Complete Neuroanatomy for Medical Students and Chiropractic Students

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NEUROANATOMY

• IMEC Inc.

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Neural TransmissionDENTRITES?Axons
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CNS/PNS Supportive cells

• Astrocyte-physical support, repair, K metabolism
• Microglia-Phagocytosis
• Oligodendrocytes - CNS myelin production
• Schwann cells- peripheral myelin production
• Ependymal cell- Inner lining of ventricles

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Glial Cells

• Glia are derived from Neuroectoderm
• Glial cells are the supporting cells for the
  neuron and its cell processes
• Astrocytes have round centers and believed to act
  as buffers, detoxifiers, and suppliers of
  nutrients. They are the principle cells in
  neuronal repair
• Oligodendrendocytes function for the myelin in
  the Central Nervous System
• Ependymal cells form a meshwork when injury
  happens in the Central nervous system
• Microglia function as the CNS Macr0phages

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Yolk Sac
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Neural Tube Development
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Neural Tube
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Neural Tube

• The neuroepithelium produces about
• 100 million neurons and neuroglial cell
• These cells begin in the INNER ependymal layer.
  and
• These cells migrate from where they are formed in
  the mantle layer to the marginal layer
• This is essentially all the neural development in
  living organisms, only a small amount of neuron
  regenerate

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The Neural Tube

• The neural tube , specifically ependymal cells
  form much of the spinal chords
• The basal plate forms the anterior and lateral
  horns
• The marginal layer forms the white matter

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Embryogenisis of Notochord
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Brain Developement

• The cranial end of the neural tube begins to
  exhibit a series of swellings along its
  longitudal axis at about three weeks of age.
• The future begins to develop the
• Forebrain
• Midbrain
• Hindbrain

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Brain Developement

• The cranial end (ROSTAL) end of the neural tube
  swells
• The Telencephalon becomes the Cerebrum,
  Cerebellum etc.
• The Metecephalon forms the cerebellum
• The Diencephalon is engulfed by the surrounding
  Telenceohalon the and becomes THALAMUS,
  HYPOTHALMUS optic chiasma
• The Mesencephalon become the tubular portions of
  the inner brain
• The Hindencephelon becomes the lumen of the 4th
  Ventricle

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Choroidal plexus

• The choroidal plexus is the cerebral spinal fluid
  membrane surrounding the Telencephalon

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Brain Wall Developement

• The brain wall as you will remember begins with
  the Neuroepithelium and the Mantle layer
• The future brain wall becomes the Corpus Striatum
• Th neopalidium begins to thicken and spread

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BRAIN STEM

• Brain stem consists of
• PONS
• MEDULLA
• MID-BRAIN
• The foramen magnum is the opening in which where
  the spinal chord becomes the brain
• The caudate equina begins at the end of the
  spinal chordL2

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CRANIAL NERVES

• MIDBRAIN
• CN 3 and CN 4
• PONS
• CN 5, CN 6, CN 7, CN 8
• MEDULLA
• CN 9, CN10, CN 11, CN, 12

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Brain Consistancy

• Grey matter consists of the cell bodies of the
  neurons,
• While white matter consists of the fibers

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Human Brain Structures
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Arachnoid mater

• Intermediate one of the three layers of meninges
• Arachnoid mater is a thin membrane which is
  pressed against the inner surface of the dura
  mater by cerebrospinal fluid pressure
• The space deep to this layer (subarachnoid space)
  has a spider web-like appearance

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DURA MATER

• Outermost of the meningeal layers covering the
  brain and spinal cord
• Latin for "tough mother" it is the most durable
  of the meninges and provides support and
  protection for the brain and spinal cord two
  types are described which differ in structure
  cranial and spinal

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Cerebrum

• The largest portion of the brain, which is
  occupies the entire upper portion of the cranium.
  The cerebrum is divided into two equal
  hemispheres (left and right hemispheres), each of
  which in turn is divided into (four lobes).
  Cerebrum controls all the mental activity,
  voluntary actions, and the sensory factors, each
  center being responsible for a specific function
  such as sight, hearing, taste, touch, and smell

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Cerebellum

• Is situated at the back of the cranium below the
  cerebrum. Partially divided into three lobes, its
  chief function is to coordinate muscular
  activity.

