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Anatomical and Functional Organization


ments with the left hand (left hemiapraxia). Anterior callosal lesions cause alien hand syndrome (diagonistic apraxia), in which the patient cannot coordinate the movements of the two hands. Disconnection syndromes are usually not seen in persons with congenital absence (agenesis) of the corpus callosum. Cytoarchitecture. Most of the cerebral cortex consists of isocortex, which has six distinct cytoarchitectural layers. The Brodmann classification of cortical areas is based on distinguishing histological features of adjacent areas of isocortex. Functional areas. The functional organization of the cerebral cortex can be studied with various techniques: direct electrical stimulation of the cortex during neurosurgical procedures, measurement of cortical electrical cortical activity (electroencephalography and evoked potentials), and measurement of regional cerebral blood flow and metabolic activity. Highly specialized areas for particular functions are found in many different parts of the brain. A lesion in one such area may produce a severe functional deficit, though partial or total recovery often occurs because adjacent uninjured areas may take over some of the function of the lost brain tissue. (The extent to which actual brain regeneration may aid functional recovery is currently unclear.) The specific anatomic patterns of functional localization in the brain are the key to understanding much of clinical neurology.

Cortical Structures
Different areas of the cerebral cortex (neocortex) may be distinguished from one another by their histological features and neuroanatomical connections. Brodmanns numbering scheme for cortical areas has been used for many years and will be introduced in this section. Projection areas. By following the course of axons entering and leaving a given cortical area, one may determine the other structures to which it is connected by afferent and efferent pathways. The primary projection areas are those that receive most of their sensory impulses directly from the thalamic relay nuclei (primary somatosensory cortex; Brodman areas 1, 2, 3), the visual (area 17), or the auditory (areas 41, 42) pathways. The primary motor cortex (area 4) sends motor impulses directly down the pyramidal pathway to somatic motor neurons within brainstem and the spinal cord. The primary projection areas are somatotopically organized and serve the contralateral half of the body. Proceeding outward along the cortical surface from the primary projection areas, one encounters the secondary projection areas (motor, areas 6, 8, 44; sensory, areas 5, 7a, 40; visual, area 18; auditory, area 42), which subserve higher functions of coordination and information processing, and the tertiary projection areas (motor, areas 9, 10, 11; sensory, areas 7b, 39; visual, areas 19, 20, 21; auditory, area 22), which are responsible for complex functions such as voluntary movement, spatial organization of sensory input, cognition, memory, language, and emotion. The two hemispheres are connected by commissural fibers, which enable bihemispheric coordination of function. The most important commissural tract is the corpus callosum; because many tasks are performed primarily by one of the two hemispheres (cerebral dominance), interruption of the corpus callosum can produce various disconnection syndromes. Total callosal transection causes splitbrain syndrome, in which the patient cannot name an object felt by the left hand when the eyes are closed, or one seen in the left visual hemifield (tactile and optic anomia), and cannot read words projected into the left visual hemifield (left hemialexia), write with the left hand (left hemiagraphia), or make pantomimic move-

Anatomical and Functional Organization

Subcortical Structures
The subcortical structures include the basal ganglia, thalamus, subthalamic nucleus, hypothalamus, red nucleus, substantia nigra, cerebellum, and brain stem, and their nerve pathways. These structures perform many different kinds of complex information processing and are anatomically and functionally interconnected with the cerebral cortex. Subcortical lesions may produce symptoms and signs resembling those of cortical lesions; special diagnostic studies may be needed for their precise localization.

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Rohkamm, Color Atlas of Neurology 2004 Thieme All rights reserved. Usage subject to terms and conditions of license.

Argo light

Argo

Anatomical and Functional Organization

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Functional areas of cortex


(as determined by measurement of regional blood flow)

9 46 10 45 11 38 44 3

5 2 1 40

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19 18

43 52 41 21 20

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Layers of isocortex

Brodmann areas (lateral view) I (Molecular layer) II (Outer granule cell layer) III (Middle pyramidal cell layer) IV (Inner granule cell layer) V (Large pyramidal cells) Commissural tracts Right (stereognosis, spatial perception, nonverbal ideation, intuition)

Perception (visual, acoustic, olfactory, somatosensory)

Left (speech, writing, calculation, abstraction, logical analysis)

VI (Polymorphic cells)

Hemispheric dominance

Caudate nucleus Thalamus Insula Lentiform nucleus Internal capsule Red nucleus Cerebral peduncle Subcortical structures
(Sections: left, horizontal; right, coronal)

Susbstantia nigra

Frontal operculum

Hippocampus

Rohkamm, Color Atlas of Neurology 2004 Thieme All rights reserved. Usage subject to terms and conditions of license.

