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For Wendy and Rosalie, new lights in my life.
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Key Features of this Edition!
• 300+ full-color illustrations
• Discussion of the latest advances in molecular and cellular biology in the context of
neuroanatomy
• Coverage of the basic structure and function of the brain, spinal cord, and peripheral nerves as
w ell a clini al pre entation of di ea e proce e invol ing pe ific tructure
• Clinical Correlations and case studies to help you interpret and remember e entia!
neuroanatomic con epts in term of function and linical a p plication
CLINICAL CORRELATIONS
� � .......
(W-.-...-�Iftor.....,..._..,...cM. ,_.....,
...... � .. tltfftloc.aflf•••
"..... ........,.��--- Clinical Correlations help you learn
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...., ... ,� .. tt��Mc-1 ..... ft\C!Nic.l neuroanatomic concepts in the context
�....,. ...... j..., ... .... ...... M .....
............. f...,.._..� ....... .�� ....
.............. o..�--..- ....... of real world examples
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• Numerous computed tomography (CT) and magnetic resonance images (MRis} of the normal brain
and pinal cord; functional magnetic re onance image that provide a norunva ive window on brain
function· and neuroimaging tudie that illu trate common pathological entitie that affect the
nervou system including troke intracerebral hemorrhage and rumor of the brain and pinal cord
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Contents
Preface xi
SECT I O N I SECT I O N II
BASIC PRINCIPLES 1 INTRODUCTION TO CLINICAL
THINKING 33
1. Fundamentals of the Nervous System 1
General Plan of the Nervous System 1
4. The Relationship Between Neuroanatomy
Peripheral Nervous System 5
and Neurology 33
Planes and Terms 5
Symptoms and Signs of Neurologic Diseases 33
References 6
Where is the lesion? 36
2. Development and Cellular Constituents What is the lesion? 38
of the Nervous System 7 Clinical Illustration 4- 1 39
Cellular Aspects of Neural Development 7 Clinical Illustration 4-2 39
Neurons 7 The Role ofNeuroimaging and Laboratory
Neuronal Groupings and Connections 11 Investigations 39
Neuroglia 11 The Treatment of Patients with Neurologic
Degeneration and Regeneration 15 Disease 40
Neurogenesis 17 Clinical Illustration 4-3 40
References 18 Clinical Illustration 4-4 40
Clinical Illustration 4-5 41
3. Signaling in the Nervous System 19 References 41
Membrane Potential 19
Generator Potentials 20
Action Potentials 20 SECT I O N Ill
The Nerve Cell Membrane Contains
Ion Channels 21 SPINAL CORD AND SPINE 43
The Effects of Myelination 22
Conduction of Action Potentials 23 5. The Spinal Cord 43
Synapses 24 Development 43
Clinical Illustration 3-1 24 External Anatomy of the Spinal Cord 43
Synaptic Transmission 26 Spinal Roots and Nerves 46
Excitatory and Inhibitory Synaptic Actions 27 Internal Divisions of the Spinal Cord 48
Synaptic Plasticity and Long-Term Potentiation 27 Pathways in White Matter 50
Presynaptic Inhibition 28 Clinical Illustration 5-1 55
The Neuromuscular Junction and Reflexes 56
the End-Plate Potential 28 Lesions in the Motor Pathways 60
Neurotransmitters 29 Examples of Specific Spinal Cord Disorders 63
Case 1 31 Case 2 64
References 32 Case 3 64
References 65
vii
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viii Contents
11.
Lumbar Puncture 71
Ventricles and Coverings of the Brain 149
Imaging of the Spine and Spinal Cord 73
Ventricular System 149
Case 4 73
Meninges and Submeningeal Spaces 150
Case 5 74
CSF 152
References 77
Barriers in the Nervous System 154
Skull 156
8.
Case 1 7 193
Cranial Nerves and Pathways 99
Case 18 194
Origin of Cranial Nerve Fibers 99
References 194
Functional Components of the Cranial Nerves 99
Anatomic Relationships of the Cranial Nerves 102 14. Somatosensory Systems 195
Case 8 116 Receptors 195
Case 9 116 Connections 195
References 118 Sensory Pathways 195
9.
Cortical Areas 196
Diencephalon 119
Pain 196
Thalamus 119
Case 1 9 199
Hypothalamus 121
Case 20 200
Subthalamus 126
References 200
Epithalamus 127
Circumventricular Organs 128 15. The Visual System 201
Case 10 129 The Eye 201
References 129 Visual Pathways 205
10.
The Visual Cortex 209
Cerebral Hemispheres/Telencephalon 131
Clinical Illustration 1 5 - 1 210
Development 131
Case 2 1 214
Anatomy of the Cerebral Hemispheres 131
References 214
Microscopic Structure of the Cortex 136
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Contents ix
17.
Skull X-Ray Films 267
The Vestibular System 221
Angiography 267
Anatomy 221
Computed Tomography 268
Vestibular Pathways 221
Magnetic Resonance Imaging 270
Functions 221
Magnetic Resonance Spectroscopy 273
Case 23 224
Diffusion-Weighted Imaging 273
References 224
Functional MRI 274
18. The Reticular Formation 225 Positron Emission Tomography 275
Anatomy 225 Single Photon Emission CT 276
Functions 225 References 276
23.
References 228
Electrodiagnostic Tests 277
19. The Limbic System 229 Electroencephalography 277
The Limbic Lobe and Limbic System 229 Evoked Potentials 278
Olfactory System 229 Transcranial Motor Cortical Stimulation 280
Hippocampal Formation 230 Electromyography 280
Clinical Illustration 1 9- 1 232 Nerve Conduction Studies 283
Functions and Disorders 236 References 284
Index 355
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Preface
Very few organ systems, if any, present as fascinating an array explicative, and memorable. This book is not meant to sup
of structures and mechanisms as the human brain and spinal plant longer, comprehensive handbooks on neuroscience and
cord. Furthermore, it is hard to think of a clinical field that neuroanatomy. On the contrary, it has been designed to pro
does not encompass at least some aspect of the neurosciences, vide a manageable and concise overview for busy medical stu
from molecular and cellular neurobiology through motor, dents and residents, as well as trainees in health-related fields
sensory, and cognitive neuroscience, to human behavior and such as physical therapy; graduate students and postdoctoral
even social interactions. It is the brain, in fact, that makes us fellows with an interest in neuroanatomy and its functional
uniquely human. No surprise, then, that neuroscience has underpinnings; and clinicians in practice, for whom minutes
emerged as one of the most exciting fields of research and now are precious.
occupies a central role as a substrate for clinical medicine. This book is unique in containing a section entitled
One of the unique things about the nervous system is its "Introduction to Clinical Thinking;' which introduces the
exquisite architecture. The nervous system contains more cell reader, early in the text, to the logical processes involved in
types than any other organ or organ system, and its con using neuroanatomy as a basis for thinking about patients.
stituent nerve cells-more than 1 00,000,000,000 of them Since some trainees remember patients better than isolated
and an even larger number of supportive glial cells are facts, I have included discussions of clinical correlates and
arranged in a complex but orderly, and functionally crucial, clinical illustrations that synthesize the most important char
way. Many disease processes affect, in a direct or indirect way, acteristics of patients selected from an extensive clinical expe
the nervous system. Thus, every clinician, and every basic sci rience. Also included are illustrative clinical images including
entist with an interest in clinical disease, needs an understand computer tomography (CT) and magnetic resonance imaging
ing of neuroanatomy. Stroke remains the most frequent cause (MRI), both of normal brain and spinal cord, and of common
of death in most industrialized societies; mood disorders such clinical entities that trainees will likely encounter.
as depression affect more than 1 person in 10; and clinical As with past editions, I owe a debt of gratitude to many
dysfunction of the nervous system occurs in 25% of patients colleagues and friends, especially members of the Department
in most general hospital settings at some time during their of Neurology at Yale Medical School. Joachim Baehring, MD,
hospital stay. An understanding of neuroanatomy is crucial and Joseph Schindler, MD, of Yale, as well as Catharina Faber,
not only for neurologists, neurosurgeons, and psychiatrists MD, at the University of Maastricht contributed invaluable
but also for clinicians in all subspecialties, since patients of clinical illustrations. Over the years, these colleagues and
every stripe will present situations that require an understand friends have helped to create an environment where learning is
ing of the nervous system, its structure, and its function. fun, a motif that I have woven into this book. I hope that read
This book, now in its 27th edition, is designed as an ers will join me in finding that neuroanatomy, which provides
accessible, easy-to-remember synopsis of neuroanatomy and much of the foundation for both neuroscience and clinical
its functional and clinical implications. Since many of us learn medicine, can be enjoyable, memorable, and easily learned.
and remember better when material is presented visually, t his
book is well illustrated not only with clinical material such as Stephen G. Waxman, MD, PhD
brain scans and pathological specimens but also with hun New Haven, Connecticut
dreds of diagrams and tables that are designed to be clear, April2013
xi
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C H A P T E R
Fundamentals of the
Nervous System
More than any other organ, the nervous system makes human GENERAL PLAN
beings special. The human central nervous system (CNS),
OF THE NERVOUS SYSTEM
smaller and weighing less than most desktop computers, is the
most complex and elegant computing device t hat exists. It re Main Divisions
ceives and interprets an immense array of sensory information,
A. Anatomy
controls a variety of simple and complex motor behaviors, and
engages in deductive and inductive logic. The brain can make Anatomically, the human nervous system is a complex of two
complex decisions, think creatively, and feel emotions. It can gen subdivisions.
eralize and possesses an elegant ability to recognize that cannot
7. CNS- The CNS, comprising the brain and spinal cord, is
be reproduced by even advanced computers. The human nerv
enclosed in bone and wrapped in protective coverings
ous system, for example, can immediately identify a familiar face
(meninges) and fluid-filled spaces.
regardless of the angle at which it is presented. It can carry out
many of these demanding tasks in a nearly simultaneous manner.
2. Peripheral nervous system (PNS)- The PNS is formed by
Given the complexity of the nervous system and the rich
the cranial and spinal nerves (Fig 1 - 1 ) .
ness of its actions, one might ask whether it can ever be under
stood. Indeed, neuroscience has begun to provide an under
B . Physiology
standing, in elegant detail, of the organization and physiology
of the nervous system and the alterations in nervous system Functionally, the nervous system is divided into two systems.
function that occur in various diseases. This understanding is
7. Somatic nervous system-This innervates the structures
firmly based on an appreciation of the structure of the nervous
of the body wall (muscles, skin, and mucous membranes).
system and the interrelation between structure and function.
The complexity of the nervous system's actions is r eflected
2. Autonomic (visceral) nervous system (ANS)-The ANS
by a rich and complex structure-in a sense, the nervous system
contains portions of the central and peripheral systems. It
can be viewed as a complex and dynamic network of interlinked
controls the activities of the smooth muscles and glands of the
computers. Nevertheless, the anatomy of the nervous system
internal organs (viscera) and the blood vessels and returns
can be readily understood. Since different parts of the brain and
sensory information to the brain.
spinal cord subserve different functions, the astute clinician can
often make relatively accurate predictions about t he site(s) of
dysfunction on the basis of the clinical history and careful neu Structu ra l U n its and Overa l l O rgan ization
rological examination. An understanding of neuroanatomy is The central portion o f the nervous system consists o f the
immediately relevant to both basic neuroscience and clinical brain and the elongated spinal cord (Fig 1 -2 and Table 1 - 1 ).
medicine. Clinical neuroanatomy (i.e., the structure of the The brain has a tiered structure and, from a gross point of
nervous system, considered in the context of disorders of the view, can be subdivided into the cerebrum, the brain stem,
nervous system) can teach us important lessons about the struc and the cerebellum.
ture and organization of the normal nervous system, and is es The most rostral part of the nervous system (cerebrum,
sential for an understanding of disorders of the nervous system. or forebrain) is the most phylogenetically advanced and is
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2 SECTION I Basic Principles
Telencephalon
(cerebral hemisphere)
Skull----"'lfl
Brain---�..,.._
Two
cranial ...c:,:::;;.�;,....._---1
nerves
�...;.-
.. --- Spinal
y Spinal cord
Spinal�-------::---,..
nerves
• --.r-....;._,.; Elements
of
vertebral
col umn
responsible for the most complex functions (eg, cognition). Functional U n its
More caudally, the brain stem, medulla, and spinal cord serve The brain, which accounts for about 2% of the body's weight,
less advanced, but essential, functions. contains many billions (perhaps even a trillion) of neurons
The cerebrum (forebrain) consists of the telencephalon and glial cells (see Chapter 2). Neurons, or nerve cells, are
and the diencephalon; the telencephalon includes the cerebral specialized cells that receive and send signals to other cells
cortex (the most highly evolved part of the brain, sometimes through their extensions (nerve fibers, or axons) . The infor
called "gray matter"), subcortical white matter, and t he basal mation is processed and encoded in a sequence of electrical or
ganglia, which are gray masses deep within the cerebral hemi chemical steps that occur, in most cases, very rapidly (in mil
spheres. The white matter carries that name because, in a freshly liseconds). Many neurons have relatively large cell bodies and
sectioned brain, it has a glistening appearance as a result of its long axons that transmit impulses quickly over a considerable
high lipid-rich myelin content; the white matter consists of distance. Interneurons, on the other hand, have small cell
myelinated fibers and does not contain neuronal cell bodies or bodies and short axons and transmit impulses locally. Nerve
synapses (Fig 1 -3). The major subdivisions of the diencephalon cells serving a common function, often with a common target,
are the thalamus and hypothalamus. The brain stem consists of are frequently grouped together into nuclei. Nerve cells with
the midbrain (mesencephalon) , pons, and medulla oblongata. common form, function, and connections that are grouped
The cerebellum includes the vermis and two lateral lobes. The together outside the CNS are called ganglia.
brain, which is hollow, contains a system of spaces called ventri Other cellular elements that support the activity of the
cles; the spinal cord has a narrow central canal that is largely neurons are the glial cells, of which there are several types.
obliterated in adulthood. These spaces are filled with cere Glial cells within the brain and spinal cord outnumber
brospinal fluid (CSF) (Figs 1-4 and 1 -5; see also Chapter 1 1). neurons 10: 1 .
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CHAPTER 1 Fundamentals of the Nervous System 3
r Cerebral cortex
Su bcortica l wh ite matter
Telencephalon
�
L
Commissures
Basal ganglia
Cerebrum
(forebrain)
r Thalamus
Hypothalamus
Diencephalon
�
L
Epitha lamus
Subtha lamus
Cerebellar cortex
Bra i n Cerebel l u m
(encepha lon) Cerebellar nuclei
Midbrain (mesencephalon)
Bra i n stem
Pons
Med u l la oblongata
White matter
Lateral col umns
Spinal cord
Anterior col u m n s
Gray matter
FIGURE 1 -3 Cross section through the spinal cord, showing gray matter (which contains neuronal and g l i a l cel l bodies, axons, dend rites,
and synapses) and wh ite matter (which contains myelinated axons and associated g l i a l cel l s). ( Reproduced, with permission, from Junqueira LC, Carneiro J ,
Kelley RO: Basic Histology: Text & Atlas, 1 1 th ed. McGraw-Hill, 2005.)
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4 SECTION I Basic Principles
Cerebral
hemisphere
Cerebral hemisphere
r,..--::�""""d��'---;;,4- Commissure
(corpus cal losum) Diencephalon
Brain stem
brain. This reflects the fact that the nervous system extracts
different aspects of its sensory surround ( eg, the shape,
FIGURE 1 -4 Photogra p h of a midsagitta l section through the weight, and temperature of an object touching the body)
head and u pper neck, showing the major d ivisions of the centra l and encodes them separately and that it controls specific as
nervous system . (Reproduced, with permission, from deGroot J: Correlative Neu pects of motor behavior (posture, muscle tone, delicate
roanatomy of Computed Tomography and Magnetic Resonance Imagery. 2 1 st ed.
movements) using different sets of neurons. The multiplic
Appleton & Lange, 1 99 1 .)
ity of tracts also endows the nervous system with a degree of
redundancy: After partial destruction of the nervous sys
tem, only some functions will be lost; other functions may
Com putation in the Nervous System be retained, increasing the probability that the organism
Nerve cells convey signals to one another at synapses (see will survive.
Chapters 2 and 3). Chemical transmitters are associated with
the function of the synapse: excitation or inhibition. A neu
ron may receive thousands of synapses, which bring it infor Sym m etry of the Nervous System
mation from many sources. By integrating the excitatory and A general theme in neuroanatomy is that, to a first approxima
inhibitory inputs from these diverse sources and producing tion, the nervous system is constructed with bilateral symme
its own message, each neuron acts as an information-pro try. This is most apparent in the cerebrum and cerebellum,
cessing device. which are organized into right and left hemispheres. On ini
Some very primitive behaviors (eg, the reflex and uncon tial consideration, these hemispheres appear symmetric.
scious contraction of the muscles around the knee in response Some higher cortical functions such as language are repre
to percussion of the patellar tendon) are mediated by a simple sented more strongly in one hemisphere than in the other, but
monosynaptic chain of two neurons connected by a synapse. to gross inspection, the hemispheres have a similar structure.
More complex behaviors, however, require larger polysynap Even in more caudal structures, such as the brain stem and
tic neural circuits in which many neurons, interconnected by spinal cord, which are not organized into hemispheres, there
synapses, are involved. is bilateral symmetry.
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CHAPTER 1 Fundamentals of the Nervous System 5
the left cerebral hemisphere controls body movements that many types of guidance molecules, probably each specific for
pertain to the right side of the external world. This includes, a particular type of axon, and t hey are laid down in gradients
of course, control of the muscles of the right arm and leg, such of varying concentration. In many parts of the developing
as the biceps, triceps, hand muscles, and gastrocnemius. There nervous system, there is initially an overabundance of young
are occasional exceptions to this pattern of "crossed innerva axons, and those that do not reach the correct targets are sub
tion'': For example, the left sternocleidomastoid muscle is con sequently lost by a process of pruning.
trolled by the left cerebral cortex. However, even this exception Although the structural organization of the brain is well
makes functional sense: As a result of its unusual biomechan established before neural function begins, the maturing brain
ics, contraction of the left sternocleidomastoid rotates the neck is susceptible to modification if an appropriate stimulus is ap
to the right. Even for the anomalous muscle, then, control of plied or withheld during a critical period, which can last only
movements relevant to the right side of the world originates in a few days or even less.
the contralateral left cerebral hemisphere, as predicted by t he
principle of crossed representation.
There is one major exception to the rule of crossed motor PERIPHERAL NERVOUS SYSTEM
control: As a result of the organization of cerebellar inputs and
outputs, each cerebellar hemisphere controls coordination The peripheral nervous system (PNS) consists of spinal
and muscle tone on the ipsilateral side of the body (see nerves, cranial nerves, and their associated ganglia (groups
Chapter 7). of nerve cells outside the CNS). The nerves contain nerve
fibers that conduct information to (afferent) or from (effer
ent) the CNS. In general, efferent fibers are involved in mo
Maps of the World Within the B ra i n tor functions, such as the contraction of muscles or secre
At each of many levels, the brain maps (contain a representa tion of glands; afferent fibers usually convey sensory
tion of) various aspects of the outside world. For example, stimuli from the skin, mucous membranes, and deeper
consider the dorsal columns (which carry sensory informa structures.
tion, particularly with respect to touch and vibration, from Individual nerves can be injured by compression or phys
sensory endings on the body surface upward within the spinal ical trauma, resulting in a motor and sensory deficit in the part
cord). Axons within the dorsal columns are arranged in an or of the body innervated by that particular nerve. Some systemic
derly manner, with fibers from the arm, trunk, and leg form illnesses such as diabetes, or exposure to toxins or drugs that
ing a map that preserves the spatial relationship of these body are neurotoxic can injure nerves throughout the body, produc
parts. Within the cerebral cortex, there is also a sensory map ing a peripheral polyneuropathy; in these cases the longest
(which has the form of a small man and is, therefore, called a nerves (those innervating the feet) are affected first.
homunculus), within the sensory cortex. There are multiple
maps of the visual world within the occipital lobes and within
the temporal and parietal lobes as well. These maps are called PLANES AND TERMS
retinotopic because they preserve the geometrical relation
ships between objects imaged on the retina and thus provide Neuroanatomists tend to think of the brain and spinal cord
spatial representations of the visual environment within the in terms of how they appear in slices, or sections. The planes
brain. Each map contains neurons that are devoted to extract of section and terms used in neuroanatomy are shown in
ing and analyzing information about one particular aspect Figure 1-6 and Table 1 -2.
(eg, form, color, or movement) of the stimulus.
Development Coronal
Su perior
The earliest tracts of nerve fibers appear at about the second plane
month of fetal life; major descending motor tracts appear at
about the fifth month. Myelination (sheathing with myelin)
of the spinal cord's nerve fibers begins about the middle of fe Rostra l
tal life; some tracts are not completely myelinated for 20 years.