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Pons

• Lies between the cerebral hemispheres, serves
  chiefly as a connecting point between the nerve
  from different parts of the nervous system and
  the nerve fibers which join the various parts of
  the brain. It involved in sleeping, waking and
  dreaming.

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Medulla

• Lies at the base of the brain and is actually
  part of the spinal cord. It controls all
  involuntary activity, e.g., respiration,
  circulation, and digestion. The nerve fibers
  passing from the brain to the spinal cord cross
  in the medulla, so that nerve centers on one side
  of the brain control the movement and sensation
  of the opposite side of the body.

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Thalamus

• A structure consisting of two egg-shaped masses
  of nerve tissue, each about the size of a walnut,
  deep within brain. The thalamus receives
  information and relays this information to the
  cerebral cortex. The cerebral cortex also sends
  information to the thalamus which then transmits
  this information to other areas of the brain and
  spinal cord.

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Thalamic Nuclei
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Medial Geniculate Nuclei
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Lateral Geniculate Nuclei
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Hypothalamus

• The hypothalamus, which is a tiny structure at
  the base of the brain, regulates many basic
  functions, such as eating, sleeping, temperature
  control, and reproduction. One part of the
  hypothalamus responsible for sexual behavior is
  larger in male brains than in female brains.

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Hypothalamus

• Light daylength and photo for generating
  circadian and seasonal rhythms
• Olfactory stimuli, including pheromones
• Steroids, including gonadal steroids and
  corticosteroids
• Neurally transmitted information arising in
  particular from the heart, the stomach, and the
  reproductive tract
• Autonomic inputs
• Blood-borne stimuli, including Leptin, Ghrerlin
  and insulin to messaging to the , pituitary
  hormones, cytokines, plasma concentrations of
  glucose and osmolarity etc
• Stress
• Invading microorganisms by increasing body
  temperature, resetting the bodys thermostat
  upward.

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• The corpus callosum is a thick band of fibers
  located between the cerebral hemispheres. It
  connects right and left hemisphere to allow for
  communication between the hemispheres.

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Amygadala

• The amygdalae, especially the basolateral nuclei,
  are involved in mediating the effects of
  emotional arousal.
• Also include basic Pavlovian tasks such as
  inhibitory avoidance.

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Hippocampus

• Part of the brain located inside the temporal
  lobe (humans and other mammals have two
  hippocampi, one in each side of the brain). It
  forms a part of the limbic system and plays a
  part in memory and spatial navigation.
• In Alzhiemers Dx, the hippocampus becomes one of
  the first regions of the brain to suffer damage
  memory problems and disorientation appear amongst
  the first symptoms.
• Damage to the hippocampus can also result from
  oxygen starvation.

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Lateral CNs 3 through 6
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Trigeminal Regions
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Facial Nerve CN VII
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Olfactory Nerve
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Auditory System
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Vestibular Nerve Nuclei
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Vestibular Labrinyth
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Nervous System

• Within the nervous system
• 31 pair of spinal nerves
• 12 pair of cranial nerves
• Note that below Thoracic nerve 1 the nerves
  present below the vertebrae
• Above Cervical Nerve 7 the nerves present above
  the vertebrae

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Atlas (C1)

• Atlas (C1)
• It has no vertebral body, only anterior
  posterior arches it articulates with the
  odontoid process of the axis (Greek, atlas refers
  to a titan who supported the earth on this
  shoulders as the atlas vertebra supports the
  head)

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Axis (C2)

• The second cervical vertebra
• The odontoid process (dens) projects superiorly
  from its body it articulates with the anterior
  arch of the atlas (Latin, the axis provides the
  odontoid process which is the pivot about which
  the atlas vertebra rotates)

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Cervical Nerves

• Cervical Nerves (8 pairs)
• These nerves supply the head, neck, shoulders,
  arms, and hands.

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8 Cervical Spine
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Vertebra prominens

• The seventh cervical vertebra (more properly, the
  vertebral spine of C7)
• It has a long, non-bifid spinous process which is
  prominent at the nape of the neck, hence its name

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Brachial Plexus

• The brachial plexus is an arrangement of nerve
  fibres (a plexus) running from the spine
  (vertebrae C5-T1), through the neck, the axilla
  (armpit region), and into the arm. The brachial
  plexus is responsible for cutaneous and muscular
  innervation of the entire upper limb, with two
  exceptions the trapezius muscle innervated by
  the spinal accessory nerve and an area of skin
  near the axilla innervated by the
  intercostobrachialis nerve. Therefore, lesions
  of the plexus can lead to severe functional
  impairment.

