometimes gray matter i nside Slightest i ncrease i n ICP = compress arteries & block blood supply to region of l ong As Ie: i f supplying i nternal capsule = devastating e ffects
Pial sheath: peri-arterial pial sheath, e xtended until precapillary ntwk Slightest i ncrease i n ICP ( ie: by hydrocephalus) can occlude arteries = block blood supply to BBB
BBB Non-Fenestrated e ndothelial l ining, held via TJs BM Perivascular feet of astrocytes Interstitial space Neural tissue MCA Inattention (can't pay attn to objects; only right MCA causes this) Hemianesthesia --> patient will also suffer with agosia (Area 43)

Neuro Notes 63 Pages

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Neural Axis

Spinal Cord (Spina Medullaris)

Spinal Cord Cont'd

nervous part of the cauda equina)

Dorsal Column - Medial Lemniscus Pathway

Descending Pain Inhibiting System

Audio Audio Recording recording ...

Anterior Horn Cells

Anterior Horn Cells

Areflexia: paralysis caused by damage to l ower motor neurons

Medul l a Obl onga ta

Internal Structure of Medulla Oblongata

Pyramidal (Motor) Decussation of Medulla

Brain Stem Cont'd

Sensory Decussation of Medulla

Sens ory Decus s a t...

Medulla Oblongata at Level of Olive

Medul l a Obl onga t...

Pons: bridge bt midbrain, medulla & cerebellum External Features (Ventral)

Basilar Part of the Pons

Pons at level of Facial Colliculus

Pons at level of Trigeminal Nuclei

TEST 1 ON MONDAY JUNE 14

Pons at level of Tri...

Section at Level of Inferior Colliculus

Midbrain @ Superior Colliculus

Connections of the Cerebellum

Connection s of the C...

Main Connections of the Vestibulocerebellum

Main connections of Paleocerebellum

Main connections of Neocerebellum

Pyramidal Tract & Associated Circuits

Cerebellum & Automatic Motor Control

Functions of Cerebellum Maintenance of Equilibrium --> balance, posture, e ye mov't

Basal Ganglia Cont'd

Basal Ganglia C...

Lobes of the Cereb...

Cortical Connections Cont'd

3rd & 4th Ventricles

Lateral Ventricle & CSF Circulation

Spinal Cord Lesions

Spinal Cord Lesions

Blood Supply of the Brain

Blood Supply of the Brain

Blood Supply of the Brain

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