Dorsa l
The oldest tracts (those common to all animals) myelin ate
first; the corticospinal tracts myelinate largely during the first
and second years after birth. Ventral
Growing axons are guided to the correct targets during
Caudal
development of the nervous system by extracellular guidance
molecules (including the netrins and semaphorins). Some of FIGURE 1 -6 Planes (coronal, horizontal, transverse) and d i rec
these act as attractants for growing axons, guiding them to tions (rostra l, caudal, etc.) freq uently u sed in the description of the
ward a particular target. Others act as repellants. There are bra i n and spinal cord. The plane of the d rawing is the m i d sagitta l.
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6 SECTION I Basic Principles
TABLE 1 -2 Terms Used in Neuroanatomy. Geschwind N, Galaburda AM: Cerebral Lateralization. Harvard
Univ Press, 1 986.
Ventral, anterior On the front {bel ly) side Kandel ER, Schwartz JN, Jessell T: Principles of Neural Science.
Dorsal, posterior On the back side Appleton & Lange, 2000.
Mai J, Paxinos G, Voss T: Atlas of the Human Brain. Elsevier, 2007.
Superior, cranial On the top {sku ll) side Martin JH: Neuroanatomy Text & Atlas, 2nd ed. Appleton & Lange,
I nferior On the lower side 1 996.
Mazziotta J, Toga A, Frackowiak R: Brain Mapping: The Disorders.
Caudal I n the lowermost position {at the tai l end)
Elsevier, 2000.
Rostral On the forward side {at the nose end) Netter FH: Nervous System (Atlas and Annotations). Vol l : The
Medial Close to or toward the middle
CIBA Collection of Medical Illustrations. CIBA Pharmaceutical
Company, 1983.
Median I n the midd le, the midplane {midsagitta l) Nicholls JG, Martin AR, Wallace BG: From Neuron to Brain, 3rd ed.
lateral Toward the side {away from the middle) Sinauer, 1992.
Parent A, Carpenter MC: Carpenter's Human Neuroanatomy, 8th ed.
I psil ateral On the same side
Williams & Wilkins, 1 996.
Contralateral On the opposite side Romanes GJ: Cunningham's Textbook ofAnatomy, 1 8th ed. Oxford
Univ Press, 1986.
Bilatera l On both sides
Shepherd GM: Neurobiology, 2nd ed. Oxford Univ Press, 1 994.
Toga A, Mazziotta J: Brain Mapping: The Systems. Elsevier, 2000.
REFERENCES
Broda! P: The Central Nervous System: Structure and Function.
Oxford Univ Press, 1 98 1 .
Damasio H : Human Brain Anatomy i n Computerized Images.
Oxford Univ Press, 1996.
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C H A P T E R
D evelopment and
C ellular Constituents
of the Nervous System
CELLULAR ASPECTS OF NEURAL Purkinje cell. Motor neurons are usually larger than sensory
neurons. Nerve cells with long processes (eg, dorsal root
DEVELOPMENT
ganglion cells) are larger than those with short processes
Early in the development of the nervous system, a hollow tube (Figs 2-2 and 2-3).
of ectodermal neural tissue forms at the embryo's dorsal mid Some neurons project from the cerebral cortex to the
line. The cellular elements of the tube appear undifferentiated lower spinal cord, a distance of less than 2 ft in infants or 4 ft
at first, but they later develop into various types of neurons or more in adults; others have very short processes, reaching,
and supporting glial cells. for example, only from cell to cell in the cerebral cortex. These
small neurons, with short axons that terminate locally, are
called interneurons.
Layers of the Neura l Tu be Extending from the nerve cell body are usually a num
The embryonic neural tube has three layers (Fig 2- 1 ) : the ven ber of processes called the axon and dendrites . Most neu
tricular zone, later called the ependyma, around the lumen rons give rise to a single axon (which branches along its
(central canal) of the tube; the intermediate zone , which is course) and to many dendrites (which also divide and subdi
formed by the dividing cells of the ventricular zone (including vide, like the branches of a tree). The receptive part of the
the earliest radial glial cell type) and stretches between the neuron is the dendrite, or dendritic zone (see Dendrites
ventricular surface and the outer (pial) layer; and the external section). The conducting (propagating or transmitting) part
marginal zone, which is formed later by processes of the is the axon, which may have one or more collateral branches.
nerve cells in the intermediate zone (Fig 2- l B). The downstream end of the axon is called the synaptic ter
The intermediate zone, or mantle layer, increases in cellu minal, or arborization. The neuron's cell body is called the
larity and becomes gray matter. The nerve cell processes in the soma, or perikaryon .
marginal zone, as well as other cell processes, become white
matter when myelinated.
Cel l Bodies
The cell body is the metabolic and genetic center of a neuron
Differentiation and M i g ration (see Fig 2-3). Although its size varies greatly in different neu
The largest neurons, which are mostly motor neurons, differen ron types, the cell body makes up only a small part of t he neu
tiate first. Sensory and small neurons, and most of the glial cells, ron's total volume.
appear later, up to the time of birth. Newly formed neurons may The cell body and dendrites constitute the receptive pole of
migrate extensively through regions of previously formed neu the neuron. Synapses from other cells or glial processes tend to
rons. When glial cells appear, they can act as a framework that cover the surface of a cell body (Fig 2-4).
guides growing neurons to the correct target areas. Because the
axonal process of a neuron may begin growing toward its target
Dend rites
during migration, nerve processes in the adult brain are often
curved rather than straight. The newer cells of the future cere Dendrites are branches of neurons that extend from the cell
bral cortex migrate from the deepest to the more superficial lay body; they receive incoming synaptic information and thus,
ers. The small neurons of the incipient cerebellum migrate first together with the cell body, provide the receptive pole of the
to the surface and later to deeper layers, and this process con neuron. Most neurons have many dendrites (see Figs 2-2, 2-3,
tinues for several months after birth. and 2-5). The receptive surface area of the dendrites is usually
far larger than that of the cell body. Because most dendrites
are long and thin, they act as resistors, isolating electrical
NEURONS events, such as postsynaptic potentials, from one another (see
Chapter 3 ) . The branching pattern of the dendrites can be
Neurons vary in size and complexity. For example, the nuclei very complex and determines how the neuron integrates
of one type of small cerebellar cortical cell (granule cell) are synaptic inputs from various sources. Some dendrites give rise
only slightly larger than the nucleoli of an adjacent large to dendritic spines, which are small mushroom-shaped
7
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8 SECTION I Basic Principles
/ Axon from
another
neuron
Peri karyon
--- Axon hillock
I n itial segment of axon
A Axon s
A single axon or nerve fiber arises from most neurons. The axon
is a cylindrical tube of cytoplasm covered by a membrane, t he
axolemma. A cytoskeleton consisting of neurofilaments and
microtubules runs through the axon. The rnicrotubules provide
a framework for fast axonal transport (see Axonal Transport sec
tion). Specialized molecular motors (kinesin molecules) bind to
Preganglionic vesicles containing molecules (eg, neurotransmitters) destined
B cel l for transport and "walk'' via a series of adenosine triphosphate
FIGURE 2-2 Schematic illustration of nerve cel l types. A: (ATP)-consuming steps along the microtubules.
Central nervous system cells: {1 ) motor neuro n projecting t o striated The axon is a specialized structure that conducts electri
m u scle, {2) special sensory n e u ron, and {3) general sensory neuron cal signals from the initial segment (the proximal part of the
from ski n . B: Autonomic cel l s to smooth m u scle. Notice how the po axon, near the cell body) to the synaptic terminals. The initial
sition of the cell body with r espect to the axon varies. segment has distinctive morphological features; it differs
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CHAPTER 2 Development and Cellular Constituents of the Nervous System 9
FIGURE 2-4 Electron micrograph of a nerve cel l body (CB) surrounded by nerve processes. The neuronal su rface is completely cov
e red by either syna ptic endings of other neurons (5) or p rocesses of glial cells. Many other p rocesses a round this cel l a re myeli nated axons (M).
CB, neuronal cel l body; N, nucleus, X SOOO. (Courtesy of Dr. DM McDonald.)
from both cell body and axon. The axolemma of the initial by Schwann cells in the peripheral nervous system (PNS) and
segment contains a high density of sodium channels, which by oligodendrocytes (a type of glial cell) in the central nervous
permit the initial segment to act as a trigger zone. In this system (CNS) (Figs 2-8 to 2- 1 1 ) . The myelin sheath is divided
zone, action potentials are generated so that they can travel into segments about 1 mm long by small gaps ( 1 11m long)
along the axon, finally invading the terminal axonal branches where myelin is absent; these are the nodes of Ranvier. The
and triggering synaptic activity, which impinges on other neu smallest axons are unmyelinated. As noted in Chapter 3 ,
rons. The initial segment does not contain Nissl substance myelin functions as a n insulator. I n general, myelination
(see Fig 2-3 ) . In large neurons, the initial segment arises con serves to increase the speed of impulse conduction along the
spicuously from the axon hillock, a cone-shaped portion of axon.
the cell body. Axons range in length from a f ew microns (in
interneurons) to well over a meter (ie, in a lumbar motor neu B. Axonal Tra nsport
ron that projects from the spinal cord to the muscles of the In addition to conducting action potentials, axons transport
foot) and in diameter from 0. 1 11m to more than 20 11m. materials from the cell body to the synaptic terminals (antero
grade transport) and from the synaptic terminals to the cell
A. Myelin body (retrograde transport ) . Because ribosomes are not
Many axons are covered b y myelin. The myelin consists of present in the axon, new protein must be synthesized and
multiple concentric layers of lipid-rich membrane produced moved to the axon. This occurs via several types of axonal
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10 SECTION I Basic Principles
Syna pses
Transmission of information between neurons occurs at
synapses. Communication between neurons usually occurs
from the axon terminal of the transmitting neuron (presyn
aptic side) to the receptive region of the receiving neuron
(postsynaptic side) (Figs 2-7 and 2-12). This specialized in
terneuronal complex is a synapse, or synaptic j unction. As
outlined in Table 2- 1 , some synapses are located between an
axon and a dendrite ( axodendritic synapses, which tend to be
excitatory), or a thorn, or mushroom-shaped dendritic spine
FIGURE 2-5 Dend rite from pyramidal neuron in the motor cor
tex. Note the spi nes on the main dend rite and on its smaller branches.
Sca le = 10 J.Lm. (Micrograph courtesy of Dr. Andrew Tan, Yale University.)
FIGURE 2-6 M icrog raphs showing dend rites of dorsal horn FIGURE 2-7 Diagram matic view, in three d imensions, of a
neurons from a normal rat ( A ) and from a rat fol l owing nerve i nj u ry prototypic neuron. Dend rites ( 1 ) rad iate from the neuronal cell
(B). Note the i ncreased n u m be r of dendritic spi nes and their alte red body, which conta ins the nucleus (3). The axon arises from the ce l l
shape fol l owing nerve i nj u ry. Bar = 1 0 J.Lm. (Modified from Tan AM et al: body a t t h e i n itial seg ment (2). Axodend ritic (4) a n d axosomatic
Rac1 -reg u l ated dendritic spine remodeling contributes to neuropathic pain after (5) synapses a re p resent. M ye l i n sheaths (6) a re present a round some
peripheral nerve i nju ry, Exper Neurol 201 1 ;232:222-233.) axons.
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CHAPTER 2 Development and Cellular Constituents of the Nervous System 11
NEURONAL GROUPINGS
AND CONNECTIONS
B Inner mesaxon Outer mesaxon Nerve cell bodies are grouped characteristically in many
parts of the nervous system. In the cerebral and cerebellar
FIGURE 2-8 A: In the peri phera l nervou s system (PN S), cortices, cell bodies aggregate to form layers called laminas.
u n myel i nated axons a re l ocated with i n g rooves on the su rface of
Nerve cell bodies in the spinal cord, brain stem, and cere
Schwann cel ls. These axons a re not, however, insu lated by a mye l i n
brum form compact groups, or nuclei. Each nucleus contains
sheath. B: Mye l i nated PNS fi bers a re su rrounded b y a mye l i n sheath
that is formed by a spiral wra pping of the axon by a Schwann cell. projection neurons , whose axons carry impulses to other
Panels 1-4 show four consecutive phases of mye l i n formation in parts of the nervous system, and interneurons, which act as
perip heral nerve fi bers. (Reproduced, with permission, from J u nq ueira LC, short relays within the nucleus. In the peripheral nervous sys
Carneiro J, Kelley RO: Basic Histology, 1 1 th ed. McGraw· Hill, 2005.) tem, these compact groups of nerve cell bodies are called
ganglia.
Groups of nerve cells are connected by pathways formed
which protrudes from the dendrite (Fig 2- 1 3). Other synapses
by bundles of axons. In some pathways, the axon bundles are
are located between an axon and a nerve cell body ( axoso
sufficiently defined to be identified as tracts, or fasciculi; in
matic synapses, which tend to be inhibitory). Still other
others, there are no discrete bundles of axons. Aggregates of
synapses are located between an axon terminal and another
tracts in the spinal cord are referred to as columns, or funi
axon; these axoaxonic synapses modulate transmitter release
culi (see Chapter 5 ) . Within the brain, certain tracts are re
by the postsynaptic axon. Synaptic transmission permits in
ferred to as lemnisci. In some regions of the brain, axons are
formation from many presynaptic neurons to converge on a
intermingled with dendrites and do not r un in bundles so that
single postsynaptic neuron. Some large cell bodies receive sev
pathways are difficult to identify. These networks are called
eral thousand synapses (see Fig 2-4) .
the neuropil (Fig 2-14).
Impulse transmission at most synaptic sites involves the
release of a chemical transmitter substance (see Chapter 3); at
other sites, current passes directly from cell to cell through NEUROGLIA
specialized junctions called electrical synapses, or gap
junctions. Electrical synapses are most common in inverte Neuroglial cells, commonly called glial cells, outnumber
brate nervous systems, although they are found in a small neurons in the brain and spinal cord 1 0 : 1 . They do not form
number of sites in the mammalian CNS. Chemical synapses synapses. These cells appear to play a number of important
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12 SECTION I Basic Principles
Axoaxonic Axon terminal Axon term inal Presynaptic i n h ibition (modu l ates transmitter
release in postsynaptic axon)
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CHAPTER 2 Development and Cellular Constituents of the Nervous System 13
blood vessels in the nervous system, and they cover the exte
rior surface of the brain and spinal cord below the pia.
Astrocytes provide structural support to nervous tissue
and act during development as guidewires that direct neu
ronal migration. They also maintain appropriate concentra
tions of ions such as K+ within the extracellular space of the
brain and spinal cord. Astrocytes may also play a role in
synaptic transmission. Many synapses are closely invested by
astrocytic processes, which appear to participate in the reup
take of neurotransmitters. Astrocytes also surround endothe
lial cells within the CNS, which are joined by tight junctions
that impede the transport of molecules across the capillary ep
ithelium, and contribute to the formation of the blood-brain
barrier (see Chapter 1 1 ) . Although astrocytic processes
around capillaries do not form a functional barrier, they can
selectively take up materials to provide an environment opti
mal for neuronal function.
Astrocytes form a covering on the entire CNS surface
and proliferate to aid in repairing damaged neural tissue
(Fig 2-1 5 ) . These reactive astrocytes are larger, are more eas
ily stained, and can be definitively identified in histological
sections because they contain a characteristic, astrocyte-spe
cific protein: glial fibrillary acidic protein (GFAP) .
Chronic astrocytic proliferation leads to gliosis, sometimes
called glial scarring. Whether glial scarring is beneficial, or
inhibits regeneration of injured neurons, is currently being
FIGURE 2 - 1 0 Oligodendrocytes form myelin i n t h e centra l studied.
nervous system (CN S). A s i n g l e o l i godend rocyte mye l i nates an en
t i re fa m i l y of axons (2-50). There is l ittl e oligodendrocyte cytop l a s m
(Cyt) i n the o l igodend rocyte p rocesses that s p i ra l around the axon Ol igodendrocytes
to fo rm mye l i n , and the mye l i n sheaths a re connected to t h e i r p a r Oligodendrocytes predominate in white matter; they extend
ent oligodendrocyte cel l body by o n l y t h i n tongues of cyto p l a s m . arm-like processes which wrap tightly around axons, extrud
T h i s may accou nt, at l east in pa rt, for the p a ucity o f remye l i nation ing the oligodendroglial cytoplasm to form a compact sheath
after damage to the mye l i n in the CNS. The mye l i n is period ica l l y
of myelin which acts as an insulator around axons in the CNS.
i nterru pted at nodes o f Ranvier, where t h e a x o n (A) is exposed to
Oligodendrocytes may also provide some nutritive support to
the extrace l l u la r space (ES). (Redrawn and reproduced with permission from
the neurons they envelop. A single oligodendrocyte may wrap
Bunge M, Bunge R. Pappas G: Ultrastructural study of r emyelination in an experimen
tal lesion in adult cat spinal cord, J Biophys Biochem Cytol May; 1 0:67-94, 1 96 1 .)
myelin sheaths around many (up to 30-40) axons (see
Figs 2 - 1 0 and 2- 1 1 ) . In peripheral nerves, by contrast, myelin
is formed by Schwann cells. Each Schwann cell myelinates a
single axon, and remyelination can occur at a brisk pace after
Astrocytes injury to the myelin in the peripheral nerves.
There are two broad classes of astrocytes: protoplasmic and
fibrous. Protoplasmic astrocytes are more delicate, and their
many processes are branched. They occur in gray matter. Fi
Microg l ia
brous astrocytes are more fibrous, and their processes (con Microglial cells are the macrophages, or scavengers, of the
taining glial fibrils) are seldom branched. Astrocytic processes CNS. They constantly survey the brain and spinal cord, acting
radiate in all directions from a small cell body. They surround as sentries designed so as to detect, and destroy, invaders
{
Cell Type Principal Functions
Glial cel l s
f Macroglia
Oligodendrocytes
Astrocytes
Myelin formation i n CNS
l
g rowing axons
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14 SECTION I Basic Principles
FIGURE 2-1 1 Electron m icrograph showi ng oligodendrocyte (OL) i n the spinal cord, which has myelinated two axons (A , A2).
X 6600. The inset shows axon A1 and its mye l i n sheath at higher magn ification. The myel i n is a spira l of ol igodendrocyte mem brane that
surro u nds the axon. M ost of the ol igodendrocyte cytoplasm is extruded from the myelin. Beca use the mye l i n is com pact, it has a high electrical
resistance and low capacitance so that it can fu nction as a n insulator around the axon. X 1 6,000.
(such as bacteria) . When an area of the brain or spinal cord is Extrace l l u l a r Space
damaged or infected, microglia activate and migrate to the site
There is some fluid-fill e d space between the various cellular
of injury to remove cellular debris. Some microglia are always
components of the CNS. This extracellular compartment
present in the brain, but when inj ury or infection occurs,
probably accounts for, under most circumstances, about 20%
others enter the brain from blood vessels. Microglia play an
of the total volume of the brain and spinal cord. Because
important role in protecting the nervous system from outside
transmembrane gradients of ions, such as K'" and Na+ , are im
invaders such as bacteria. Their role after endogenous insults,
portant in electrical signaling in the nervous system (see
including stroke or neurodegenerative diseases such as
Chapter 3), regulation of the levels of these ions in the extra
Alzheimer disease, is less well understood, and it is not clear
cellular compartment ( ionic homeostasis) is an important
at this time whether activation of microglia in these disorders
function, which is, at least in part, performed by astrocytes.
is protective or is maladaptative.
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CHAPTER 2 Development and Cellular Constituents of the Nervous System 15
� Postsynaptic
membrane The capillaries within the CNS are completely invested by glial
Synaptic
cleft or neural processes. Moreover, capillary endothelial cells in
the brain (in contrast to capillary endothelial cells in other or
FIGURE 2-1 2 Schematic drawing of a synaptic terminal.
gans) form tight j unctions, which are impermeable to diffu
Vesicles fuse with the presyna ptic membra n e and release transmitter
sion, thus creating a blood-brain barrier. This barrier iso
molecules i nto the synaptic cleft so that they can bind t o receptors in
lates the brain extracellular space from the intravascular
the postsyna ptic mem brane.
compartment.