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Brachial Plexus
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Thoracic Nerves

• Thoracic Nerves (12 pairs)
• Connects portions of the upper abdomen and
  muscles in the back and chest areas.

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12 Thoracic Spine
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5 Lumbar Spine

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Lumbar Nerves

• Lumbar Nerves (5 pairs)
• Feeds the lower back and legs.

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LUMBAR VERTEBRA
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Sacral Nerves

• Sacral Nerves (5 pairs)
• Supplies the buttocks, legs, feet, anal and
  genital areas of the body.

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5 Sacral Spine

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1 Coccygeal

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Caudate Equina

• The sacral portion of the spinal cord ends at the
  Caudate Equina.
• This is a area in which has many branches into
  the region

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Spinal Cord Disks
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Dermatomes

• Dermatomes
• Areas on the skin surface supplied by nerve
  fibers from one spinal root.

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Nerve Pathways

• There are many nerve pathways that transmit
  signals up and down the spinal cord. Some supply
  sensation from the skin and outer portions of the
  body. Others supply sensation from deeper
  structures such as the organs in the belly, the
  pelvis, or other areas. Other nerves transmit
  signals from the brain to the body. Still others
  work at the level of the spinal cord and act as
  "go betweens" in the signal transmission process.

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Upper Motor Neuron

• The upper motor neuron refers to injuries that
  are above the level of the anterior horn cell.
  This results in a spastic type of paralysis.

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Lower Motor Neuron

• Lower motor neuron injury refers to an injury at
  or below the anterior horn cell that results in
  the flaccid type paralysis.

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Spinothalmic Tract

• The tracts that carry sensations of pain and
  temperature to the brain are in the middle part
  of the spinal cord. These tracts are called the
  "spinothalamic."

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Dorsal Columns

• These nerve impulses are carried along the back
  part of the spinal cord in what are called
  "dorsal columns" of the spinal cord transmitting
  position and light touch

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Autonomic Function
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Parasympathetic Nerves 

• The parasympathetic nerves act in an opposite
  manner to the sympathetic nerves. These nerves
  tend to dilate blood vessels and slow down the
  heart. The most important nerve that carries
  sympathetic fibers is the vagus nerve. This nerve
  carries parasympathetic signals to the heart to
  decrease heart rate. Other nerves supply the
  blood vessels to the organs of the abdomen and
  skin.
• The parasympathetic nerves arise from two areas.
  Upper and Lower

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Sympathetic Nerves

• The sympathetic nerves also cause constriction of
  the blood vessels throughout the body. When this
  happens, the amount of blood that is returned to
  the heart increases. These effects will increase
  blood pressure. Other effects include an increase
  in sweating and increased irritability or a
  sensation of anxiety.
•   When spinal cord injury is at or above the T6
  level the sympathetic nerves below the injury
  become disconnected from the nerves above.

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Syringomyelia

• A post-traumatic enlargement of the central canal
  of the spinal cord is termed syringomyelia. It
  occurs in approximately 1-3 of all spinal
  cord-injured individuals. The primary risk of
  syringomyelia is a loss of function above the
  level of the original spinal cord injury. For
  example, in a patient with a thoracic-level
  spinal cord injury may complain to his or her
  physician of numbness and weakness involving the
  extremities.