Anatomical and Functional Organization


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Brain Stem
The brain stem consists of the midbrain (mesencephalon), pons, and medulla. It contains the nuclei of the cranial nerves and ascending and descending tracts running to and from the brain, cerebellum, and spinal cord. It also contains autonomic centers that regulate cardiovascular function, breathing, and eating behavior as well as acoustic and vestibular relay nuclei. The flow of information along afferent and efferent pathways is regulated by reflex systems. spinal cord through the vestibulospinal tract. Examination: Suppression of visual fixation: the subject extends his arms and stares at his thumbs while spinning on a swivel chair. Nystagmus does not occur in normal subjects. Oculocephalic reflex (dolls eyes phenomenon): Horizontal or vertical passive rotation of the subjects head causes the eyes to rotate in the opposite direction; normally suppressible by awake persons, this reflex is seen in patients with impaired consciousness but preserved vestibular function. Caloric testing: The examiner first confirms that the patients eardrums are intact, then instills cold water in the external auditory canal with the head elevated at a 30 angle (which inactivates the ipsilateral horizontal semicircular canal). This normally causes nystagmus in the contralateral direction, i.e., slow ipsilateral conjugate deviation of the eyes, followed by a quick jerk to the other side. Corneal reflex. Afferent arm, CN V/1; efferent arm, CN VII, which innervates the orbicularis oculi muscle. Examination: Touching the cornea from the side while the subject looks forward evokes blinking. The reflex can also be assessed by electromyography (EMG). Pharyngeal (gag) reflex. Afferent arm, mainly CN IX, X, and V/2; efferent arm, CN IX and X. The gag reflex may be absent in normal persons. Examination: Touching the soft palate or back of the pharynx evokes pharyngeal muscle contraction. Cough reflex. Afferent arm, CN IX and X; efferent arm, via the solitary tract to the diaphragm and other participating muscle groups. Examination: Tested in intubated patients with endotracheal suction (tracheal reflex). Masseter (jaw jerk) reflex. Afferent arm, probably CN V/3; efferent arm, CN V. Examination: Tapping the chin evokes jaw closure. Acoustic reflex (p. 68). Afferent arm, projections of the cochlear nuclei to the RAS. Examination: Sudden, intense acoustic stimuli evoke a fright reaction including lid closure, startle, turning of the head, and increased alertness.

Nerve Pathways
All motor (p. 44) and sensory projection systems (p. 104) pass through the brain stem and communicate with its intrinsic structures at various sites. The central sympathetic pathway (p. 90) originates in the hypothalamus.

Brain Stem
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Reticular Formation
The reticular formation (RF) is a network of nuclei and interconnecting fibers that is anatomically intertwined with the cranial nerve nuclei and other fiber tracts of the brain stem. Different parts of the reticular formation perform different functions. The reticular activating system (RAS) provides the anatomical and physiological basis for wakeful consciousness (p. 116). The medullary RF contains the vital centers controlling the heartbeat, breathing, and circulation as well as reflex centers for swallowing and vomiting. The pontine RF contains centers for coordination of acoustic, vestibular, respiratory, and cardiovascular processes. The midbrain RF contains centers subserving visuospatial orientation and eating behavior (chewing, sucking, licking).

Reflex Systems (pp. 118ff)


Pupillary light reflex. The EdingerWestphal nucleus in the midbrain, which is adjacent to the oculomotor nucleus, provides the efferent arm of the reflex loop (p. 90; examination, p. 92.) Vestibulo-ocular reflex (VOR, p. 84). The vestibular nuclei receive their main input from the labyrinthine semicircular canals and collateral input from the cerebellar nuclei; their output is conveyed to the extraocular muscles through the medial longitudinal fasciculus, and to the

Rohkamm, Color Atlas of Neurology 2004 Thieme All rights reserved. Usage subject to terms and conditions of license.