Postsynaptic
cell
C l i n ica l Correlation
In cerebral edema , there is an increase in the bulk of the
/ Dendritic spine
brain. Cerebral edema can be either vasogenic (primarily ex
tracellular) or cytotoxic (primarily intracellular). Because of
the limited size of the cranial vault within the skull, cerebral
'\
, Axodendritic edema must be treated emergently:
DEGENERATION
Axodendritic
AND REGENERATION
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16 SECTION I Basic Principles
Several months
F I G U R E 2-1 6 Main changes that take place i n an injured nerve fiber. A: Normal nerve fi ber, with its perika ryon and the effector
cel l (stri ated skeletal m u scle). N otice the position of the n e u ro n n ucleus and the a m o u nt and d i stribution of N i ssl bodies. B: When the fi ber
is i nj u red, the n e u ro n a l n ucleus m oves to the cel l periphery, Nissl bodies beco m e g reatly red uced i n n u m be r (chromatolysis), and the nerve
fi ber d i sta l to the i nj u ry degenerates a l o n g with its mye l i n sheath. Debris is p h a g ocytized by m a c rophages. C: The m uscle fi ber shows
p ro n o u nced disuse atrop hy. Schwa n n cel l s prolife rate, forming a com pact cord that is penetrated by the g rowi n g axon . The axon g rows at a
rate of 0.5 to 3 m m/d. D: In this exa m ple, the n erve fi ber regeneration was successfu l, and the m uscle fi ber was a l s o regenerated after
rece iving nerve sti m u l i . E: When the axon does not penetrate the cord of Schwa n n ce l l s, its g rowt h i s not organ ized and s u ccessfu l regenera
tion does n ot occ u r. (Red rawn and reproduced, with permission, from Willis RA, Wi l l i s AT: The Principles of Pathology and Bacteriology, 3rd ed. Butterworth, 1 972.)
Distal to the level of axonal transection when a peripheral swelling of nearby astrocytes, and activation of microglia.
nerve is injured, Schwann cells dedifferentiate and divide. To Successful axonal regeneration does not commonly occur af
gether with macrophages, they phagocytize the remnants of ter injury to the CNS. Many neurons appear to be dependent
the myelin sheaths, which lose their integrity as the axon on connection with appropriate target cells; if t he axon fails
degenerates. to regenerate and form a new synaptic connection with the
After injury to its axon, the neuronal cell body exhibits correct postsynaptic cells, the axotomized neuron may die or
a distinct set of histological changes (which have been atrophy.
termed the axon reaction or chromatolysis ) . The changes
include swelling of the cell body and nucleus, which is usu
ally displaced from the center of the cell to an eccentric loca
Reg eneration
tion. The regular arrays of ribosome-studded endoplasmic A. Periphera l Nerves
reticulum, which characterize most neurons, are dispersed Regeneration denotes a nerve's ability to regrow to an appro
and replaced by polyribosomes. (The ribosome-studded en priate target, including the reestablishment of functionally
doplasmic reticulum, which had been termed the Nissl sub useful connections (see Figs 2 - 1 6 and 2 - 1 7 ) . Shortly ( 1 -3
stance by classical neuroanatomists, normally stains densely days) after an axon is cut, the tips of the proximal stumps form
with basic dyes. The loss of staining of the Nissl substance, as enlargements, or growth cones. The growth cones send out
a result of dispersion of the endoplasmic reticulum during exploratory pseudopodia that are similar to the axonal growth
the axon reaction, led these early scientists to use the term cones formed in normal development. Each axonal growth
"chromatolysis:') In association with the axon reaction in cone is capable of forming many branches that continue to ad
some CNS neurons, there is detachment of afferent synapses, vance away from the site of the original cut. If these branches
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CHAPTER 2 Development and Cellular Constituents of the Nervous System 17
Axon branch Receptor now appreciated that molecules such as NoGo act as "stop
-)
(sustaining collateral) signs" that inhibit regeneration of axons within the brain and
spinal cord. Neutralization of NoGo has been shown to pro
mote the regeneration of axons within t he spinal cord in ex
perimental animals. When confronted with a permissive envi
Retrograde Receptor ronment (eg, when the transected axons of CNS neurons are
degeneration hypersensitive permitted to regrow into a peripheral nerve, or transplanted
Site of injury into the CNS as a "bridge"), CNS axons can regenerate for dis
---1- - - - -·
tances of at least a few centimeters. Moreover, some of the re
generated axons can establish synaptic connections with ap
\ I propriate target cells.
Retrograde Regenerative Orthograde
reaction: sprouting (wallerian)
chromatolysis degeneration C. Remyeli nation
In a number of disorders of the peripheral nervous system
FIGURE 2-1 7 S u m m a ry of changes occurring in a neuron and
(such as the Guillain-Barre syndrome), there is demyelina
the structure it innervates when its axon is crushed or cut at the
tion, which interferes with conduction (see Chapter 3). This
point ma rked X. (Modified from Ries D. Reproduced, with permission, from
condition is often followed by remyelination by Schwann cells,
Ganong WF: Review of Medical Physiology, 22nd ed. McGraw-Hill, 2005.)
which are capable of elaborating new myelin sheaths in t he pe
ripheral nervous system. In contrast, remyelination occurs
can cross the scar tissue and enter the distal nerve stump, suc much more slowly (if at all) in the CNS. Little remyelination
cessful regeneration with restoration of function may occur. occurs within demyelinated plaques within the brain and
The importance of axonal regeneration through the spinal cord in multiple sclerosis. A different form of plasticity
Schwarm cell tubes surrounded by basal lamina (Biingner's (ie, the molecular reorganization of the axon membrane that
bands) in the distal stump explains the different degrees of re acquires sodium channels in demyelinated zones) appears to
generation that are seen after nerve crush compared with nerve underlie clinical remissions (in which there is neurological
transection. After a crush injury to a peripheral nerve, the ax improvement) in patients with multiple sclerosis.
ons may be severed, but the Schwann cells, surrounding basal
lamina, and perineurium maintain continuity through the le D. Col latera l Sprouti ng
sion, facilitating regeneration of axons through the injured
This phenomenon has been demonstrated in the CNS as well
nerve. In contrast, if the nerve is cut, the continuity of these
as in the peripheral nervous system (see Fig 2-14). It occurs
pathways is disrupted. Even with meticulous surgery, it can be
when an innervated structure has been partially denervated.
difficult to align the proximal and distal parts of each axon's
The remaining axons then form new collaterals that reinner
pathway; successful regeneration is, t herefore, less likely.
vate the denervated part of the end organ. This kind of regen
Peripheral system axons will reinnervate both muscle and
eration demonstrates that there is considerable plasticity in
sensory targets; however, motor axons will not connect to sen
the nervous system and that one axon can take over the synap
sory structures, or sensory axons to muscle. Although a motor
tic sites formerly occupied by another.
axon will reinnervate any denervated muscle, it will preferen
tially connect to its original muscle. Innervation of an incor
rect muscle by a regenerated motor axon results in anomalous
NEUROGENESIS
reinnervation, which can be accompanied by inappropriate
and unwanted movements. Such movements include "j aw It has classically been believed t hat neurogenesis-the capa
winking;' in which motor axons destined for the jaw muscles bility for production of neurons from undifferentiated, prolif
reinnervate muscles around the eye after injury. erative progenitor cells-is confined to t he development pe
riod that precedes birth in mammals. According to this
B. Centra l Nervous System traditional view, after pathological insults t hat result in neu
Axonal regeneration is typically abortive in the CNS. The rea ronal death, the number of neurons is permanently reduced.
sons for regeneration failure are not yet entirely clear. Classi However, recent evidence has indicated that a small number
cal neuropathologists suggested that the glial scar, which is of neuronal precursor cells, capable of dividing and t hen dif
largely formed by astrocytic processes, may be partly respon ferentiating into neurons, may exist in t he forebrain of adult
sible. The properties of the oligodendroglial cells (in contrast mammals, including humans. These rare precursor cells re
to those of the Schwarm cells of peripheral nerves) may also side in the subventricular zone. For example, there is some ev
account for the difference in regenerative capacity: Recent idence for postnatal neurogenesis in the dentate gy.rus of the
work suggests that the glial s car may not present a mechanical hippocampus, and it has been suggested that the rate of gen
barrier to axonal regeneration in the CNS. An inhibitory fac eration of new neurons in this critical region can be acceler
tor produced by oligodendrocytes, CNS myelin, or both may ated in an enriched environment. While the number of new
interfere with regeneration of axons through the CNS. It is neurons that can be produced within the adult human brain is
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18 SECTION I Basic Principles
still being debated, the existence of these precursor cells may Kettenmann H, Ransom BR: Neuroglia, 2nd ed. Oxford Univ Press,
suggest strategies for restoring function after inj ury to the 2005.
CNS. This is an area of intense research. Kordower J, Tuszynski M: CNS Regeneration. Elsevier, 2007.
Laming PR: Glial Cells. Cambridge Univ Press, 1 998.
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Levitan I, Kaczmark LK: The Neuron: Cell and Molecular Biology,
3rd ed. Oxford Univ Press, 200 1 .
Cafferty WB, McGee AW, Strittmatter SM: Axonal growth t hera Peters A , Palay SL, Webster H d e F : The Fine Structure o f the
peutics: regeneration or sprouting or plasticity. Trends Neurosci Nervous System, 3rd ed. Oxford Univ Press, 1989.
2007;3 1:2 1 5-220. Rakic P: A century of progress in corticoneurogenesis: from silver
Cajal S: Histologie du Systeme Nerveux de I 'Homme et des Vertebres, impregnation to genetic engineering. Cereb Cortex 2006; 1 6
vol 2. Librairie Maloine, 1 9 1 1 . (Suppl. 1 ) : 1 3 - 1 7.
Hall ZW (editor) : An Introduction t o Molecular Neurobiology. Sanes D, Reh T, Harris W: Development of the Nervous System.
Sinauer, 1992. Elsevier, 2005.
Hare! NY, Strittmatter SM: Can regenerating axons recapitulate Sasaki M, Li B, Lankford KL, Radtke C, Kocsis JD: Remyelination of
developmental guidance during recovery from spinal cord the injured spinal cord. Prog Brain Res 2007; 1 6 1 :419-433.
injury? Nat Rev Neurosci 2006;7:603-615. Siegel G, Albers RW, Brady S, Price DL (editors) : Basic
Hastings MB, Tanapat B, Gould E: Comparative views of neuro Neurochemisry. Lippincott Williams & Wilkins, 2005.
genesis. The Neurologist 2000;6: 3 1 5 . Tan AM, Waxman SG: Spinal cord injury, dendritic spine remodel
Junqueira LC, Carneiro J, Kelley RO: Basic Histology, 9th ed. ing, and spinal memory mechanisms. Exp Neurol 201 2;235:
Appleton & Lange, 1998. 142- 1 5 1 .
Kalb RG, Strittmatter SM (editors) : Neurobiology of Spinal Cord Waxman SG, Kocsis JD, Stys P K (editors) : The Axon: Structure,
Injury. Humana, 200 1 . Function, and Pathophysiology. Oxford Univ Press, 1 995.
Kempermann G , Kuhn HG, Gage FH: More hippocampal neurons Yuste R: Dendritic spines MIT. Press, 2010.
in adult mice living in an enriched environment. Nature
1 997;386:393.
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C H A P T E R
Si gnaling in the
Nervous System
Along with muscle cells, neurons are unique in that they are (see Table 3 - 1 ) . The Nernst equation, which would be used to
excitable; that is, they respond to stimuli by generating elec determine membrane potential across a membrane permeable
trical impulses. Electrical r esponses of neurons (modifications only to r ions, is as follows:
of the electrical potential across their membranes) may be lo
cal (restricted to the place that received the stimulus) or prop
agated (may travel through the neuron and its axon) . Propa
gated electrical impulses are termed action potentials. where
Neurons communicate with each other at synapses by a E equilibrium potential (no net flow across the
process called synaptic transmission. membrane)
K potassium
T temperature
M EM BRANE POTENTIAL R gas constant
The membranes of cells, including nerve cells, are structured F Faraday constant (relates charge in coulombs t o
so that a difference in electrical potential exists between t he concentration i n moles)
inside (negative) and the outside (positive). This results in a N valence (for potassium, valence = 1)
resting potential across the cell membrane, which is normally [K + L concentration of potassium inside cell
about -70 m V. [K+ l o = concentration of potassium outside cell
The electrical potential across the neuronal cell mem
brane is the result of its selective permeability to certain
charged ions. Cell membranes are highly permeable to most At physiologic temperatures
inorganic ions, but they are almost impermeable to proteins
and many other organic ions. The difference ( gradient) in ion EK = 58 log [[�tf
composition inside and outside the cell membrane is main
tained by ion pumps in the membrane, which maintain a
nearly constant concentration of inorganic ions within the cell The equilibrium potential (E Na) for sodium can be found
(Fig 3 - 1 and Table 3 - 1 ) . The pump that maintains Na + and by substituting [Na + l i and [Na + ] 0 in the Nernst equation; this
K + gradients across the membrane is Na, K-ATPase; this spe potential would be found across a membrane that was perme
+ able only to sodium. In reality, most cell membranes are not
cialized protein molecule extrudes a from the intracellular
compartment, moving it to the extracellular space, and im perfectly selective; that is, they are permeable to several ionic
ports K + from the extracellular space, carrying it across the species. For these membranes, potential is the weighted average
membrane into the cell. In carrying out this essential activity, of the equilibrium potentials for each permeable ion, with the
the pump consumes adenosine triphosphate (ATP) . contribution for each ion weighted to reflect its contribution to
Two types o f passive forces maintain an equilibrium of Na + total membrane permeability. This is described mathemati
+ +
and K+ across the membrane: A chemical force tends to move cally, for a membrane that is permeable to Na and K , by the
Na + inward and K + outward, from the compartment containing Goldman-Hodgkin-Katz equation (also known as the con
high concentration to the compartment containing low concen stant field equation):
tration, and an electrical force (the membrane potential) tends to
move Na + and K + inward. When the chemical and electrical
forces are equally strong, an equilibrium potential exists.
For an idealized membrane that is permeable to only K + ,
where
the Nernst equation, which describes the relationship be
[NaL = concentration of sodium inside cell
tween these forces, is used to calculate the magnitude of the
equilibrium potential (ie, the membrane potential at which [Na] 0 = concentration of sodium outside cell
equilibrium exists) . Normally, there is a much higher concen PNa = membrane permeability to sodium
tration of K + inside the cell ( [K + h) than outside the cell ( [K + l o ) PK = membrane permeability to potassium
19
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20 SECTION I Basic Principles
Exterior Cell Interior PK-PNa ratio is approximately 20: 1 . Thus, when a neuron is
membrane inactive ( resting), the Goldman-Hodgkin- Katz equation
is dominated by K + permeability so that membrane potential
is close to the equilibrium potential for K (EK)· This accounts
for the resting potential of approximately -70 m V.
GENERATOR POTENTIALS
ACTION POTENTIALS
As seen in this equation, membrane potential is affected
by the relative permeability to each ion. If permeability to a Neurons communicate by producing electrical impulses called
certain ion increases ( eg, by the opening of pores or channels action potentials. Action potentials are self-regenerative elec
specifically permeable to that ion ) , membrane potential trical signals that tend to propagate throughout a neuron and
moves closer to the equilibrium potential for that ion. Con along its axon. The action potential is a depolarization of a bout
versely, if permeability to that ion decreases ( eg, by closing of 1 00 mV (a large signal for a neuron). The action potential is all
pores or channels permeable to that ion) , membrane potential or none. Its size is constant for each neuron.
moves away from the equilibrium potential for that ion. Neurons can generate action potentials because they
In the membrane of resting neurons, K + permeability is contain specialized molecules, called sodium channels, that
much higher ( -20-fold) than Na + permeability; that is, t he
Concentration
(mmoi/L H20)
Equilibrium
I on Inside Cell Outside Cell Potential (mV)
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CHAPTER 3 Signaling in the Nervous System 21
respond to depolarization by opening (activating) . When t his another action potential cannot b e generated, and t he relative
occurs, the relative permeability of the membrane t o Na + in refractory period (lasting up to a few milliseconds), during
creases, and the membrane moves closer to the equilibrium which a second action potential can be generated but conduc
potential for Na + , as predicted by the Goldman-Hodgkin tion velocity is decreased and threshold increased. The refrac
Katz equation, thus causing further depolarization. When a tory period limits the ability of the axon to conduct high
depolarization (from a generator potential, synaptic potential, frequency trains of action potentials.
or oncoming action potential) impinges on a neuronal mem
brane, sodium channels activate and, as a result, the mem
brane begins to further depolarize . This action tends to acti THE NERVE CELL MEMBRANE
vate still other sodium channels, which also open and cause CONTAINS ION CHANNELS
depolarization. If a sufficient number of sodium channels are
activated, there is a depolarization of about 1 5 mV, and Voltage-sensitive ion channels are specialized protein mole
threshold is reached so that the rate of depolarization in cules that span the cell membrane. These doughnut-shaped
creases sharply to produce an action potential (Fig 3-3). Thus, molecules contain a pore that acts as a tunnel, permitting spe
the membrane generates an explosive, ali-or-none action po cific ions (eg, Na + or K+ ), but not other ions, to permeate. The
tential. As the impulse passes, repolarization occurs rapidly channel also possesses a voltage sensor, which, in response to
at first and then more slowly. Membrane potential thus re changes in potential across the membrane, either opens (acti
turns to resting potential. The action potential tends to last for vates) or closes (inactivates) the channel.
a few milliseconds. The neuronal membrane has the ability to generate im
In some fibers, membrane potential becomes transiently pulses because it contains voltage-sensitive Na+ channels,
hyperpolarized (the after-hyperpolarization) as a result of the which are selectively permeable to Na + and tend to open when
opening of the K+ channels, which tends to drive the mem the membrane is depolarized. Because these channels open in
brane toward EK. In the wake of an action potential, t here is a response to depolarization, and because by opening they drive
refractory period of decreased excitability. This period has two the membrane closer to Na + equilibrium potential (ENa), they
phases: the initial absolute refractory period , during which tend to further depolarize the membrane (Fig 3-4). If a suffi
cient number of these channels are opened, there is an explo
sive, ali-or-none response, termed the action potential (see
Fig 3-3). The degree of depolarization necessary to elicit t he
+35
action potential is called the threshold.
Other voltage-sensitive ion channels ( voltage
sensitive K+ channels) open (usually more slowly than Na +
0
channels) in response to depolarization and are selectively
>
E
Stimulus
\
-5 5 artifact
Na+
-70 channels
Na+ ions
Latent Iperiod
enter cell
open
Time
Stimu lator
I
Axon Microelectrode
inside axon
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22 SECTION I Basic Principles
- 70
n !
�::-:-
K+
+++++++++++++++++
+ 35
mV
r"
mV
N a+
- -�} :
+
+
+
+ + -
+ + ::. .::- +
+ +
+ -_-
+
++++++++++++ ++++++++++++++++++
+ 35
mV
0 mV - - - - - - - -
FIGURE 3-5 Conduction of the nerve impulse
through a nonmyelinated nerve fiber. In the resting
axon, there is a d ifference of - 70 mV between the i nterior
of the axon and the outer su rface of its mem brane (rest
ing potential). During the conduction of an action poten
tial, Na + passes i nto the axon i nterior and su bsequently
K + migrates i n the o pposite d i rection. In consequence,
the membrane pola rity changes (the mem brane becomes
- 70 t---- relatively positive o n its inner su rface), and the r esting po
mV
tential is replaced by a n action potential ( + 35 mV here).
(Reproduced, with permission, from Junqueira LC, Carneiro J , Kel l ey
Time RO: Basic Histology, 7th ed. Appleton & Lange, 1 992.)
permeable to K + . When these channels open, the membrane contrary, it is periodically interrupted by small gaps (approxi
+ mately 1 f.!m long), called the nodes of Ranvier, where the axon
potential is driven toward the K equilibrium potential (EK),
leading to hyperpolarization. is exposed. In mammalian myelinated fibers, the voltage-sensi
tive Na + and K + channels are not distributed uniformly. Na +
channels are clustered in high density (about 1 000/ f.!m2 ) in the
THE EFFECTS OF MYELINATION axon membrane at the node ofRanvier, but are sparse in the in
ternodal axon membrane, under the myelin. K + channels, on
Myelin is present around some axons within the peripheral the other hand, tend to be localized in the "internodal" and
nervous system (PNS) (where it is produced by Schwann cells) "paranodal" axon membrane, that is, the axon membrane cov
and within the central nervous system (CNS) (where it is pro ered by the myelin (Fig 3-6).
duced by oligodendrocytes). Myelination has profound effects
on the conduction of action potentials along the axon.