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Oculomotor Palsy

• Loss of Medial Gaze in Right Eye

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Eye Pathways

• Ciliary Reflex
• Ciliary Ganglion
• Occulomotor
• Occulomotor
• Occulomotor
• Lat Gen Nuc
• Edinger-West
• Edinger-west
• Periquaductal
• Pre-tect

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Eye

• CN 7 CLOSES EYE
• CN 3 PILLAR EYE OPEN

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4th Nerve Palsy-SO4
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6th Nerve Palsy-LR6
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Edinger-Westphall _at_ (CN11)
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OLFACTORY BULB
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RETICULAR/VESTIBULARNUCLEUS
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BLOOD BRAIN BARRIER

• Choroid plexus
• Intercerebral capillaries
• Arachnoid
• CIA

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Blood Brain Barrier of Astrocyte
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BLOOD SUPPLY

• There are two main pairs arteries in the brain
• Two internal carotid arteries
• Splits into MCA and ACA
• Two vertebral arteries
• Otherwise called Basilar Arteries at pons
• Posterior cerebral at cerebellum

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BLOOD SUPPLY

• Middle Cerebral Artery (MCA)
• MCA OCCUSION IS UPPER BODY
• 4 direct/6 indirect branches
• Anterior Cerebral Artery (ACA)
• ACA OCCLUSION IS LOWER BODY
• Posterior Cerebral Artery (PCA)
• Posterior Inferior Cerebellar Artery (PICA)
• Feeds must of the cerebellum
• LOOK AT HAL (Head, Arms, Legs)
• Next slide

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THE CIRCLE OF WILLIS

• 8 branches of intrancranial arteries from the
  AORTA
• MS-----------medial striate
• LS------------lateral striate
• Ach----------anterior choroidal
• IC------------internal carotid
• EC-----------external carotid
• CC-----------common carotid
• V-------------vertebral
• S--------------subclavian

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THE CIRCLE OF WILLIS

• The Circle of Willis is fed by the
• BASILAR ARTERY
• Which if obstructed would lead to total blindness
• VERTEBRAL ARTERY
• No deficit because other vertebral would
  compensate

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Contrast Media to Brain

• If media is place on the right side via the right
  brachial to right subclavian route at the level
  of the right vertebral
• FRONT AND BACK CEREBRAL
• If media is placed in the left side only
  posterior circulation, since the left common
  carotid comes directly from the aorta
• POSTERIOR CIRCULATION

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VEINS

• NO COUNTERPART TO WILLIS
• SINUSES
• SUPERIOR SAGITTAL SINUS
• DRAINS SPINAL FLUID
• CAVEROUS SINUS
• EYE, PERIORBITAL AND FACIAL
• INFERIOR SAGITTAL SINUS
• IN FALX CEREBRA
• STRAIGHT SINUS
• IN TENTORIUM OF CEREBELLI
• TRANSVERSE SINUS
• CEREBELLI

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HEMORRHAGES (P.A.D) pia/arachnoid/dura

• Sub-arachnoid hemorrhage
• Sub-dural hemorrhage is tearing of bridging
  vein---more of an oozing
• Epidural hemorrhage- very serious as with the
  MCA-Coincides many times with skull fracture and
  shifting
• PCA is most frequently damaged with severe
  seizure activity

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Epidural Hematoma
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INTRAPARENCHTMAL HEMORRHAGE (possible MCA)
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CSF

• The walls of ventricle contain choroid plexus,
  which secrete CSF
• CSF flows from two lateral ventricles through the
  two intraventicular foramen into a single third
  ventricle
• From there it travels though the adaeduct of
  Sylius to the 4th ventricle
• There is travel through one of 3 openings
• a middle foramen of Magendie and
• two foramen of Luschka entering the subarachoid
  space
• OBSTRUCTION OF THIS PATHWAY LEADS TO
  HYDROCEPHALUS

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HYDROCEPHALUS
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BLOCKS

• Saddle block- S2
• Lumbar block-L2
• CSF dram _at_ FMg, base of skull

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Zones

• AREAS (44-45) BROCAs SPEECH AREA
• AREA (3, 2, 1)Primary SOMATIC-Contralateral
  impairment of , touch, pressure, and
  proprioception
• AREA (41, 42)---auditory area (unilateral) bilat
  usually CN 8
• AREA (22)---auditory aphasia, speaks babble
• AREA (40)association tracts, body image
• AREA (39)read and write (alexia and agraphi)
• AREA (17, 18, 19) total destruction blindness
  also object recognition
• AREA 8frontal eye field-voluntary opposite side
• AREA 4---Primary motor, flaccid paralysis,
  possible Babinski reflex
• AREA 6 Supplementary motor, spacticity, inc deep
  tendon reflex

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CRANIAL NERVES
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CRANIAL NERVES