Nonmyelinated axons, in the mammalian PNS and CNS,
generally have a small diameter (less than 1 f.!m in the PNS
and less than 0.2 f.!m in the CNS). The action potential travels
in a continuous manner along these axons because of a rela
tively uniform distribution of voltage-sensitive Na + and K +
channels. As the action potential invades a given region of the
axon, it depolarizes the region in front of it, so that the im
pulse crawls slowly and continuously along t he entire length
of the axon (Fig 3-5). In nonmyelinated axons, activation of FIGURE 3-6 Na + and K + channel distributions in myelinated
Na+ channels accounts for the depolarization phase of the ac axons are not uniform. Na + channels (gN,) a re clustered in high
tion potential, and activation of K + channels produces repo density i n the axon m e m bra n e at the node of Ranvier, where they a re
larization. ava i lable to p roduce the depola rization needed for the action poten
Myelinated axons, in contrast, are covered by myelin tial. K + channels (g K), o n the other hand, a re l ocated largely i n the i n
sheaths. The myelin has a high electrical resistance and low ca ternodal axon m e m brane u nder the myelin, so that they a re masked.
pacitance, permitting it to act as an insulator. The myelin sheath (Reproduced with permission from Waxman SG: Membra nes, myelin and the patho
physiology of m u ltiple sclerosis, N Eng/ J Med Jun 24;306(25): 1 529-33, 1 982.)
is not continuous along the entire length of the axon. On the
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CHAPTER 3 Signaling in the Nervous System 23
. . . .. .. .. . .. .. .. .. .. .. ... . _
.,· .. . ..
� -- · · · � - - - - - - - -�
B
-
.. . . . . . . . . . . . . . . . . . . . . ..... . . . . . .
.
-�·
.
FIGURE 3-7 A: Saltatory conduction in a mye l i nated axon. The myelin fu nctions as an insu lator beca use of its high r esista n ce and low ca
pacitance. Thus, when the action potential ( cross-hatching) is at a given node of Ranvier, the majority of the electrical cu rrent is shu nted t o the
next node (a long the pathway shown by the broken arrow). Conduction of the action potentia l proceeds i n a disconti nuous m a n ner, j u m ping
from node to node with a high conduction velocity. B: I n demyelinated axons there is loss of cu rrent t h rough the damaged myelin. As a r esu lt,
it either ta kes longer t o reach t h reshold and conduction velocity is r educed, or threshold is n ot reached a n d the actio n potential fa ils to propa
gate. (Reproduced, with permission, from Waxman SG: Membranes, myelin and the pathophysiology of mu ltiple sclerosis. N Eng/ J Med 1 982;306: 1 529.)
Because the current flow through the insulating myelin is large and myelinated, conduct rapidly, and carry various mo
very small and physiologically negligible, t he action potential tor or sensory impulses. They are most susceptible to injury
in myelinated axons jumps from one node to the next in a by mechanical pressure or lack of oxygen . B fibers are
mode of conduction that has been termed saltatory (Fig 3-7). smaller myelinated axons that conduct less rapidly than A
There are several important consequences to this saltatory fibers. These fibers serve autonomic functions. C fibers are
mode of conduction in myelinated fibers. First, the energy re the smallest and are nonmyelinated; they conduct impulses
quirement for impulse conduction is lower in myelinated the slowest and serve pain conduction and autonomic func
fibers; therefore, the metabolic cost of conduction is lower. tions. An alternative classification, used t o describe sensory
Second, myelination results in an increased conduction ve axons in peripheral nerves, is shown in Table 3-3.
locity. Figure 3-8 shows conduction velocity as a function of
diameter for nonmyelinated and myelinated axons. For non
myelinated axons, conduction velocity is proportional to
(diameter)112• In contrast, conduction velocity in myelinated
axons increases linearly with diameter. A myelinated axon can 8
conduct impulses at a much higher conduction velocity t han
a nonmyelinated axon of the same size. To conduct as rapidly
as a 1 0 - !lm myelinated fiber, a nonmyelinated axon would
need a diameter of more than 1 00 11m. By increasing the con
duction velocity, myelination reduces the time it takes for im
pulses to travel from one region to another, thus reducing the
time needed for reflex activities and permitting the brain to
operate as a high-speed computer.
Nerve fibers within peripheral nerves have been divided into FIGURE 3-8 Relationship between cond uction velocity and di
three types according to their diameters, conduction veloci a m eter i n mye l i nated and non mye l i nated axons. Myelinated axons
ties, and physiologic characteristics (Table 3-2). A fibers are conduct more rapidly than non myelinated axons of the same size.
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24 SECTION I Basic Principles
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CHAPTER 3 Signaling in the Nervous System 25
FIGURE 3-9 Atrophy (loss of m uscle mass) i n the hands of a patient with hereditary sensori m otor neu ropathy. Peri pheral neuropathies
affect the longest nerve fi bers fi rst, and the f eet and hands thus a re affected i n early stages of the d isease. (Courtesy of Dr. Catherina Faber.)
components at chemical synapses communicate via diffu mine whether it will fire or not (see Excitatory and In
sion of neurotransmitter molecules; some common trans hibitory Synaptic Actions section) .
mitters that consist of relatively small molecules are listed Neurotransmitter in presynaptic terminals is contained
with their main areas of concentration in the nervous in membrane-bound presynaptic vesicles. Release of neuro
system in Table 3 - 5 . As a result of depolarization of the transmitter occurs when the presynaptic vesicles fuse with
presynaptic ending by action potentials, neurotransmitter the presynaptic membrane, permitting release of their con
molecules are released from the presynaptic ending, diffuse tents by exocytosis . Vesicular transmitter release is triggered
across the synaptic cleft, and bind to postsynaptic recep by an influx of Ca2 + into the presynaptic terminal, an event
tors . These receptors are associated with and trigger the mediated by the activation of presynaptic Ca 2 + channels by
opening of (or, in some cases, closing of) ligand-gated ion the invading action potential. As a result of t his activity-in
channels . The opening (or closing) of these channels pro duced increase in Ca2 + in the presynaptic terminal, there is
duces postsynaptic potentials. These depolarizations and phosphorylation of proteins called synapsins, which appear
hyperpolarizations are integrated by the neuron and deter- to cross-link vesicles to the cytoskeleton, thereby preventing
Reproduced, with permission, from Ganong WF: Review of Medical Physiology, 22nd ed. McGraw·Hi/1, 2005.
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26 SECTION I Basic Principles
TABLE 3-3 Nu meric Classification Sometimes Used TAB L E 3-5 Areas of Concentration of Common
for Sensory Neurons. Neurotransm itters.
Ill Pa i n and temperature receptors; A 'O Norepinephrine ( N E) Sympathetic nervous system, locus
some touch receptors ceruleus, lateral tegmentum
IV Pa in and other receptors c Dopamine (DA) Hypotha lamus, mid bra i n nigrostriatal
system
Reproduced, with permission, from Ganong WF: Review of Medica l Physiology, 22nd
ed. McGraw-Hiil, 2005.
Serotonin (5-HT) Parasympathetic neurons in g ut, pineal
gla nd, nucleus raphe magnus of pons
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CHAPTER 3 Signaling in the Nervous System 27
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28 SECTION I Basic Principles
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CHAPTER 3 Signaling in the Nervous System 29
I
inhibition
Hypothalamic-releasing hormones
Thyrotropin-releasing hormone (TRH)
Gonadotropi n-releasing hormone
Somatostatin
Corticotropi n-releasing factor (CRF)
Growth-hormone-releasing hormone
Luteinizing-hormone-releasing hormone (LHRH)
\
Pitu itary peptides
Corticotropin (ACTH)
Growth hormone (GH), somatotropin Direct
Li potropin inhibition
Alpha melanocyte-stimu lating hormone (a l pha MSH)
Prolactin
Luteinizing hormone
Thyrotropin
Neurohypophyseal hormones
Vasopressin
Oxytocin
Neurophysin (s)
Circulating hormones
Angiotensin
Calcitonin
Gl ucagon
Insulin
Gut-brain peptldes
Vasoactive intestinal peptide ( VI P)
Cholecystokinin (CCK)
Gastrin
Mot i l i n
Pancreatic polypeptide
Secretin
Substance P
Bombesin
Neurotensin
Opioid peptides FIGURE 3-1 1 Top: Schematic i l l u stration of two types of inhi
Dynorphin bition i n the spinal cord. In d i rect i n h i bition (a lso called postsynaptic
Beta-endorphin i n h i bition), a chemica l mediator released from a n i n h i bitory neuro n
Met-en kephalin cau ses hyperpola rization ( i n h i bitory postsynaptic potential) of a
Leu-en kepha l i n
m otor neuron. I n p resynaptic i n h i bition, a second chem i ca l media
Kyotorphin
tor released onto the ending (axon) of a n excitatory neuro n causes
Others a red uction in the size of the postsy n a ptic excitatory potential.
Bradyki nin Bottom : Diagram of a s pecific i n h i b itory system involving an
Carnosine
i n h i b itory i nterneuron (Renshaw cel l).
Neuropeptide Y
Proctol i n
Substance K
Epidermal growth factor (EGF)
parasympathetic neurons. Postganglionic parasympathetic
neurons, as well as one particular type of postganglionic
sympathetic axon (ie, the fibers innervating sweat glands) ,
Acetylcho l i n e use ACh as their transmitter (M-type, muscarinic recep
ACh i s synthesized by choline acetyltransferase and i s broken tors).
down after release into the synaptic cleft by acetyl Within the CNS, several well-defmed groups of neurons
cholinesterase (AChase) . These enzymes are synthesized in use ACh as a transmitter. These groups include neurons that
the neuronal cell body and are carried by axonal transport to project widely from the basal forebrain nucleus of Meynert
the presynaptic terminal; synthesis of ACh occurs in the to the cerebral cortex and from the septal nucleus to the hip
presynaptic terminal. pocampus. Cholinergic neurons, located in the brain stem
ACh acts as a transmitter at a variety of sites in the PNS tegmentum, project to the hypothalamus and thalamus, where
and CNS. ACh, for example, is responsible for excitatory they use ACh as a transmitter.
transmission at the neuromuscular j unction (N-type, nico Considerable interest has been focused recently on the
tinic ACh receptors) . It is also the transmitter in autonomic role of cholinergic CNS neurons in neurodegenerative dis
ganglia and is released by preganglionic sympathetic and eases. Cholinergic neurons in the basal forebrain nucleus
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30 SECTION I Basic Principles
A
A. Myasthenia Gravis and the Myasthenic
Syndrome
Mya sthenia g ravis is an a uto i m m u n e disorder in which a nti
bodies agai nst the ACh receptor {ie, the postsynaptic recep
tor at the neuro m u scu l a r j u nction) a re produced. As a resu lt,
the res pons iveness of m u scle to activity in m otor nerves
and to syn a ptic activati o n i s red uced. Pati ents classica l l y
co m p l a i n o f fatigue a n d weakness i nvolvi ng t h e l i m b m u s
cles a nd, i n some patients, b u l b a r m u scles such as those
contro l l i n g eye movement and swa l lowing. Upon repetitive
electrical sti m u l ation, the i nvolved m u scles ra p i d l y show
FIGURE 3-1 2 Schematic i l l ustrations of a myoneural j unc fatigue and fi n a l ly do n ot respond at a l l; excita bil ity u s u a l l y
tion. A: Motor fi ber s u pplying severa l m u scle fibers. B: Cross section returns after a rest period.
as seen i n a n electron microg ra ph. Myasthenic syndrome (a l s o ca l l ed Lambert-Eaton
syndrome), i n contrast, i s a d i sorder i nvolvi ng the presy
degenerate, and their cholinergic terminals in t he cortex are n a ptic component of the n e u ro m u scu l a r j u nction. Myas
lost in Alzheimer's disease. thenic synd rome is a para neoplastic disorder and often oc
curs i n the context of systemic neoplasms, especially those
involving the l u n g and breast. Antibodies d i rected agai nst
Gl utamate Ca2+ channels located in presyna ptic terminals at the neu
The amino acid glutamate has been identified as a major ex rom uscu lar ju nction interfere with transm itter release, ca u s
citatory transmitter in the mammalian brain and spinal cord. ing wea kness.
Four types of postsynaptic glutamate receptors have been B. Myotonia
identified. Three of these are ionotropic and are linked to ion
In this class of d isorders, affected m u scles show a prolonged
channels. These receptors are named for drugs that bind
response to a single sti m u l us. Some of these d i so rders in
specifically to them. The kainate and AMPA types of gluta
vo l ve a n a b n o r m a l ity of vo ltage-sens itive N a+ c h a n n e l s,
mate receptor are linked to Na + channels, and when gluta
which fa il to close fol lowi ng an action potentia l. As a resu lt,
mate binds to these receptors they produce EPSPs. The
inappropriate, susta ined m uscle contraction may occur.
NMDA receptor is linked to a channel that is permeable to
both Ca2 + and Na + . The NMDA-activated channel, however,
is blocked (so that influx of these ions cannot occur) unless
the postsynaptic membrane is depolarized. Thus, NMDA feedback, resulting in a damaging avalanche of depolariza
type synapses mediate Ca 2 + influx, but only when activity at tion and calcium influx into neurons. This excitotoxic mech
these synapses is paired with excitation via other synaptic in anism of neuronal injury may be important in acute neuro
puts that depolarize the postsynaptic neuron. The Ca 2 + influx logic disorders, such as stroke and CNS trauma, and possibly
mediated by these synapses may lead to structural changes in some chronic neurodegenerative diseases, such as
that strengthen the synapse. The N MDA-typ e glutamate Alzheimer's.
synapses appear to be designed to detect coincident activity
in two different neural pathways and, in response to such
paired activity, alter the strength of the synaptic connection. Catechola m i nes
It has been hypothesized that this alteration may provide a The catecholamines norepinephrine (noradrenaline), epi
basis for memory. nephrine (adrenaline) , and dopamine are formed by hydrox
A metabotropic type of glutamate receptor has also been ylation and decarboxylation of the essential amino acid
identified. When the transmitter glutamate binds to this re phenylalanine. Phenyl-ethanolamine- N- methyltransferase,
ceptor, the second messengers, IP3 and DAG, are liberated. the enzyme responsible for converting norepinephrine to
This liberation can lead to increased levels of intracellular epinephrine, is found in high concentration primarily in the
Ca2 + , which may activate a spectrum of enzymes that alter adrenal medulla. Epinephrine is found at only a few sites in
neuronal function and structure. the CNS.
It has been suggested that excessive activation of gluta Dopamine is synthesized, via the intermediate molecule
matergic synapses can lead to very large influxes of Ca 2 + into dihydroxyphenylalanine (DOPA), from the amino acid tyro
neurons, which can cause neuronal cell death. Because gluta sine by tyrosine hydroxylase and DOPA decarboxylase. Nor
mate is an excitatory transmitter, excessive glutamate release epinephrine, in turn, is produced via hydroxylation of
might lead to further excitation of neuronal circuits by positive dopamine. Dopamine, like norepinephrine, is inactivated by
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CHAPTER 3 Signaling in the Nervous System 31
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32 SECTION I Basic Principles
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C H A P T E R
Neurology, more than any other specialty, rests on clini SYM PTOMS AND SIGNS
coanatomic correlation. Patients do not arrive at the neurolo
OF NEUROLOGIC DISEASES
gist's office saying "the motor cortex in my right hemisphere is
damaged;' but they do tell, or show, the neurologist that there In taking a history and examining the patient, the neurologic
is weakness of the face and arm on the left. Since the nervous clinician elicits both symptoms and signs. Symptoms are sub
system is constructed in a modular manner, with different jective experiences resulting from the disorder (ie, "I have a
parts of the brain and spinal cord subserving different func headache"; "The vision in my right eye b ecame blurry a
tions, it is often possible to infer, from a careful physical exam month ago"). Signs are obj ective abnormalities detected on
ination and history together with knowledge of neu examination or via laboratory tests ( eg, a hyperactive reflex or
roanatomy, which part of the nervous system is affected, even abnormal eye movements).
prior to ordering or viewing imaging studies. The neurologic The history may provide crucial information about diag
clinician thus attempts, with each patient, to answer two ques nosis. For example, a patient was admitted to the hospital in a
tions: ( 1 ) Where is (are) the lesion(s)? and (2) What is (are) coma. His wife told the admitting physician that "my husband
the lesion(s)? has high blood pressure but doesn't like to take his medicine.
Lesions of the nervous system can be anatomic, with dys This morning he complained of the worst headache in his life.
function resulting from structural damage (examples are pro Then he passed ouf' On the basis of this history and a brief
vided by stroke, trauma, and brain tumors). Lesions can also (but careful) examination, the physician rapidly reached a ten
be physiologic, reflecting physiologic dysfunction in the ab tative diagnosis of subarachnoid hemorrhage (bleeding from
sence of demonstrable anatomic abnormalities. An example is an aneurysm, ie, a defect in a cerebral artery into the subarach
provided by transient ischemic attacks, in which reversible noid space) . He confirmed this diagnostic impression with ap
loss of function of part of the brain occurs without structural propriate (but focused) imaging and laboratory tests and insti
damage to neurons or glial cells, as a result of metabolic tuted appropriate therapy.
changes caused by vascular insufficiency. The astute clinical observer may be able to detect signs
This chapter gives a brief overview of clinical thinking of neurologic disease by carefully observing the patients'
in neurology and emphasizes the relationship between sp ontaneous behavior as they walk into the room and tell
neuroanatomy and neurology. It has been included to help their story. Even before touching the patient, the clinician may
the reader begin to think as the clinician does and thus to observe the "festinating" (shuffling, small-stepped) gait of
place neuroanatomy, as outlined in the subsequent chap Parkinson's disease, hemiparesis (weakness of one side of the
ters, in a patient-oriented framework. Together with the body) resulting from a hemispheric lesion such as a stroke, or
Clinical Illustrations and Cases placed throughout this a third nerve palsy suggesting an intracranial mass. The way
book, this chapter provides a clinical perspective on neuro patients tell their story also may be informative; for example,
anatomy. it may reveal aphasia (difficulty with language) , confusion, or
33
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34 SECTION II Introduction to Clinical Thinking
impaired memory. Details of history taking and the neuro As a corollary of the principle of localized function, it is
logic examination are included in Appendix A. often possible to predict, from neurologic signs and symptoms,
In synthesizing the information obtained from the history which parts of the nervous system are involved. By obtaining
and examination, the clinician usually keeps asking the ques an accurate history and performing a careful examination, the
tions, "Where is the lesion? What is the lesion?" This thinking clinician can obtain important clues about t he localization of
process will usually result in the correct diagnosis. Several dysfunction in the nervous system.
points should be kept in mind while one is going through the
diagnostic process.
Man ifestations of Neurologic Disease
May Be Negative or Positive
Neurologic Signs a n d Sym ptoms
Negative manifestations result from loss of function ( eg,
Often Reflect Foca l Pathology hemiparesis, weakness of an eye muscle, impaired s ensation, or
of the Nervous System loss of memory) . Negative manifestations of neurologic disease
I n the early 1 900s, some investigators believed t hat the nerv may reflect damage to neurons ( eg, in stroke, where there is of
ous system operated via a principle of mass action . Accord ten loss of neurons located within a particular vascular t erri
ing to this now outdated principle of mass action, neurons tory, and in Parkinson's disease, where there is degeneration of
distributed widely throughout the brain contribute to any neurons in the substantia nigra) or to glial cells or myelin (eg,
given function, and few if any functions depend on localized in multiple sclerosis, in which there is inflammatory damage to
groups of neurons within a single, demarcated part of the myelin). Positive abnormalities result from inappropriate ex
brain. If the brain were, in fact, organized according to the citation. These include, for example, seizures (caused by abnor
principle of mass action, a lesion affecting any region of the mal cortical discharge) and spasticity (from the loss of inhibi
brain would be expected to impair many functions, and few tion of motor neurons) .
if any functions would be totally lost as a result of a well-cir
cumscribed, localized lesion affecting a single part of the
Lesions of Wh ite and G ray Matter Cause
brain.
We now know that, with respect to many functions, the Neurologic Dysfu nction
principle of mass action is incorrect. Different parts of the Damage to gray or white matter (or both) interferes with nor
nervous system subserve different functions. In turn, in many mal neurologic function. Lesions in gray matter interfere with
parts of the brain or spinal cord, even relatively small well-cir the function of neuronal cell bodies and synapses, thereby
cumscribed lesions produce loss or severe impairment of a leading to negative or positive abnormalities, as previously de
specific function. This effect reflects the principle of localized scribed. Lesions in white matter, on the other hand, interfere
function within the nervous system. with axonal conduction and produce disconnection syn
There are numerous examples of localized function. ( 1 ) dromes, which usually cause negative manifestations. Exam
Aphasia (difficulty producing o r understanding language) ples of these syndromes include optic neuritis (demyelination
often results from damage to well-lo calized speech areas of the optic nerve), which interferes with vision; and infarc
within the left cerebral hemisphere. (2) Control of fine tion affecting pyramidal tract axons, which descend from the
movements of each hand is dependent on signals sent from motor cortex in regions such as the internal capsule, which
a hand area within the motor cortex in the contralateral cere can cause "pure motor stroke'' (Fig 4- 1 ) .
bral hemisphere. The motor cortex is organized in the form Some neurologic disorders affect primarily gray matter
of a map, or "homunculus;' reflecting control of different ( eg, amyotrophic lateral sclerosis, a degenerative disease lead
parts of the body by different parts of the motor cortex (see ing to the death of motor neurons in the cerebral cortex and
Chapter 1 0 , especially Fig 1 0 - 1 4 ) . A lesion affecting the gray matter of the spinal cord). Others primarily affect white
hand area or the h ighly circumscribed p athways that de matter (eg, multiple sclerosis). Still other disorders affect both
scend from it to the spinal cord can result in loss of skilled gray and white matter ( eg, large strokes, which lead to necrosis
movements or even paralysis of the hand. (3) At a more ba of the cerebral cortex and underlying white matter) .
sic level, many simple and complex reflexes, which are tested
as part of the neurologic examination, depend on circuits
that run through particular parts of the nervous system. For Neurologic Disease Ca n Result
example, the patellar reflex (knee j erk) depends on afferent i n Syndromes
and efferent nerve fibers in the femoral nerve and L3 and L4 A syndrome is a constellation of signs and symptoms fre
spinal roots and the L3 and L4 spinal segments, where affer quently associated with each other and suggests that the signs
ent Ia axons synapse with motor neurons that subserve the and symptoms have a common origin. An example is Wallen
reflex. D amage to any of the parts of this circuit (nerve, berg's syndrome, which is characterized by vertigo, nausea,
spinal roots, or L3 or L4 spinal segments) can interfere with hoarseness, and dysphagia (difficulty swallowing) . Other
the reflex. signs and symptoms include ipsilateral ataxia, ptosis, and
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CHAPTER 4 The Relationship Between Neuroanatomy and Neurology 35
..,_______+- Hypoglossal
root fibers
A B
FIGURE 4-2 A: Section thro u g h the med u l la, sta ined for myelin, from a patient with m u ltiple sclerosis. Notice the m u ltiple demyelinated
plaques (labeled 1 -4) that a re disseminated throughout the central nervous system ( CNS). B: Even a single lesion can interfere with fu nctio n in
m u lti p l e neighboring pa rts of the CNS. Notice that plaque 3 involves the hypog lossal r oot (prod ucing weakness of the tong ue) and the medial
lemn isci (causing a n i m pairment of vibratory and t ouch-pressu re sense). Fig u re 7-7B shows, for com parison, a diagram of the normal m ed u l l a
at t h i s level.
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36 SECTION II Introduction to Clinical Thinking
Destruction Stroke Neurons (often cortical) Acute destruction, within hours of loss of blood flow
Destruction Pa rkinson's disease Neurons (subcortical) Chronic degeneration of neurons i n su bstantia nigra
Destruction Spinal cord i nj u ry Ascending and descending axons I nj u ry to fi ber tracts from trauma
Destruction Multiple sclerosis Myelin Inflam matory damage to myelin sheaths i n CNS
Com pression Subdural hematoma Cerebral hemisphere Expanding blood clot i nj u res u nderlying bra i n tissue
Compromise of Cerebel lar tumor Fourth ventricle Expa nding mass compresses ventricle, i m pairs CSF
ventricular pathways outflow
Compression can also cause dysfunction, without the in In thinking about a patient, the physician should ask, "Is
vasion of the brain and spinal cord per s e. This occurs, for ex there a single lesion that can account for the signs and symp
ample, in subdural hematoma, when an expanding blood clot, toms?" In some cases a single, critically placed lesion can
contained by the skull vault, compresses the adj acent brain, injure several fiber tracts and/or nuclei. By carefully assessing
initially causing reversible dysfunction, before triggering the the patient's signs and symptoms, and asking whether t here is
death of neural tissue. Early recognition and surgical drainage a single site in the nervous system where a lesion can produce
of the clot can lead to full recovery. all of these abnormalities, the clinician may be able to help the
Finally, compromise of ventricular pathways or of the radiologist to focus neuroimaging studies on areas that have a
vasculature can lead to neurologic signs and symptoms. For high likelihood of being involved.
example, a small cerebellar astrocytoma, critically located Multifocal Process: Multifocal pathology results in dam
above the fourth ventricle, may compress the ventricle and ob age to the nervous system at numerous separate sites. In mul
struct the outflow of cerebrospinal fluid. The tumor may lead tiple sclerosis, for example, lesions are disseminated through
to obstructive hydrocephalus with widespread destructive ef out the nervous system in the spatial domain, and develop at
fects on both cerebral hemispheres. In this case, a small, criti different points in time. Figure 4-2 shows the multifocal
cally placed mass produces widespread neural dysfunction as nature of the pathology in a patient with multiple sclerosis.
a result of its effect on the outflow tracts for cerebrospinal
fluid. Critically placed vascular lesions can also produce dev
astating effects on the nervous system. Because certain cere
bral arteries nourish the same parts of the brain in all humans,
occlusion of these arteries produces characteristic clinical syn
dromes. For example, occlusion of the carotid artery, owing to
atherosclerosis in the neck, can lead to infarction of much of
the cerebral hemisphere which it supplies. Occlusion of the
posterior cerebral artery produces infarction of t he occipital
lobe which depends on it for nourishment.
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CHAPTER 4 The Relationship Between Neuroanatomy and Neurology 37
Another example is provided by leptomeningeal seeding of a For example, consider a patient with weakness of t he left
tumor. As a result of dissemination throughout the subarach leg. This condition could be caused by a lesion involving t he
noid space, tumor deposits can affect numerous spinal and cra nerves innervating the leg or by a lesion affecting the corti
nial nerve roots distributed along the entire neuraxis and can cospinal pathway at any level from the cortex through the
also block cerebrospinal fluid outflow, thereby producing hy midbrain and down to the lumbar spinal cord. If the patient
drocephalus. also had loss of vibratory and position sense of the left leg (in
Diffuse Process: Diffuse dysfunction of the nervous system dicating dysfunction in the dorsal column pathway) and loss
can be produced by a number of toxins and metabolic abnormal of pain and temperature sensation over the right leg (indicat
ities. In arriving at a diagnosis, the clinician must ask, "Is there a ing impaired function of the spinothalamic pathway), the cli
systemic disorder that can account for the patient's signs and nician would then think about dysfunction of the left half of
symptoms?" Metabolic or toxic coma, for instance, can result in the spinal cord, above the decussation of the spinothalamic
abnormal function of neurons throughout the nervous system. fibers. These fibers decussate within the spinal cord, close to
the level where they enter the cord but below the medullary
cervical spinal cord junction, where the corticospinal tract de
Rostrocaudal Loca l ization cussates. Furthermore, normal function in the arms and trunk
In deciding o n the rostrocaudal localization o fthe lesion, i t i s im suggests normal function in cervical and thoracic parts of the
portant for the clinician to determine the nuclei and fiber tracts spinal cord (which carry fibers for the arm and trunk) . The
that are affected and to consider the constellation of structures in combination of deficits could, in fact, be parsimoniously ex
volved Here, the clinician is aided by a design feature of the hu plained by a single lesion, located in the left side of the spinal
man nervous system: Each of the major motor (descending) and cord.
sensory (ascending) pathways decussates (ie, crosses from one
side of the neuraxis to the other) at a specific level. The levels of
decussation of three major pathways are briefly summarized in Tran sverse Loca l ization
Figure 4-4 and are discussed in Chapter 5. By examining the con In localizing the lesion, the clinician must also consider its
stellation of deficits in a given patient and relating them to appro placement in the transverse plane, that is, within the cross
priate tracts and nuclei, it is often possible for a clinician to place section of the brain or spinal cord. Here again, neighborhood
the lesion at the appropriate level along the rostrocaudal axis. signs are important. In the previously described patient with
Thalamus
Sensory nerve
to arm
Spinal
cord 1 Dorsal root
I ganglion cell
Sensory nerve
Motor nerve to leg
to leg
A B c
FIGURE 4-4 A: Pyra m idal tract. B: Dorsal col u m n system. C: Spi n othalamic system.
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38 SECTION II Introduction to Clinical Thinking
a spinal cord lesion, the dorsal and lateral white matter WHAT IS THE LESION?
columns in the spinal cord must be involved because the
dorsal column pathway and corticospinal tract are involved. The pathologic nature of a lesion may be inferred from the ex
Moreover, the clinician can predict that the lesion is cen amination and history. The age of the patient must be consid
tered in the left half of the spinal cord because there is no ered. Cerebrovascular disease, for example, is more common
evidence of dysfunction of the corticospinal tract, dorsal in individuals older than 50; in contrast, multiple s clerosis is a
column system, or spinothalamic tract on the right side in disease of the second and third decades and rarely presents in
this patient. elderly individuals.
By carefully considering the tracts and nuclei involved The gender of the patient may provide important infor
and their relationships along the rostrocaudal axis and in the mation. Duchenne's muscular dystrophy, for instance, is a
transverse plane, the astute clinician can identify, with a high sex-linked disorder that occurs only in males. Carcinomas of
degree of probability, the site(s) of the nervous system that are the prostate (a male disease) and of the breast (predominantly
involved in a given patient. a female disease) commonly metastasize to the vertebral
A Time ----•
I I
1111
B
II
c
FIGURE 4-5 Characteristic time cou rses for various neurologic disorders. A: Brief episodes of dysfu nction may represent seizures or
migraine attacks. B: A pattern of recent-on set headaches on wa ken ing may be caused by an expa nding brain tumor. C: A relapsing-remitting
cou rse is cha racteristic of m u ltiple sclerosis. D: Sudden onset of a fixed deficit is characteristic of cerebrovascu lar disease. E: Slowly progressive
dysfu nction is suggestive of neurodegenerative diseases, such as Alzheimer's or Parkinson's. F: Su bacutely p rog ressive dysfu nction, which
adva nces over weeks t o m o nths, is often seen with bra i n tumors.
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CHAPTER 4 The Relationship Between Neuroanatomy and Neurology 39
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40 SECTION II Introduction to Clinical Thinking
A 5 2-year-old accou ntant weighing 320 lbs complai ned of A 45-year-old Latin tea cher was eva l u ated by her fa m i l y
back pain and wea kness in his legs. A neurologic consu ltant doctor after s h e com pl ained o f p a i n i n her left a r m . Becau se
found wea kness in both legs associated with hyperactive r e of wea kness, the d octor suspected a hern iated i nterverte
flexes, Babinski's reflexes, and sensory loss below the u m bili bral disk and ordered cervical spine x-rays, which r evea led
cus. There was focal tenderness over the spine at the TS level. a n i ntervertebra l d i s k p rotrusion at the C6-7 l eve l, which
Weakness of the legs, associated with signs of upper-mo was confirmed by CT scans. The pain progressed over sev
tor-ne u ron dysfu nction (hyperactive deep tendon reflexes era l weeks, and s u rgery (excision of the protruded disk) was
and Babinski's responses), suggested the possi bil ity of a lesion co nsidered.
affecting the spinal cord. The sensory loss, which extended to As part of her worku p, the patient was seen by a neurol
the T1 0 level, indicated that the lesion was located above this ogist. Carefu l exa m i nation revea led sensory loss in the d is
level. Because of the patient's focal back pain, the neurologist tribution of the C6, Cl, a n d CB dermatomes. There was a
suspected that a mass was compressing the spinal cord, close patte rn of wea kness that d i d n ot co nform to a ny s i n g l e
to the TS level of the s p i n a l col u m n . Beca use the patient nerve root b u t rather suggested i nvolvement o f t h e lower
would not fit in the MRI scanner at the hospita l, he was sent t o bra c h i a l plexus. The n e u ro l o g i st concluded that the p ro
another clinic 60 miles away, where a n older MRI scanner with truding disk was not the cause of the patient's sym ptoms
a wider bore cou l d accommodate him. The neurologist's re and i n itiated a worku p for lesions that can i n j u re the
port, outlining his findings and requesting an MRI scan of the brachial plexus. Chest x-ray demonstrated a small cel l carci
enti re spine, including thoracic regions, was lost in transit. The noma l ocated i n the a pex of the l u n g, which had i nvaded
radiologist, who had not examined the patient, noted his his the brachial p lexus. The patient was referred for chemother
tory of leg weakness and obta i ned MRI scans of the l u mbar apy, which resu lted in i m p rovem ent.
spinal cord. No lesion was seen. Th i s case i l l u strates that rad i o g ra p h i c studies can, i n
Despite the report of a "n ormal" MRI sca n, the neurolo some patients, reveal structural abnormal ities that a re not
g i st rea soned there was a lesion co m p ress i n g the s p i n a l releva nt to the patient's disease. In this ca se, the patient's
cord i n t h e m i dthoracic reg ion. He ordered a second imag hern iated cervical d i s k had not caused symptoms. The fa m
ing study that revea led a meningioma at the T4 l evel. This ily physician ascri bed the patient's pain to the wrong lesion
treata ble lesion wou l d not have been found on the basis of (the asymptomatic hern iated intervertebral disk) and was
the first MRI study. l u l led i nto a fa l se sense of security, so h e m i ssed the rele
This case i l l ustrates severa l poi nts. First, a carefu l history vant pathologic lesion: the patient's tum or.
and exa mination, together with knowledge of neuroanatomy, A more complete exa mi nation, coupled with the ques
provides crucial information to g uide the neuroradiologist so tion "Where is the lesion?'; wou l d have led t o the concl usion
that the proper regions of the nervous system are examined. that the brachial plexus was invo lved. Once this loca l ization
In this case, the neurologist's guidance might have focused was a p p reciated, the rad i o log ist obta i ned a p ical views of
the radiologist's attention on the a p p rop riate part of the the l u n g s to exa m i n e the poss i b i l ity of a t u m o r that had
spinal column. Second, clinical i ntu ition can be as good as, or spread to the brach ial p lexus. As i l l ustrated by this case, ab
in some cases better than, imaging. "Normal" radiologic resu lts normal resu lts of neuroimaging studies d o not necessarily
most com monly reflect normal anatomy but can a lso r esult lead to a defi n itive d iagnosis. A carefu l exa m i nation of the
from tech nical d ifficulties, improper patient positioni ng, or patient with a ppropriate emphasis on neu roa natomy m u st
imaging methodology. When imaging resu lts are not consis be correlated with the neuroimaging studies.
tent with the history and examination, a repeated exa mi na A n u m be r of other l a b o ratory tests ca n p rovide
tion, together with a reconsideration of the questions "Where additional information about the patient's i l l ness. The l u m
is the lesion? What is the lesion?'; can be helpfu l. bar p u n ctu re, o r s p i n a l tap, for i n sta n ce, provides cere
brospinal fl uid (CS F). Lu mbar pu ncture is fu rther d i scussed
in Cha pter 24.
Electrophysiologic tests permit the measurement of
THE TREATMENT OF PATIENTS electrica l a ctivity from the brain, spinal cord, and peri pheral
WITH NEUROLOGIC DISEASE nerves a n d ca n provide im portant i nformation. These tests
include the electroencephalogram (EEG), evoked poten
In collecting a history, performing an examination, and im tials, electromyography ( E M G J . a n d nerve conduction
plementing treatment, the clinician is "acting" not only as studies. Like the resu lts of CSF ana lysis, the res u lts of elec
doctor to patient but also as caregiver t o another human be trophysiologic stu d ies should be i nterpreted in the context
ing. Listening is very important. Neurologic clinicians do not of the history and physical exa m i nation. These tests are d is
just treat cases or diseases; they treat people. An example is cu ssed fu rther in Cha pter 23.
provided in Clinical illustration 4-5.
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CHAPTER 4 The Relationship Between Neuroanatomy and Neurology 41
A neu rologic con s u ltant was asked to eva l u ate a patient who i n attention syndrome and d ressing a p raxia, together with a
was known to h ave a mal ignant mela n o ma . The patient had m i l d l eft hemiparesis, suggested a lesion in the rig ht cerebra l
been i n the hospita l for 1 0 days, and the n u rsing staff noticed hemisphere, and t h e history suggested metastatic melanoma.
that he did not d ress h i mself properly, tended to get lost while Su bseq uent imaging confi rmed the diagnosis.
wa lking on the ward, and b u m ped into thi ngs. After the exa mination, the neurologic consu lta nt asked the
Alth o u g h the patient had no com p l a i nts, h i s wife reca l l ed patient a n d his wife whether they had any questions. H i s wife
that, beg i n n i n g several months ea rlier, he had had d ifficu lty repl ied, "We know that my h u s band has metastatic cancer and
putting on his clothes properly. He had been fired after work that he wi l l d ie. He has been i n the hospital for 10 d ays, but no
ing for 30 yea rs as a truck d river beca use he had beg u n to have body has exp l a i ned what w i l l happen. Wi l l my husband have
difficu lty rea ding a map. pain? Wi l l he need to be sedated? Wi l l he be able to make out a
Exa m i nation revea led a hem i-i nattention syndrome. The pa w i l l ? As he gets wo rse, w i l l he be a b l e to recogn ize the c h i l
tient tended to neglect the left h a lf of the world. When asked d ren?"
to d raw a clock, he squ eezed a l l of the n u m bers i n the rig ht I n this instance, the patient's physician had correctly diag
hand half. He d rew o n ly the right half of a flower and t ended to nosed and managed the primary melanoma. However, he did
eat only off the right h a lf of his plate. When asked to put o n h i s not have a strong knowledge of neuroanatomy, a n d d u ring the
hospital robe, he wrapped it a round his waist but was u n a b l e neurologic exa m i nation he fa iled to recogn ize the presence of
t o p ro perly put it o n . Exa m i n ation of t h e m oto r system re meta stasis in the b ra i n . Equally i m portant, the treati ng physi
vea led that, in add ition, the patient had a m i l d left hemi paresis. cian had focused his attention on the patient's disease and not
"Hemi-inattention" synd rome usually occ u rs a s a res ult of le met his needs as a person . An open, relaxed d iscussion ("How
sions in the nondo m i n a nt (rig ht) cerebra l h e m i s p here, most do you feel about you r d i sease? What frig hte ns you the most?
commonly the pa rieta l lobe. Lesions i n this a rea can a l so cause Do you have any q uestions?") is a n essential part of the physi
d ifficu lty d ressing ("dressing apraxia"). The presence of a hemi- cia n's role.
REFERENCES Posner JB, Saper C, Schiff N, Plum F: Plum and Posners Diagnosis
of Stupor and Coma, 5th ed. FA Davis, 2007.
Berg BO: Principles of Child Neurology. McGraw-Hill, 1 996. Rowland LP (editor) : Merritts Textbook of Neurology, l Oth ed. Lea
Bradley WG, Daroff RB, Fenichel GM, Marsden CD (editors): Neu & Febiger, 2005.
rology in Clinical Practice, 4th ed. Butterworth-Heinemann, Simon RP, Aminoff MF, Greenberg DA: Clinical Neurology, 4th ed.
2005. Appleton & Lange, 1 999.
Brazis PW, Masdeu JC, Biller J: Localization in Clinical Neurology. Victor M, Rapper AH: Principles of Neurology, 7th ed. McGraw
Little, Brown and Co., 2006. Hill, 200 1 .
Gilman S (editor) : Clinical Examination of the Nervous System. Waxman S G (editor): From Neuroscience t o Neurology. Elsevier,
McGraw-Hill, 2000. 2005.
Menkes JH, Sarnat H, Moria BL: Textbook of Child Neurology, 7th
ed. Williams & Wilkins, 2005.
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C H A P T E R
T he Spinal Cord
The spinal cord provides a crucial information conduit, con An investing layer of ectodermal cells around the primi
necting the brain with most of the body. It is the target of a tive cord forms the two inner meninges: the arachnoid and pia
number of disease processes, some of which ( eg, spinal cord mater (pia) (see Fig 5-2B). The thicker outer investment, the
compression) are treatable but rapidly progressive if not dura mater (dura), is formed from mesenchyma.
treated. Failure to diagnose some disorders of the spinal cord,
such as spinal cord compression, can be catastrophic and may
relegate the patient to a lifetime of paralysis. A knowledge of EXTERNAL ANATOMY
the architecture of the spinal cord and its coverings, and of the OF THE SPINAL CORD
fiber tracts and cell groups that comprise it, is essential.
The spinal cord occupies the upper two-thirds of the adult
spinal canal within the vertebral column (Fig 5-3). The cord
DEVELOPMENT is normally 42 to 45 em long in adults and is continuous with
the medulla at its upper end. The conus medullaris is the con
Differentiation ical distal (inferior) end of the spinal cord. In adults, the conus
At about the third week of prenatal development, the ecto ends at the Ll or 12 level of the vertebral column . The filum
derm of the embryonic disk forms the neural plate, which terminale extends from the tip of the conus and attaches to
folds at the edges into the neural tube (neuraxis) . A group of the distal dural sac. The filum terminale consists of pia and
cells migrates to form the neural crest, which gives rise to glial fibers and often contains a vein.
dorsal and autonomic ganglia, the adrenal medulla, and other
structures (Fig 5 - l ) . The middle portion of the neural tube
closes first; the openings at each end close later.