• On-------------------?Olfactory
• Old------------------?Optic
• Olympus------------?Oculomotor
• Towering-----------? Trochlear
• Tops-----------------?Trigeminal
• A---------------------?Abducens
• Finn------------------? Facial
• And------------------? Vestibulocochlear
• German-------------? Glossopharygeal
• Viewed--------------? Vagus
• Some----------------? Accessory
• Hops-----------------? Hypoglossal

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CRANIAL NERVES Motor or sensory

• Some-------------------------CN 1 OLFACTORY
• Says--------------------------CN 2 OPTIC
• Make ------------------------CN3 OCULOMOTOR
• Money-----------------------CN4 TROCHLEAR
• But ---------------------------CN5 TRIGEMINAL
• My----------------------------CN6 ABDUCENS
• Brother-----------------------CN7 FACIAL
• Says---------------------------CN8
  VESTIBULOCOCHLEAR
• Big----------------------------CN9
  GLOSSOPHARNYGEAL
• Breasts------------------------CN10 VAGUS
• Matter-------------------------CN11 ACCESSORY
• Most---------------------------CN12 HYPOGLOSSAL

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Medullary Blood Supply
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Types of Respiratory Patterns

• Periodic breathing
• Consider abnormal (10-20 second pauses)
• Cheyne-Stokes
• Cerebral brain damage (starts and stops)
• Apneustic
• Occurs at pons, shuts off insp ramp
• Apnea
• Pauses in breathing greater than 20 seconds
• Kussmaul
• At MIDBRAIN, can be seen in keto-acidosis,
• Very fast, deep, regular breathing

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PATHWAYS
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Cervical to lumbar
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Basal Ganglia
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Basal Ganglia Disorders

• Parkinsonism- degeneration of basal ganglia and
  substantia nigra
• Ridgidity,
• mask-like face
• shuffling gait,
• Chorea
• Sudden Jerky Movements
• Syndhams found with rheumatic fever
• Huntingtons found as inherited disorder
• Athestosis
• Slow snakelike movements in fingers and wrists
• Hemiballismus
• A sudden wild flail-like movement in one arm

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THALAMUS
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Functions of Thalamic Nuclei

• Lateral geniculate-
• Visual
• Medial geniculate
• Auditory
• Ventral posterior nucleus
• Body senses (pain, touch,properioception,
  vibration)
• Ventral posterior nucleus
• Facial sensation (including pain)
• Ventral anterior/lateral
• Motor

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Coronel section
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Cerebellum
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Cerebellar Disorders

• ATAXIA-Awkward gait.
• Overshooting a goal in mechanical movement
• Inability to do rapid alternating movements
• Irregularily spaced speech
• Decreased tendon reflex
• Asthenia-Muscle tire more easily
• Tremor-usually an intention tremor
• Nystagmus

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DIENCEPHALON
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Hypothalamus Lesions

• Can cause HYPERPHAGIA, INCREASED CSF, VISUAL
  PROBLEMS, THIRST, CHANGE IN TEMPERATURE

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Hypothalamus

• Posteriorconserves body heat
• Suprachiasmic- circadian rhythm
• Ventramedial- (hunger)
• Septate nuclei- sexual urges
• Mammilary body- memory
• Anterior- cool down, (autonomic regulation)
• PARAMYPATHETIC
• Para ventricular nucleus-
• ADH, oxytocin
• Supraoptic-
• ADH, oxytocin (THIRST AND WATER )

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Papez circuit
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Neuro-transmitters

• Histamine
• Tuberullomammilary nucleus
• Norepinephrine
• Locus ceruleus
• Serotonin
• Raphe nuclei
• Dopamine
• Substantia Nigra ventricular tegmentum
• Actetylcholine
• Striatum, basal and septal Nucleai

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LESIONS
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Right ACA lesion

• Weakness
• Decreased all sensory modalities
• LEG gt ARM
• HYPERFLEXIA
• REMEMBER HAL

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Right MCA lesion

• Weakness
• Decreased all sensory modalities
• ARM gtLEG
• HYPERFLEXIA
• REMEMBER HAL

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ALS

• Muscle atrophy
• Fasciculations
• Hyperflexia

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PERIPHERAL NEUROPATHY

• WEAKNESS
• DECREASED SENSORY AT LIMB ENDS
• Hands, wrists
• Feet, ankles
• HYPOFLEXIA
• Alcoholism or diabetis