The cells in the wall of the neural tube divide and dif CLIN ICAL CORRELATIONS
ferentiate, forming an ependymal layer that encircles the
central canal and is surrounded by intermediate (mantle) Fa i l u re o f t h e neural t u b e to cl ose at the cra n i a l e n d results
and marginal zones of primitive neurons and glial cells i n a nencepha ly, a type of m a l d eve lopment of the bra i n
(Figs 5-l and 5-2). The mantle zone differentiates into an and sku l l that is i ncompati ble with life. Fa i l u re o f closure at
alar plate, which contains mostly sensory neurons, and a the caudal end results in spina bifida, which is associated
basal plate, which is primarily composed of motor neurons. with maldevelopment of the vertebrae (see Fig 6-9).
These two regions are demarcated by the sulcus limitans, a Sometimes the meninges balloon out to f orm a sac, or
groove on the wall of the central canal (see Fig 5 - l D ) . The meningocele, is associated with a defect in the overlying
alar plate differentiates into a dorsal gray column; t he basal vertebra. I f such a sac conta i n s n e rvo u s tissue, it i s a
plate becomes a ventral gray column. The processes of the meningomyelocele a n d is associated with seve re d i st u r
mantle zone and other cells are contained in the marginal ba nces of fu nction.
43
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44 SECTION III Spinal Cord and Spine
I
""':�',.;._
... __ Neural plate Pia Dorsal root
V�
ganglion
Sulcus "
B lim itans
Neural crest cells
Mantle
layer
Dorsal root ganglion
Ependyma root fibers
A B
Seg ments
The spinal cord can be thought of as consisting of approxi
mately 30 segments (see Fig 5-3 and Appendix C)-8 cervical
E
':.---- Marginal layer (C) segments, 1 2 thoracic (T) segments (termed dorsal in
+-+�--- Central canal some texts) , 5 lumbar (L) segments, 5 sacral (S) segments,
and a few small coccygeal (Co) segments-that correspond to
attachments of groups of nerve roots (Figs 5-3 and 5-4) .
There are no sharp boundaries between segments within the
cord itself.
F Because the spinal cord is shorter than the vertebral col
umn, each spinal cord segment at lower levels is located above
the similarly numbered vertebral body. The relation between
spinal cord segments and vertebral bodies is shown in Table
5-1 and Figure 5-4.
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CHAPTER 5 The Spinal Cord 45
Brain stem
Cervical
Cervical
Cervical
enlargement
Thoracic
Thoracic
12
Lumbar
3
Sacral Lumbar
Cauda
{!
equina
S� l
Coccygeal
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46 SECTION III Spinal Cord and Spine
T1 2 T9 T8
LS T1 1 T1 0
Ventral column
Cord segment
Sympathetic
ramus
chain ganglion
FIGURE 5-6 Schematic i l l u stration of a
cord segment with its roots, ganglia, and
branches.
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CHAPTER 5 The Spinal Cord 47
motor axons that arise from several adjacent spinal roots. Nev
ertheless, lesions of a single spinal root, in many cases, can cause
weakness and atrophy of a muscle. Table 5-2 lists segment
pointer muscles, whose weakness or atrophy may suggest a
FIGURE 5-8 Seg mental distri bution of the body viewed in the lesion involving a single nerve root or a pair of adjacent nerve
approximate quadruped position . roots.
• The dermatomes for C5, C6, C7, CB, and T l are confined to
the arm, and the C4 and T2 dermatomes are contiguous INTERNAL DIV ISIONS
over the anterior trunk. OF THE SPINAL CORD
• The thumb, middle finger, and fifth digit are within the C6,
C7, and C8 dermatomes, respectively. G ray Matter
• The nipple is at the level of T4. A. Columns
• The umbilicus is at the level of T l O. A cross section o f the spinal cord shows a n H -shaped internal
mass of gray matter surrounded by white matter (see Fig 5-5).
The territories of dermatomes tend to overlap, making it
The gray matter is made up of two symmetric portions j oined
difficult to determine the absence of a single segmental inner
across the midline by a transverse connection (commissure) of
vation on the basis of sensory testing (Fig 5-9) .
gray matter that contains the minute central canal or its rem
nants. This gray matter extends up and down the entire length of
Myotomes the spinal cord, and is considered to consist of columns. The
The term myotome refers to the skeletal musculature innervated ventral (or anterior) gray column (also called the ventral, or an
by motor axons in a given spinal root. The organization of my terior, hom) is in front of the central canal. It contains the cells
otomes is the same from person to person, and the testing of of origin of the fibers of the ventral roots, including alpha and
motor functions (see Appendix B) can be very useful in deter gamma motor neurons ("lower" motor neurons).
mining the extent of a lesion in the nerve, spinal cord segment, or The intermediolateral gray column (or hom) is the por
tract, especially when combined with a careful s ensory examina tion of gray matter between the dorsal and ventral gray
tion. Most muscles, as indicated in Appendix B, are innervated by columns; it is a prominent lateral triangular projection in t he
thoracic and upper lumbar regions but not in the midsacral
region. It contains preganglionic cells for the autonomic nerv
ous system. Within spinal segments Tl to L2, preganglionic
sympathetic neurons within the intermediolateral gray col
umn give rise to sympathetic axons that leave the spinal cord
within the ventral roots and then travel to the sympathetic
ganglia via the white rami communicantes. Within spinal s eg
ments S2, S3, and S4, there are sacral parasympathetic neu
rons within the intermediolateral gray column. These neu
FIGURE 5-9 Diagra m of the position of the nipple in the sen rons give rise to preganglionic parasympathetic axons that
sory skin fields of the third, fourth, and fifth thoracic spinal roots leave the spinal cord within the sacral ventral roots. After pro
showing the overlapping of the cuta neous a reas. jecting to the pelvic viscera within the pelvic nerves, these
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CHAPTER 5 The Spinal Cord 49
B. Laminas
A cross section of the gray matter of the spinal cord shows a
number of laminas (layers of nerve cells), termed Rexed's lam
inae after the neuroanatomist who described them (Fig 5- 1 1 ) .
A s a general principle, superficial laminae tend to b e involved
in pain signaling, while deeper laminae are involved in non
painful as well as painful sensation.
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50 SECTION III Spinal Cord and Spine
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CHAPTER 5 The Spinal Cord 51
From
�
ciortex
cerebral
Medul lary pyramids
Anterior
corticospinal
To arm muscles tract Pyramidal decussation
Lateral
corticospinal
tract
Anterior corticospinal
tract
To leg muscles
FIGURE 5-1 3 Schematic i l l ustration of the cou rse of corticospinal tract fibers in the spinal cord, t ogether with cross sections at represen
tative l evels. This and the fol lowi ng schematic i l l u strations show the cord in a n u pright position.
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52 SECTION III Spinal Cord and Spine
Lateral corticospinal Fine motor function Motor and premotor Anterior horn cel ls Lateral col u m n
(pyramidal) tract (controls distal cortex (interneurons and (crosses i n med u l l a
musculature) lower motor neurons) at pyramidal
Modulation of decussation)
sensory fu nctions
Anterior corticospinal Gross and postural Motor and premotor Anterior horn neurons Anterior col u m n
tract motor fu nction cortex (interneurons and (uncrossed until
(proximal and axial lower motor neurons) after descending,
musculature) when some fi bers
decussate)
Vesti bulospinal tract Postural reflexes Lateral and medial Anterior horn i nter Ventral col u m n
vestibular nucleus neurons and motor
neurons (for extensors)
Reticulospinal Modulation of Brain stem reticular Dorsal and ventra l Anterior col u m n
sensory transm ission formation horn
(especia l l y pain)
Modulation of spinal reflexes
Tectospinal Reflex head turning Midbrai n Ventral horn i nter- Ventra l col u m n
neurons
Medial longitudinal Coord ination of head Vestibular nuclei Cervical g ray Ventral col u m n
fasciculus and eye movements
Dorsal col u m n system Fine touch, Skin, joi nts, tendons Dorsal col u m n nuclei. Dorsal col u m n
proprioception, two Second-order neurons
point d iscrimi nation project to contralateral
thalamus (cross in med u l l a
at lemniscal decussation)
Spinothalamic tracts Sharp pa in, Skin Dorsal horn. Second Ventrolateral col u m n
temperatu re, crude order neurons project
touch to contra lateral thalamus
(cross i n spinal cord close
to level of entry)
Dorsal spinocerebellar Movement and M uscle spindles, Golgi Cerebellar Lateral col u m n
tract position mechanisms tendon organs, touch paleocortex (via
and pressure receptors ipsilatera l i nferior
(via nucleus dorsalis cerebellar pedu ncle)
[Clarke's col u m n])
Ventra l spinocerebellar Movement and Muscle spind les, Cerebellar paleocortex Latera l col u m n
position mechanisms Golgi tendon organs, (via contra latera l and
touch and pressure i psilatera l superior
receptors cerebellar peduncle)
Spinoreticular pathway Deep and chronic pa i n Deep somatic Reticu lar formation Polysynaptic, diffuse
structures of brain stem pathway in
ventrolatera l col u m n
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CHAPTER 5 The Spinal Cord 53
gray interneurons. It causes head turning in response to sud terns decussate at different levels. In general, ascending axons
den visual or auditory stimuli. synapse within the spinal cord before decussating.
Lemniscal fibers
ascending to
thalamus
Cerebral cortex
Lemniscal decussation
From arm
Fasciculus gracilis
Afferent axon
(Ia) from leg
�
FIGURE 5- 1 4 The dorsal col u m n system in the spinal cord.
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54 SECTION III Spinal Cord and Spine
G racile fasciculus
Dorsal
Lateral column
.
Cervical
} Lateral
corticospinal
Lumbar tract
Sacral
•
Cerv1ca
1
} . .
Sp1 nothalam1c tracts FIGURE 5-1 5 Somatotopic organi
zation (segmental a rra ngement) i n the
spinal cord.
ones. Thus, one dorsal column contains fibers from all seg C. C l i n ical Correlations
ments of the ipsilateral half of the body arranged in an or The second-order neurons of both the dorsal column system
derly somatotopic fashion from medial to lateral (Fig 5 - 1 5 ) . and spinothalamic tracts decussate. The pattern of decussa
Ascending fibers i n the gracile and cuneate fasciculi ter tion is different, however. The axons of second-order neurons
minate on neurons in the gracile and cuneate nuclei (dorsal of the dorsal column system cross in the lemniscal decussa
column nuclei) in the lower medulla. These second-order tion in the medulla; these second- order sensory axons are
neurons send their axons, in turn, across the midline via the called internal arcuate fibers where they cross. In contrast,
lemniscal decussation ( also called the internal arcuate the axons of second-order neurons in the spinothalamic tracts
tract) and the medial lemniscus to the thalamus . From the cross at every segmental level in the spinal cord. This fact aids
ventral posterolateral thalamic nuclei, s ensory information in determining whether a lesion is in the brain or the spinal
is relayed upward to the somatosensory cortex. cord. With lesions in the brain stem or higher, deficits of pain
perception, touch sensation, and proprioception are all con
B. Spi nothalamic Tracts tralateral to the lesion. With spinal cord lesions, however, the
Small-diameter sensory axons conveying the sensations of deficit in pain perception is contralateral to the lesion,
sharp (noxious) pain, temperature, and crudely localized whereas the other deficits are ipsilateral. Clinical Illustration
touch course upward, after entering the spinal cord via t he 5-1 provides an example.
dorsal root, for one or two segments at the periphery of the
dorsal horn. These short, ascending stretches of incoming D. Spinoreticular Pathway
fibers that are termed the dorsolateral fasciculus, or Lis The ill-defmed spinoreticular tract courses within the ventro
sauer's tract , then synapse with dorsal column neurons, es lateral portion of the spinal cord, arising from cord neurons
pecially in laminas I, II, and V (Figs 5- 1 1 and 5 - 1 6 ) . After and ending (without crossing) in the reticular formation of
one or more synapses, subsequent fibers cross t o the oppo the brain stem. This tract plays an important role in the sen
site side of the spinal cord and then ascend within the sation of pain, especially deep, chronic pain (see Chapter 14).
spinothalamic tracts, also called the ventrolateral (or ante
rior) system . These spinothalamic tracts actually consist of E. Spinocerebellar Tracts
two adj acent pathways: The anterior spinothalamic tract
Two ascending pathways (of lesser importance in human neu
carries information about light touch, and the lateral
rology) provide input from the spinal cord to the cerebellum
spinothalamic tract conveys pain and temperature sensibil
(Fig 5 - 1 7 and Table 5-4).
ity upward.
1 . Dorsal spinocerebellar tract-Afferent fibers from mus
The spinothalamic tracts, like the dorsal column system,
cle and skin (which convey information from muscle spin
show somatotopic organization (see Fig 5 - 1 5 ) . Sensation
dles, Golgi tendon organs, and touch and pressure recep
from sacral parts of the body is carried in lateral parts of the
tors) enter the spinal cord via dorsal roots at levels Tl to 12
spinothalamic tracts, whereas impulses originating in cervi
and synapse on second-order neurons of the nucleus dor
cal regions are carried by fibers in medial parts of the
salis (Clarke's column) . Afferent fibers originating in sacral
spinothalamic tracts . Axons of the spinothalamic tracts
and lower lumb ar levels ascend within the spinal cord
project rostrally after sending branches to the reticular for
(within the dorsal columns) to reach the lower portion of
mation in the brain stem and project to the thalamus (ventral
the nucleus dorsalis.
posterolateral, intralarninar thalamic nuclei) .
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CHAPTER 5 The Spinal Cord 55
Cerebral cortex
U p p e r medulla
Lower medulla
From arm
A 27-year-o ld electrician was stabbed i n t h e back a t t h e midtho s p i n a l cord, which occurs most co m m o n l y i n the context of
racic level. On exami nation, he was unable to move his right leg, stab i nj u ries or g u n shot wou nds. There is ipsi lateral wea kness
and there was moderate weakness of fi nger flexion, abd uction, and loss of position and vibration sense below the lesion as a
and add uction on the rig ht. There was loss of position sense in resu lt oftransection of the lateral corticospinal tract a n d dorsal
the right leg, and the patient cou l d not appreciate a vibrati ng co l u m ns. A loss of pain a n d temperature sensi bility man ifests a
tuning fork that was placed on his toes or bony prominences at few segments below the level of the lesion beca use the decus
the right an kle, knee, o r i l iac crest. There was loss of pain and sati ng fi bers enter the spinothalamic tract a few segments ros
temperature sensibil ity below the T2 level on the left. tral to the level of entry of the nerve root.
After undergoing magnetic resonance imaging, which showed Seg regation of seco n d-order sensory axo n s carrying pain
a hemorrhagic lesion involving the spinal cord at the C8-T1 level, sensibility within the latera l spi nothalamic tract is of consider
the patient was taken to the operating room. A blood clot that was able cli nical i m portan ce. As m i g ht be expected, u n i l atera l i nter
partially compressing the cord was removed, and several bone ruption of the latera l spinothalamic tract causes a loss of sensi
fragments were retrieved from the spinal ca nal. The surgeon ob b i l ity to pain and tem p e ratu re, beg i n n i n g a bout a seg ment
served that the spinal c ord had been partially severed, on the right below the level correspond i n g to the lesion, on the opposite
side, at the C8 level. The patient's deficits did not improve. side of the body. Neurosurgeons occasiona l ly may take advan
Th i s case p rovides an exa m p l e of Brown -Seq u ard syn tage of this fact when performing a n a nterolatera l cordotomy
drome res u lti ng from u n i l ateral lesions or tran sections of the in patients with i ntracta ble pain syndrome.
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56 SECTION III Spinal Cord and Spine
Cerebellum Cerebellum
/.
//:··
'
Ventral
spinocerebellar ....:.=:::
. � :: �:;�
tracts
From leg
� spinocerebellar
tract
REFLEXES
FIGURE 5- 1 8 Diagra m i l l ustrating the pathways responsible for
Reflexes are subconscious stimulus-response mechanisms. The the stretch reflex and the inverse stretch reflex. Stretch stim u lates the
reflexes are extremely important in the diagnosis and localiza m uscle spindle, and impu lses pass u p the Ia fiber to excite the lower
tion of neurologic lesions (see Appendix B). (a l pha) motor neuron. Stretch a lso stim u lates the Golgi t endon organ,
which is a rra nged in series with the m uscle, and i m p u lses passing u p
the l b fiber activate the i n h i bitory neuron. With strong stretch, the re
S i m p l e Reflex Arc su lting hyperpolarization of the motor neuron is so g reat that it stops
The reflex arc (Fig 5- 1 8 ) includes a receptor (eg, a special discharging. (Reproduced, with permission, from Ganong WF: Review of Medical
Physiology, 22nd ed. McGraw-H i l l, 2005.)
sense organ, cutaneous end- organ, or muscle spindle,
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CHAPTER 5 The Spinal Cord 57
Superficial reflexes
Cornea l Crania i V Pons Cranial V I I
Nasal (sneeze) Cranial V Brain stem and upper cord Crania Is V, VII, IX, X , and s p i n a l nerves o f
expiration
Pharyngea l and uvular Cranial IX Med u l la Cranial X
Upper abdom inal T7, 8, 9, 1 0 T7, 8, 9, 1 0 T7, 8, 9, 1 0
Lower abdominal T1 0, 1 1 , 1 2 T1 0, 1 1 , 1 2 T1 0, 1 1 , 1 2
Cremasteric Femoral L1 Gen itofemoral
Plantar Ti bial 51 , 2 Ti bial
Anal Pudenda l 54, 5 Pudenda l
Tendon reflexes
Jaw Cranial V Pons Cra n ia i V
Biceps Musculocutaneous C5, 6 Musculocutaneous
Triceps Rad ial C7, 8 Rad ial
Brachioradialis Rad ial C5, 6 Rad ial
Patellar Femoral L3, 4 Femoral
Ach i l l es Ti bial 51 , 2 Ti bial
Visceral reflexes
Light Cranial I I Midbrai n Cranial I l l
Accommodation Cranial I I Occipita l cortex Cranial I l l
Ciliospinal A sensory nerve T1 , 2 Cervical sym pathetics
Ocu locardiac Crania i V Med u l la Cranial X
Carotid sinus Cranial IX Med u l la Cranial X
Bul bocavernosus Pudenda l 52, 3, 4 Pelvic a utonomic
Bladder and rectal Pudenda l 52, 3, 4 Pudenda l and a utonomies
Abnormal reflexes
Extensor plantar (Babi nski) Pla ntar L3-5, 5 1 Extensor hall ucis longus
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58 SECTION III Spinal Cord and Spine
e
cle length (the dynamic response ) . The static response is
generated by nuclear chain fibers; the dynamic response is
generated by nuclear b ag fib ers. After entering the spinal
gray matter, Ia afferents from the muscle spindle m ake
Muscle contracted
monosynaptic, excitatory conn ections with alpha motor
neurons.
The muscle spindles are distributed in parallel with the
extrafusal muscle fibers. Lengthening or stretching t he muscle
distorts the sensory endings in the spindle and generates a re
ceptor potential. This causes the afferent axons from the mus
cle spindle (Ia afferents) to fire, with a frequency that is pro
portionate to the degree of stretch (Fig 5 - 1 9 ) . Conversely,
contraction of the muscle shortens the spindles and leads to a I ncreased gamma efferent discharge
Extrafusal muscle fibers, responsible for muscle contraction, locities of 70- 1 20 m/s, so that they rapidly reach their tar
are innervated by large anterior horn neurons t ermed alpha get muscles .
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CHAPTER 5 The Spinal Cord 59
Ia neuron
I nterneuron
motor neurons
FIGURE 5-20 Schem atic i l
l ustration of t h e n e u ro n s i nvolved
i n the stretch refl ex (right h a lf)
showing innervation of extrafusal
(striated m u sc l e) fi bers by a l pha
motor n e u rons, a n d of intrafusal
fi bers (with i n m uscle spind le) by
Spindle
gamma motor n e u rons. The left
h a l f of the d iagram shows an i n Spindle (intrafusal)
h i bitory refl ex a rc, w h i c h i n c l udes muscle fiber
a n i nte rca lated i n h i bitory Sensory
i nterneuron. ending
D. Gamma Motor Neurons arranged in series with extrafusal muscle fibers and are acti
Each muscle spindle contains, within i ts capsule, 2 to 1 0 small vated by either stretching or contracting t he muscle. Group
intrafusal fibers. Intrafusal muscle fibers receive their own in Ib afferent fibers run from the tendon organs via t he dorsal
nervation from gamma motor neurons, which are small, spe roots to the spinal gray matter. Here, they end on interneu
cialized motor neurons whose cell bodies are located in the ven rons that inhibit the alpha motor neuron innervating t he ag
tral horn (Fig5-20) . Gamma motor neurons have relatively onist muscle, thus mediating the inverse stretch reflex (see
small axons (in the Ay groups,3-6 1-Lm in diameter) that make Fig 5 - 1 8 ) . As a result of this feedb ack arrangement, these
up about 25% to 30% of the fibers in the ventral root. Firing in specialized receptors prevent overactivity of alpha motor
These interneurons, located i n the ventral horn, proj ect to suggests injury to the afferent or efferent nerve fibers in t he
alpha motor neurons and are inhibitory. Renshaw cells re nerves or roots supplying that reflex.
ceive excitatory synaptic input via collaterals, which branch The large extensor muscles that support the body are kept
from alpha motor neurons. These cells are p art of lo cal constantly active by coactivation of alpha and gamm a motor
feedback circuits that prevent overactivity in alpha motor neurons. Transection of the spinal cord acutely reduces mus
neurons. cle tone b elow the level of the lesion, indicating that
supraspinal descending axons modulate the alpha and gamma
motor neurons. In the chronic phase after transection of the
F. Golgi Tendon Organs
spinal cord, there is hyperactivity of stretch reflexes below t he
A second set of receptors, the Golgi tendon organs, is pres
level of the lesion, producing spasticity. This condition is a re
ent within muscle tendons. These stretch receptors are
sult of the loss of descending, modulatory influences. Spasticity
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60 SECTION III Spinal Cord and Spine
tendon), polysynaptic, crossed extensor reflexes are not lim Lesions of the LMNs may be located in the cells of the
ited to one muscle; they usually involve many muscles on the ventral gray column of the spinal cord or brain stem or in
same or opposite side of the body (Fig 5-2 1 ) . These reflexes their axons, which constitute the ventral roots of t he spinal
have several physiologic characteristics: or cranial nerves. Lesions can result from trauma, toxins, in
fections ( eg, poliomyelitis, which can affect purely lower
1. Reciprocal action of an tagonists-Flexors are excited motor neurons) , vascular disorders, degenerative processes,
and extensors inhibited on one side of the body; the opposite neoplasms, or congenital malformations affecting LMNs in
occurs on the opposite side of the body. the brain stem or spinal cord. Compression of ventral root
axons (ie, the axons of LMNs in the spinal cord) by herniated
2. Divergence-Stimuli from a few receptors are distributed intervertebral disks is a common cause of LMN dysfunction .
to many motor neurons in the cord. Signs of L M N lesions include flaccid paralysis of t h e i n
volved muscles ( s e e Table 5-6); muscle atrophy with degen
3. Summation-Consecutive or simultaneous subthreshold eration of muscle fibers after some time has elapsed; dimin
stimuli may combine to initiate the reflex. ished or absent deep tendon reflexes (hyp oreflexia or
areflexia) of the involved muscle; and absence of pathologic
4. Hierarchy-When two antagonistic reflexes are elicited si reflexes ( discussed next) . Fasciculations and fibrillations
multaneously, one overrides the other. may be present.
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CHAPTER 5 The Spinal Cord 61
Babinski
(stroke) I
\______-,-
Upper FIGURE 5-23 Testi ng for extensor plantar reflexes.
motor
neuron
and hyperreflexia. Isolated lesions of the corticospinal tract are
rare; when these lesions occur, they cause loss of fine motor
control ( eg, loss of dexterity of the individual fingers) but tend
to spare axial muscle groups (ie, those located proximally in
the limbs) that control gross trunk and limb movement
FIGURE 5-22 Motor pathways d ivided i nto u p per- and l ower Loca l ization of Spinal Cord Lesions
motor-neuron regions. I n localizing spinal cord lesions, i t i s important to ask the fol
lowing questions:
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62 SECTION III Spinal Cord and Spine
Types of S p i n a l Co rd Lesions
Several typical sites o f pathologic lesions i n t he spinal cord
produce characteristic syndromes:
( 1 ) A small central lesion can affect the decussating fibers of
the spinothalamic tract from both sides without affecting A. Small central lesion
other ascending or descending tracts. As a result, these
lesions can produce dissociated sensory abnormalities
with loss of pain and temperature sensibility in appropri
ate dermatomes but with preserved vibration and position
sense. This occurs, for example, in syringomyelia (see the
following section) (Fig 5-24A) .
B. Large central lesion
(2) A large central lesion involves, in addition to the pain and
temperature pathways, portions of adjacent tracts, adja
cent gray matter, or both. Thus, t here can be LMN weak
ness in the segments involved, together with upper-motor
neuron dysfunction and, in some cases, loss of vibratory
and position sense at levels below t he lesion (Fig 5-24B ) .
(3) A dorsal column lesion affects t h e dorsal columns, leav C. Dorsal column lesion
ing other parts of the spinal cord intact. Thus, propriocep
tive and vibratory sensation are involved, but other func
tions are normal. Isolated involvement of the dorsal
columns occurs in tabes dorsalis, a form of tertiary
syphilis (see later discussion), which is fortunately rare at
present because of the availability of antibiotics (Fig
D. I rregular lesion
5-24C) .
(4) An irregular peripheral lesion (eg, stab wound or com
pression of the cord) involves long pathways and gray
matter; functions below the level of the lesion are abol
ished. In practice, many penetrating wounds of the spinal
cord (stab wounds, gunshot wounds) cause irregular
lesions (Fig 5-24D). E. Complete hemisection
(5) Complete hemisection of the cord produces a
Brown-Sequard syndrome (see later discussion; Figs
5-24E and 5-25).
Lesions outside the cord (extramedullary lesions) may af
fect the function of the cord itself as a result of direct mechan
ical injury or secondary ischemic injury resulting from the
compromise of the vascular structures or vasospasm. F. Dorsal root tumor
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CHAPTER 5 The Spinal Cord 63
Impaired
proprioception,
vibration, 2-point
discrimination,
and joint and
position sensation
Tabes Dorsa l i s
Tabes dorsalis, a form o f tertiary neurosyphilis, i s now rare, but
EXAMPLES OF SPECIFIC SPINAL
was common in the pre-antibiotic era, and is characterized by
CORD DISORDERS damage to the dorsal roots and dorsal columns. As a result of
this damage, there is impairment of proprioception and vibra
Spinal Cord Co m p ression
tory sensation, together with loss of deep tendon reflexes,
Spinal cord compression-due, for example, to a n ex which cannot be elicited because the Ia afferent pathway has
tramedullary tumor such as meningioma, neurofibroma, or been damaged. Patients exhibit "sensory ataxia:' Romberg's
metastatic cancer, an epidural abscess, or a ruptured inter sign (inability to maintain a steady posture with t he feet close
vertebral disc- can inj ure the spinal cord and can rapidly together, after the eyes are closed, because of loss of proprio
progress to irreversible paraplegia or quadriplegia if not ceptive input) is usually present. Charcot's joints (destruction
promptly diagnosed and treated. Thus, patients in whom spinal of articular surfaces as a result of repeated injury of insensitive
cord compression is suspected, for example, patients with joints) are sometimes present. Subjective sensory disturbances
weakness in the legs, or with a sensory level, should be eval known as tabetic crises consist of severe cramping pains in the
uated on an urgent basis. stomach, larynx, or other viscera.
Syringomyelia
Syringomyelia presents a classical clinical picture, character
ized by loss of pain and temperature sensation at several seg
mental levels, although t he patient usually retains touch and
pressure sense as well as vibration and position sense ( disso
ciated anesthesia) (Fig 5-26). Because the lesion usually in
volves the central part of the spinal cord and is confined to a
limited number of segments, it affects decussating spinothala
mic tracts only in these segments and results in a pattern of
segmental loss of pain and temperature sense. When this type
of injury occurs in the cervical region, there is a cape-like pat
tern of sensory loss. If the lesion also involves the ventral gray FIGURE 5-27 Wasting of the sma l l m u scles of the hands in a
wom a n with syringomyelia.
matter, there may be LMN lesions (Fig 5-27) .
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64 SECTION III Spinal Cord and Spine
Brown-Seq uard Synd rome syndromes are rare because most lesions of the spinal cord are
irregular.
This syndrome is caused b y hemisection o f the spinal cord as
a result of, for example, bullet or stab wounds, syringomyelia,
spinal cord tumor, or hematomyelia. Signs and symptoms in Su bacute Com bi ned Degeneration
clude ipsilateral LMN paralysis in the segment of the leswn.
( Posterolatera l Sclerosis)
(resulting from damage to LMNs) (see Fig 5-25); i psilateral
upper-motor-neuron paralysis below the level of the lesion Deficiency in intake (or metabolism) of vitamin B 1 2
(resulting from damage to the lateral corticospinal t ract) ; an (cyanocobalamin) may result in degeneration in the dorsal
ipsilateral zone of cutaneous anesthesia in the segment of the and lateral white columns. There is a loss of position sense,
lesion (resulting from damage to afferent fibers that have en two -point discrimination, and vibratory sensation. Ataxic
tered the cord and have not yet crossed); and i psilateral loss gait, muscle weakness, hyperactive deep muscle reflexes, spas
of proprioceptive, vibratory, and two-point discrimination ticity of the extremities, and a positive Babinski sign are s een.
sense below the level of the lesion (resulting from damage to
the dorsal columns) . There is also a contralateral loss of pain
Spinal Shock
and temperature sense below the lesion (resulting from darn
age to the spinothalamic tracts, which have already decus This syndrome results from acute transection of, or severe in
sated below the lesion) . Hyperesthesia may be present in the jury to, the spinal cord from sudden loss of stimulation from
segment of the lesion or below the level of the lesion, ipsilat higher levels or from an overdose of spinal anesthetic. All
erally, or on both sides. In practice, "pure" Brown-Sequard body segments below the level of the injury become paralyzed
and have no sensation; all reflexes below the lesion, including
autonomic reflexes, are suppressed. Spinal shock is usually
transient; it may disappear in 3 to 6 weeks and is followed by
I
C A S E 2 a period of increased reflex response.
I
ness of the legs that had progressed for 2 weeks. Two
C A S E 3
years earlier, she had begun to have pain between the
shoulder blades. The pain, which radiated into the left
A 66-year-old photographer was referred for evaluation
arm and into the middle finger of the left hand, could be
of progressive weakness of both legs, which had started
accentuated by coughing, sneezing, or laughing. A chi
some 9 months earlier. Two months previously, his arms
ropractor had manipulated the spine ; however, mild
had become weak but to a lesser degree. The patient had
pain persisted high in the back. The left leg and, more
recently begun to have difficulty swallowing solid food,
recently, the right leg had become weak and numb. In
and his speech had become "thick." He had lost almost
the past few days, the patient had found it difficult to
14 kg (30 lbs).
start micturition.
Neurologic examination showed loss of function in
Neurologic examination showed a minimal degree of
the muscles of facial expression, poor elevation of the
weakness in the left upper extremity and wrist. Volun
uvula, a hoarse voice, and loss of tongue mobility. Mus
tary movement was markedly decreased in the left leg
cular atrophy was noted about the shoulders, in the in
and less so in the right leg . The j oints of the left leg
trinsic hand muscles, and in the proximal leg muscles,
showed increased resistance to passive motion and
being slightly more pronounced on the left than on the
spasticity. The biceps and radial reflexes were de
right. All four extremities showed fasciculations at rest.
creased on the left but normal on the right side; knee
Strength in all extremities was poor. Cerebellar tests
jerk and ankle jerk reflexes were increased bilaterally.
were normal. All reflexes were reduced and some were
Both plantar responses were extensor. Abdominal re
absent; both plantar responses were extensor. All sen
flexes were absent bilaterally. Pain sensation was de
sory modalities were intact everywhere.
creased to the level of C8 bilaterally ; light touch sensa
Muscle biopsy revealed various stages of denerva
tion was decreased to the level of C7.
tion atrophy. What is the most likely diagnosis?
Where is the lesion? What is the differential diagno
Cases are discussed further in Chapter 25 .
sis? Which imaging procedures would be most inform
ative? What is the most likely diagnosis?
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CHAPTER 5 The Spinal Cord 65
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T he Vertebral Column
C H A P T E R
Arachnoid Mater
The arachnoid is a thin, transparent sheath separated from the I nvestment of S p i n a l Nerves
underlying pia by the subarachnoid space, which contains
As the ventral and dorsal roots (on each side) at each segmen
cerebrospinal fluid (CSF).
tal level converge to become a spinal nerve, they are enclosed
in sleeves of arachnoidal and dural tissue (see Fig 6-2). The
dorsal root sleeve contains the dorsal root ganglion near the
Pia Mater point at which both sleeves merge to become t he connective
The pia mater closely surrounds the spinal cord and sends tissue sheath (perineurium) of a spinal nerve. The dorsal root
septa into its substance. The pia also contributes to the forma (with its ganglion) and the ventral root of the nerve (sur
tion of the filum terminate internum, a whitish fibrous fila rounded by fat and blood vessels) course through the interver
ment that extends from the conus medullaris to the tip of the tebral foramen, except in the sacral segments where the dorsal
dural sac. The filum is surrounded by the cauda equina, and root ganglia lie within the sacrum itself.
67
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68 SECTION III Spinal Cord and Spine
Ventral
Sulcal arteries branch from the coronal arteries at most levels. THE VERTEBRAL COLUMN
Anterior sulcal arteries arise at various levels along t he cervi
cal and thoracic cord within the ventral sulcus (see Fig 6-4); The vertebral column consists of 33 vertebrae j oined by liga
they supply the ventral and lateral columns on either side of ments and cartilage. The upper 24 vertebrae are separate and
the spinal cord. movable, but the lower 9 are fixed: 5 are fused to form the
sacrum, and the last 4 are usually fused to form the coccyx.
Veins The vertebral column consists of 7 cervical (C1 -7), 12 tho
An irregular external venous plexus lies in the epidural space; it racic (T l - 12), 5 lumbar (Ll -5), 5 sacral (S1 -5), and 4 coc
cygeal (Co 1-4) vertebrae. In some individuals, vertebra 15 is
communicates with segmental veins, basivertebral veins from
the vertebral column, the basilar plexus in the head, and, by way partly or completely fused with the sacrum.
of the pedicular veins, a smaller internal venous plexus t hat lies Figure 6-1 illustrates the relation of the spinal cord itself
in the subarachnoid space. All venous drainage is ultimately into to the surrounding vertebrae. Recall that the spinal cord ta
the venae cavae. Both plexuses extend the length of the cord. pers and ends at the Ll or 12 level of t he vertebral column.
A 6 1 -yea r-old former house pai nter with a hi story of alcoholism I ma g i n g of the s p i n a l co l u m n revea led an e p i d u ra l ma ss.
was adm itted to the medical service after being fou n d i n a ho The patient was taken to s u rgery, and a n epidural a bscess, ex
tel room i n a confused state that was att r i b u ted to a l cohol tend i n g over five vertebral segments, wa s f o u n d . The s p i n a l
with d rawal synd rome. The patient d i d not complain of pain but cord u nder t h e abscess w a s com pressed and pale, probably a s
said he was wea k and could not get out of bed. He had a fever. a res ult o f ischemia (vasospasm l e a d i n g t o inadeq uate perfu
The intern's i n itial neurologic exa m i n ation d i d not revea l any sion with blood).
focal neurologic signs. The lumbar puncture yielded CSF con The motor status of this patient suggested a spinal cord l e
ta in ing a moderate n u m ber of wh ite blood cel l s and protein of sion, which was confi rmed on sensory examination. Percussion
about 1 00 mg/d l (elevated) with normal CSF g l u cose. Despite tenderness over the spine, which is often seen with epidural ab
treatment with antibioti cs, the patient d i d not i m p rove, a n d scesses or tumors, provided additional evidence for d isease of
neurologic consu ltation w a s o btai ned. the spinal column. Epid ural spinal cord compression is especia l ly
On exa mination, the patient was confused and uncoopera common in the context of neoplasms (eg, breast, prostate) that
tive. He stated he was wea k and cou ld not walk. Motor exami metastasize to the spine. The possibility of spinal cord compres
nation revea led flaccid paraparesis. Deep tendon reflexes were sion should be considered, and the vertebral col u m n gently per
a bsent in the l egs, and the p l a ntar res ponses were exte nsor. cu ssed, in any patient with a known m a l i g n a ncy and recent
The patient was not cooperative for vibratory or position sense on set or worsening back pa in. As noted earlier, epid u ral spinal
testing. He denied feeling a pin as pai nful over any part of the cord compression can be effectively treated in many patients if
body; however, when the exa miner watched for a fa cial wince recognized early i n its cou rse. However, if it is not diagnosed and
on pin prick, a sensory level TS-6 cou l d be demonstrated. On ra pidly treated, it can progress to ca use irreversible paraplegia or
gentle percussion of the spinal col u m n , there was tenderness quadriplegia. Any patient with suspected spinal cord compres
at T9- 1 0. sion, therefore, must be eva luated on an u rgent basis.
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70 SECTION III Spinal Cord and Spine
Subclavian artery
Below that level, the dural sac within the vertebral column
contains the cauda equina.
G reat ventral
The vertebral column is slightly S-shaped when seen from rad icular artery
the side (Fig 6-6) . The cervical spine is ventrally convex, the (artery of Adamkiewicz)
thoracic spine ventrally concave, and the lumbar spine ven
trally convex, with its curve ending at the lumbosacral angle.
Ventral convexity is sometimes referred to as normal lordosis
and dorsal convexity as normal kyphosis. The pelvic curve
(sacrum plus coccyx) is concave downward and ventrally from
the lumbosacral angle to the tip of the coccyx. The spinal col Lumbar
umn in an adult is often slightly twisted along its long axis; this
is called normal scoliosis.
Vertebrae
Most vertebrae share a common architectural plan. A typical
vertebra (not C l , however) has a body and a vertebral (neu
ral) arch that together surround the vertebral (spinal) canal
(Fig 6-7). The neural arch is composed of a pedicle on each
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CHAPTER 6 The Vertebral Column and Other Structures Surrounding t he Spinal Cord 71
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72 SECTION III Spinal Cord and Spine
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CHAPTER 6 The Vertebral Column and Other Structures Surrounding t he Spinal Cord 73
CSF Analysis
Roentgenog raphy
CSF examination i s discussed i n Chapter 24.
Because roentgenograms (plain films) demonstrate the pres
ence of calcium, various projections (anteroposterior, lateral,
IMAGING OF THE SPINE and oblique) of the affected area show the skeletal components
AND SPINAL CORD of the spine and foramens (Figs 6- 1 1 and 6- 12). Fractures or
erosions of the vertebral column's bony elements are often eas
Imaging methods have great value in determining t he precise site ily seen, but the films provide little or no information about
and extent of the involvement of pathologic processes in the spine the spinal cord or other soft tissues.
C A S E 4
I
A 49-year-old dock worker was reasonably healthy until a his right arm and left leg, but the left arm continued to be
heavy piece of equipment fell high on his back, knocking weak. Pain sensation was not tested at this time.
him down but not rendering him unconscious. He was un Neurologic examination 3 weeks later disclosed fascic
able to move his arms and legs and complained of shoot ulations in the left deltoid, marked weakness in the left arm
ing pains in both arms and tingling in his right side below (more pronounced distally), mild spasticity of the left el
the axilla. bow, and minimal spasticity in the left knee on passive mo
In the emergency room, the following neurologic ab tion. Some deep tendon reflexes-all on the left side-were
normalities were recorded: flaccid left hemiplegia, right increased: biceps, triceps, quadriceps, and Achilles tendon.
triceps weakness, and left extensor plantar response. Pain There was a left extensor plantar response. Position and vi
sensation was lost on the right side from the shoulder bration senses were intact, and pain sensation was absent
down, including the axilla and hand but not the thumb. on the right half of the body up to the level of the clavicle.
What is the tentative diagnosis? What imaging proce What is the sequence of pathologic events? Where is the
dure would you request to localize the lesion? lesion, and which neural structures are involved? Which
The patient underwent neck surgery to correct the prob syndrome is incompletely represented in this case? Which
lem. A few days postoperatively, he regained strength in components of the complete syndrome are not present?
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74 SECTION III Spinal Cord and Spine
C A S E 5
Two months before presentation, a 40-year-old camp coun sent on the right and normal on the left, and there were
selor sustained a minor injury while playing baseball, feel flexor plantar responses on both sides. All sensory modal
ing a snap and a stab of pain to his lower back when he slid ities were intact. There was marked spasm of the right
feet first into third base. Shortly after the incident, he noticed paravertebral muscles and local tenderness on palpation of
dull pains in the same region in the mornings; these pains the spine at L5-S l and at the sciatic nerve in the right but
seemed to subside during the day. Several weeks later, he tock. Straight leg raising was limited to 30° on the right but
began to feel electric shock-like pain shooting down the was normal on the left. Radiographs of the lumbar spine
back of his right leg to his toes on the right side. The pain were normal. MRI revealed a lesion. The patient was
seemed to start in the right buttock and could be precipitated treated with nonsteroidal anti-inflammatory medications,
by coughing, sneezing, straining, or bending backward. The together with bed rest. His pain resolved.
patient had also noticed occasional tingling of his right calf What is the most likely diagnosis?
and some spasms of the back and right leg muscles.