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Tertiary Syphylis

• Decreased Proprioception lower limbs
• Rhomberg Positive
• Sharp intermittent Pains

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Hemisection of Spinal Chord

• SPACTIC PARALYSIS
• DECREASED PROPRIOCEPTION
• HYPERFLEXIA
• AT LEVEL OF LESION
• DECREASED PAIN AND TEMP
• ONE LEVEL BELOW THE LEVEL OF LESION

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Syringomyelia

• DECREASED PAIN AND TEMP IN UPPER LIMBS
• LIGHT TOUCH AND PRESSURE INTACT
• USUALLY A CYST IN SPINAL CHORD AT LEVEL OF LESION

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Total Transection

• SPACTIC PARALYSIS
• LOSS OF ALL SENSORY MODALITIES
• HYPERFLEXIA

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Perniscious anemia

• DECREASED PROPRIOCEPTION
• PARESIS
• HYPERFLEXIA
• BABINSKI REFLEX

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Guillian-Barre

• FLACCID PARALYSIS
• ASCENDING
• INCREASE IN ALL SENSORY

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Polio ( anterior horn)

• PARALYSIS
• MUSCLE ATROPHY
• HYPOFLEXIA

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Radial nerve injury

• WEAKNESS ELBOW AND WRIST EXTENSION
• NUMBNESS DORSUM OF HAND
• DECREASED TRICEP REFLEX

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Median nerve

• WEAKNESS, FLEXON OR WRIST, INDEX AND MIDDLE
  FINGER
• ATHROPHY OF THENAR EMINENCE
• PAIN-ABOVE FINGERS

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Ulnar Nerve

• CLAW HAND
• NUMBNESS- SMALL FINGER AND ULNAR ASPECT OF RING
  FINGER
• ATROPHY-HYPOTHENAR EMINENCE

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Cauda Equina Lesion

• DECREASE ALL SENSORY MODALITIES IN BUTTOCKS AND
  UPPER QUADROCEPS
• IMPOTENCE

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Lesion _at_ medulla

• SPASTIC PARALYSIS
• HYPERFLEXIA
• DECREASED PROPRIOCEPTION
• PAIN-TEMP INTACT
• TONGUE WEAKNES OPPISITE SIDE

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Syndrome of PICA

• DECREASED PAIN AND TEMP BELOW HEAD
• ATAXIA
• DECREASED PAIN AND TEMP (FACE) SAME SIDE
• DECREASE TASTE
• HOARSNESS
• DIFFICULTY SWALLOWING

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Lesion of R Caudal Pons
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MS

• DECREASED VISION
• BABINSKI SIGN/ATAXIA SAME SIDE
• INTERNUCLEAR OPTHALMOPLEGIA
• NYSTAGMUS
• FACIAL WEANKESS (OPPISITE SIDE)

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Pons

• SAMESIDE
• FACIAL MUSCLE ANSTHESIA AND MASSETER MUSCLE
  WEAKNESS
• OPPISITE SIDE
• MUSCLE WEALNESS, ARM, LEG

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HORNERS SYNDROME

• PTOSIS
• MIOSIS
• DECREASE IN SWEATING ON INVOLVED SIDE OF FACE

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Cranial Nerve

• On-------------------?Olfactory
• Old------------------?Optic
• Olympus------------?Oculomotor
• Towering-----------? Trochlear
• Tops-----------------?Trigeminal
• A---------------------?Abducens
• Finn------------------? Facial
• And------------------? Vestibulocochlear
• German-------------? Glossopharygeal
• Viewed--------------? Vagus
• Some----------------? Accessory
• Hops-----------------? Hypoglossal

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Cranial Nerve Pathways

• Cribiform ------------------------? CN I
• Optic Canal----------------------? CN II
• Superior Orbital Fissure------? CN III, IV, V, VI
  
• Foramen Rotundum-------------? V2
• Foramen Ovale-------------------? V3
• Internal Auditory Meatus-------? VII, VIII
• Jugular Foramen------------------? CN IX, X, XI
• Hypoglossal Canal---------------? CN 12

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Pleural Effusion

• Usually seen _at_
• Costo-Diaphramatic Recess

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