Cases are discussed further in Chapter 25. Questions
Neurologic examination showed no impairment of mus
and answers pertaining to Chapters 5 and 6 are found in
cle strength, and there were normal deep tendon reflexes in
Appendix D .
the upper extremities. The Achilles tendon reflex was ab-
Vertebral
canal
C3-4
disk space
C5 body
S h oulder
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CHAPTER 6 The Vertebral Column and Other Structures Surrounding t he Spinal Cord 75
Mag netic Resonance Ima ging (MRI) calcium of bone does not yield a magnetic resonance signal,
MRI is especially useful in showing suspected lesions of the
Magnetic resonance imaging can be used i n any plane. It has
soft tissues in and around the vertebral column (Figs 6- 1 6 and
been used, especially with sagittal images, to demonstrate the
6- 1 9) .
anatomy or pathology of the spinal cord and surrounding
spaces and structures ( Figs 6 - 1 5 to 6- 1 8 ) . B ecause the
kidney
Abdominal fat
Lumbar nerves
FIGURE 6-1 5 Magnetic resonance image of a coronal section through the body and (cu rved) l u mbar spi ne. (Reprod uced, with permission, from
deGroot J: Correlative Neuroanatomy of Computed Tomography and Magnetic Resonance Imaging. 2 1 st ed. Appleton & Lange, 1 99 1 .)
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76 SECTION III Spinal Cord and Spine
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C H A P T E R
The brain stem includes the medulla and pons, located ventral The quadrigeminal plate, the midbrain tegmentum, and
to the cerebellum. In addition to housing essential ascending the cerebral peduncles develop from the mesencephalon
and descending tracts, the brain stem contains nuclei t hat are (midbrain; see Fig 7- 1 ) , and the cerebral aqueduct courses
essential for maintenance of life. As a result of t he relatively through it. The rhombencephalon (see Fig 7- 1A) gives rise to
tight packaging of numerous ascending and descending the metencephalon and the myelencephalon. The meten
tracts, as well as nuclei, within the brain stem, even small le cephalon forms the cerebellum and pons; it contains part of
sions within it can injure multiple tracts and nuclei within it the fourth ventricle. The myelencephalon forms the medulla
and thus can produce very significant neurologic deficits. The oblongata; the lower part of the fourth ventricle lies within
cerebellum, located just dorsal to the brain stem, plays a ma this portion of the brain stem.
jor role in motor coordination. Because of its proximity to the As in the spinal cord, the embryonic brain stem has a cen
brain stem, injuries which cause swelling of the cerebellum tral gray core with an alar plate (consisting mostly of sensory
can compress the brain stem, and thus can rapidly become components) and a basal plate (composed primarily of motor
life-threatening. components) . The gray columns are not continuous in the
brain stem, however, and the development of the fourth ven
tricle causes wide lateral displacement of t he alar plate in the
DEVELOPMENT OF THE BRAIN STEM lower brain stem. The basal plate takes the shape of a hinge
AND CRANIAL NERVES (see Fig 7-2) . The process is reversed at the other end, result
ing in the rhomboid shape of the floor of the fourth ventricle.
The lower part of the cranial portion of the neural tube In addition, long tracts, short neuronal connections, and nu
(neuraxis) gives rise to the brain stem. The brain stem is divided clei become apposed to the brain stem. The cranial nerves,
into the mesencephalon and rhombencephalon (Fig 7- 1 ) . like the spinal nerves, take their origin from the basal plate
The primitive central canal widens into a four-sided pyra cells (motor nerves) or from synapses in the alar plate cell
mid shape with a rhomboid floor (Fig 7-2). This becomes the groups (sensory nerves) . Unlike spinal nerves, most cranial
fourth ventricle, which extends over the future pons and the nerves emerge as one or more bundles of fibers from the basal
medulla. or basilateral aspect of the brain stem (Figs 7- 1 and 7-3). In
The neural tube undergoes local enlargement and shows addition, not all cranial nerves are mixed; some have only sen
two permanent flexures: the cephalic flexure at the upper end sory components and others have only motor components
and the cervical flexure at the lower end. The cephalic flexure (see Chapter 8).
in an adult brain is the angle between the brain stem and the
horizontal plane of the brain (see Fig 1-6).
The central canal in the rostral brain stem becomes the BRAIN STEM ORGANIZATION
cerebral aqueduct. The roof of the rostral fourth ventricle un
dergoes intense cellular proliferation, and this lip produces the Main Divisions and External Landma rks
neurons and glia that will populate both t he cerebellum and Three major external divisions of the brain stem are recogniz
the inferior olivary nucleus . able: the medulla (medulla oblongata), the pons together with
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80 SECTION IV Anatomy of the Brain
Prosencephalon Somatic
Mesencephalon Alar plate afferent nucleus
efferent nucleus
Spinal
cord
Dien
cephalon
Telencephalic
vesicle
Dien
cephalon
_.___,.,.- � Fou rth
ventricle
-- Somatic
afferent
Vagus nucleus
Somatic
Hypoglossus efferent
c
nucleus
Optic portion covers the open portion of the medulla. The closed
nerves medulla forms the transition to the spinal cord.
Three pairs of cerebellar peduncles (inferior, middle,
and superior) form connections with the cerebellum. The dor
Cerebellum
sal aspect of the midbrain shows four hillocks: the two supe
rior and the two inferior colliculi, collectively called the cor
Medulla pora quadrigemina or quadrigeminal plate.
cranial nerves
I nternal Structural Com ponents
D A. Descending and Ascending Tracts
All descending tracts that terminate in the spinal cord ( eg, the
FIGURE 7-1 Fou r stages in early deve l o pment of brain and corticospinal tract; see Chapter 5) pass through the brain stem.
cra n i a l nerves (times a re a p p roxi mate). A: 3M weeks. B: 4M weeks. In addition, several descending fiber systems terminate or orig
C: 7 weeks. D : 1 1 weeks. inate in the brain stem. Similarly, all ascending t racts (eg, the
spinothalamic tracts) that reach the brain stem or the cerebral
cortex pass through part or all of this region; other ascending
the cerebellum, and the midbrain (mesencephalon) (Figs 7-3 tracts originate in the brain stem. The brain stem is, therefore,
and 7-4) . The three internal longitudinal divisions of the an important conduit or relay station for many longitudinal
brain stem are the tectum (mainly in the midbrain), tegmen pathways, both descending and ascending (Table 7- 1 ) .
tum, and basis (see Fig 7-4) . Thus, the pons, for example, can
be considered to consist of a dorsal pontine tegmentum and B. Cra n i a l Nerve N uclei
a ventral basis pontis. The main external structures, seen Almost all the cranial nerve nuclei are located in the brain
from the dorsal aspect, are shown in Figure 7-5. The superior stem. (The exceptions are the first two cranial nerve nuclei,
portion of the rhomboid fossa (which forms the floor of the which are evaginations of the brain itself.) Portions of the cra
fourth ventricle) extends over the pons, whereas the inferior nial nerves also pass through the brain stem.
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CHAPTER 7 The Brain Stem and Cerebellum 81
Oculomotor nerve ( I l l )
Trochlear nerve ( IV)
Cerebral
peduncle
in midbrain
I
Trigeminal nerve (V)
����{;����-�!_ Gnerve
trigeminal
nerve lossopharyngeal
(IX)
FIGURE 7-3 Ventra l view of the brain stem, i n relation to cerebral hemispheres and cerebe l l um, showing the cranial nerves.
I nferior colliculus
Lateral
geniculate
body
nerve
Cerebellum
ventricle
FIGURE 7-4 Drawing of the divisions of the bra i n stem in a
(Rhomboid
mid sagittal plane. The major i nternal longitud inal divisions a re the fossa)
tectum, teg mentum, and basis. The major external d ivisions a re the Tractus graci lis
mid brain, pons, and med u l la. Tractus cuneatus
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82 SECTION IV Anatomy of the Brain
TABLE 7-1 Major Ascending and Descending involved with movements of the tongue and eye, such as t he
Pathways in the Bra i n Stem. hypoglossal nucleus of XII, oculomotor nucleus of III,
trochlear nucleus of iV, and abducens nucleus of VI.
Ascending Descending
Branchial efferent (BE) components , sometimes re
Medial lemniscus Corticospinal tract ferred to as special visceral efferents (SVE) , innervate mus
cles that are derived from the branchial arches and are in
Spinothalamic tract Corticonuclear tract
volved in chewing, making facial expressions, swallowing,
Trigeminal lemniscus Corticopontine fibers producing vocal sounds, and turning the head. Examples in
Lateral lemn iscus Rubrospinal tract clude the masticatory nucleus of V; facial nucleus of VII; am
Reticu l a r system fi bers Tectospinal tract
biguus nucleus of IX, X, and XI; and spinal accessory nucleus
of XI located in the cord.
Medial longitudinal fasciculus Med ial longitudinal fasciculus
General visceral efferent (VE or GVE) components are
i nferior cerebel lar ped uncle Vestibu lospinal tract parasympathetic preganglionic components that provide au
Superior cerebel lar peduncle Reticuiospinal tract tonomic innervation of smooth muscles and the glands in the
head, neck, and torso. Examples include the Edinger-West
Secondary vestibulary fi bers Centra l tegmental tract
phal nucleus of III, superior salivatory nucleus ofVII, inferior
Secondary gustatory fibers Descending tract of nerve V salivatory nucleus of IX, and dorsal motor nucleus of X.
MEDULLA
Motor (Efferent) Com ponents
Three types of basal plate derivatives (motor nuclei) are lo The medulla (medulla oblongata) can be divided into a caudal
cated within the brain stem (see Table 7-2). (closed; Fig 7-7B) portion and a rostral (open; Fig 7-7C) por
General somatic efferent (SE or GSE) components in tion. The division is based on the absence or presence of the
nervate striated muscles that are derived from somites and are lower fourth ventricle.
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CHAPTER 7 The Brain Stem and Cerebellum 83
Trochlear
nucleus (IV)
Motor
....----+- Motor
nucleus
Abducens of V
nucleus (VI)
Facial
nucleus
(VI I )
Superior
salivatory Vestibu lar
nucleus (VI I ) nuclei
Inferior
�·��---..,...- N ucleus
sal ivatory of VI
nucleus ( I X)
Ambiguus Nucleus
of V I I
nucleus
( I X, X , X I )
Hypoglossal
nucleus (XI I ) Hypoglossal nucleus
Cochlear
nuclei
Descending spinal
tract of V
FIGURE 7-6 Cra n ial nerve nuclei. Left: Dorsa l view of the human b ra i n stem with the positions of the cra n i a l nerve n u clei projected o n
the su rface. Motor n u c l e i a re o n the left; sensory n uclei a re o n the right. Right: Tra nsverse sections at the levels ind icated b y the arrows.
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84 SECTION IV Anatomy of the Brain
TAB L E 7-2 Cranial Nerves and N uclei i n the The medial longitudinal fasciculus is an important
Bra i n Stem. pathway involved with control of gaze and head movements.
It descends into the cervical cord. The medial longitudinal fas
Name Nerve N uclei
ciculus arises in the vestibular nuclei and carries vestibular in
Oculomotor Ill Oculomotor, Edinger-Westphal fluences downward (see Fig 1 7-2). More rostrally in the pons,
the medial longitudinal fasciculus carries projections rostrally
Trochlear IV Trochlear
from the vestibular nuclei to the abducens, trochlear, and ocu
Trigeminal v Main sensory, spinal (descending), lomotor nuclei and from the lateral gaze center in t he pons to
mesencephalic, motor
the oculomotor nuclei (see Fig 8-7) .
(masticatory)
The tectospinal tract carries descending axons from the
Abducens VI Abducens
superior colliculus in the midbrain to the cervical spinal cord.
Facial VII Facial, superior sal ivatory, It relays impulses controlling neck and trunk movements in
g ustatory (solitary)* response to visual stimuli.
Vestibu lococh lear VIII Coch lear (two nuclei), vestibular
(four nuclei)
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CHAPTER 7 The Brain Stem and Cerebellum 85
N ucleus gracilis
N ucleus cuneatus
Dorsal spinocerebellar tract
Spinal nucleus of V
Decussation of pyramids
B. Closed med u l l a
A
Medial longitudinal fascicu lus
Hypoglossal nucleus
C. O pen med u l l a
Dentate nucleus
Cerebellum
(cut section)
_ Vermis
Pontine reticular
formation Facial colliculus
��--=-----�-t- Nucleus of nerve VI
Medial lemniscus
VI
D. Lower p o n s ; level of nerves VI and VII
FIGURE 7-7 A: Key to levels of sections. B-G: Schematic transverse sections through the bra i n stem. The corticospinal tracts and the
dorsal col u m n nuclei/med ial lemn isci a re shown i n color so that they can be f o l l owed as they course through the bra i n stem .
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86 SECTION IV Anatomy of the Brain
Cerebellar
hemisphere
(cut section)
Medial longitudinal
fasciculus
Spi nothalamic
tract
Medial lemniscus
Corticospinal tract
I
Temporopontine tract Substantia nigra
Cerebral peduncle
Corticospinal tract
Crus cerebri
Ill
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CHAPTER 7 The Brain Stem and Cerebellum 87
I nferior Cerebel l a r Ped uncle corticopontine pathway, and pontocerebellar fibers from the
pontine nuclei, which cross and project to most of the neo
A peduncle i s a stalk-like bundle o f nerve fibers containing
cerebellum by way of the large middle cerebellar peduncle.
one or more axon tracts . The inferior cerebellar peduncle is
Along the midline of the pons and part of the medulla lie the
formed in the open medulla from several components: the
raphe nuclei . Serotonin-containing neurons in these nuclei
cuneocerebellar and the dorsal spinocerebellar tracts ,
project widely to the cortex and hippocampus, basal ganglia,
fibers from the lateral reticular nucleus, olivocerebellar
thalamus, cerebellum, and spinal cord. These cells are impor
fibers from the contralateral inferior olivary nucleus, fibers
tant in controlling the level of arousal and modulate the
from the vestibular division of nerve VIII, and fibers that
sleep-wake cycle. They also modulate sensory input, particu
arise in the vestibular nuclei. All fibers are afferent to the
larly for pain.
cerebellum.
To thalamus (VPM)
l
Ventral
Ophthalmic
branch
Maxillary
branch
Mandibular
branch
N ucleus interpolaris
"""-l....
l _ ...., _ Descending spinal
nucleus (nucleus
caudalis) and tract
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88 SECTION IV Anatomy of the Brain
ft
from the midbrain to the inferior olivary nucleus and ascend (corticonuclear)
pathways from
ing fibers that run from the brain stem reticular formation to motor cortex
the thalamus, and runs dorsolateral to the medial lemniscus.
The tectospinal tract (from midbrain to cervical cord) and
the medial longitudinal fasciculus are additional compo
nents of the pontine tegmentum.
Facial nuclei
Aud itory Pathways for muscles
The auditory system from the cochlear nuclei in the pon of upper and
lower face
tomedullary junction includes fibers that ascend ipsilaterally
in the lateral lemniscus (see Chapter 1 6 ) . It also includes Nerve X I I 4----J.- Hypog lossal
(LMN) nucleus
crossing fibers (the trapezoid body) that ascend in the oppo
site lateral lemniscus. A small superior olivary nucleus sends
fibers into the cochlear division of nerve VIII as the olive
cochlear bundle (see Fig 7-7D ) ; this pathway modifies the
sensory input from the organ of Corti in the cochlea. FIGURE 7-9 Cortico b u l ba r pathways to the n uclei of cranial
nerves VII and X I I . Notice that the facial nucleus for m uscles of the
u pper face receives descen ding i n put from the motor cortex o n both
Trigem i n a l System sides, whereas the facial nucleus for lower facial m uscles receives in
put from o n ly the contra l atera l cortex.
The three divisions of the trigeminal nerve (nerve V; see
Figs 7-7D and E and Fig 7-8) all project to the brain stem.
Fine touch function is relayed by the main sensory nucleus;
pain and temperature are relayed into t he descending spinal (whose cells contain neuromelanin) receives afferent fibers
from the cerebral cortex and the striatum; it sends dopamin
tract of V; and proprioceptive fibers form a mesencephalic
tract and nucleus in the midbrain. The s econd-order neurons ergic efferent fibers to the striatum. The substantia nigra plays
a key role in motor control. Degeneration of the substantia ni
from the main sensory nucleus cross and ascend to the thala
gra occurs in Parkinson's disease (see Chapter 1 3 ) . The exter
mus. The descending spinal tract of V sends fibers to the pars
caudalis (the spinal nucleus in the medulla), the pars interpo nal aspect of the basis of the midbrain is called the cerebral
peduncle.
laris (a link between trigeminal afferent components and t he
cerebellum) , and the pars oralis. The masticatory nucleus, The corticobulbar fibers from the motor cortex to in
which is medial to the main sensory nucleus, sends branchial terneurons of the efferent nuclei of cranial nerves are homol
ogous with the corticospinal fibers. The corticobulbar fibers
efferent fibers into the mandibular division of nerve V to in
nervate most of the muscles of mastication and the tensor to the lower portion of the facial nucleus and the hypoglossal
tympani of the middle ear. nucleus are crossed (from the opposite cerebral cortex) . All
other corticobulbar proj ections are bilaterally crossed (from
both cortices) .
M IDBRAIN The fibers of the oculomotor (III) nerve exit between the
cerebral peduncles (see Fig 7-6) in the interpeduncular
The midbrain forms a transition (and fiber conduit) to the fossa. The fibers of the trochlear (IV) nerve exit on t he other
cerebrum (see Figs 1-2 and 7-9). It also contains a number of side of the midbrain, the tegmentum (see Fig 7-5 ) .
important cell groups, including several cranial nerve nuclei.
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CHAPTER 7 The Brain Stem and Cerebellum 89
FIGURE 7-1 0 Pri ncipal a rteries of the brain stem (ventral view).
Tectu m
The tectum, o r roof, of the midbrain i s formed by two pairs of
colliculi and the corpora quadrigemina . The superior colli
culi contain neurons that receive visual as well as other input
inferior cerebellar artery, the anterior inferior cerebellar ar
and serve ocular reflexes; the inferior colliculi are involved in
tery, the superior cerebellar artery, the posterior cerebral ar
auditory reflexes and in determining the side on which a sound
tery, and the pontine artery. Each of these vessels sends small
originates. The inferior colliculi receive input from both ears,
branches (a few or many) into the underlying brain stem
and they project to the medial geniculate nucleus of the thala
structures along its course. Other vessels are classified as
mus by way of the inferior quadrigeminal brachium. The su
median (paramedian) perforators because they penetrate
perior quadrigeminal brachium links the lateral geniculate
the brain stem from the basilar artery. Small medullary and
nucleus and the superior colliculus. The colliculi contribute to
spinal branches of the vertebral artery make up a third group
the formation of the crossed tectospinal tracts, which are in
of vessels.
volved in blinking and head-turning reflexes after sudden
sounds or visual images.
Lesions of the Bra i n Stem
The brain stem is an anatomically compact, functionally di
Periaq ueductal G ray Matter
verse, and clinically important structure. Even a single, r ela
The periaqueductal gray matter contains descending auto
tively small lesion nearly always damages several nuclei, re
nomic tracts as well as endorphin-producing cells that sup
flex centers, tracts, or pathways . Such lesions are often
press pain. This region has been used as the target for brain
vascular in nature (eg, infarct or hemorrhage ) , but tumors,
stimulating implants in patients with chronic pain.
trauma, and degenerative or demyelinating processes can
also injure the brain stem . The following are typical syn
dromes caused by intrinsic (intra-axial) lesions of the brain
Su perior Cerebel lar Ped uncle
stem.
The superior cerebellar peduncle contains efferent fibers from
Medial (basal) medullary syndrome usually involves t he
the dentate nucleus of the cerebellum to the opposite red nu
pyramid, part or all of the medial lemniscus, and nerve XII. I f
cleus (the dentatorubrothalarnic system) and the ventral spin
it is unilateral, it is also known as alternating hypoglossal
ocerebellar tracts. The cerebellar fibers decussate j ust below
hemiplegia (Fig 7- 1 1 ); the term refers to the finding that the
the red nuclei.
cranial nerve weakness is on the same side as the lesion, but
the body paralysis is on the opposite side. Larger lesions can
result in bilateral defects. The area involved is supplied by t he
VASCULARIZATION
anterior spinal artery or by medial branches of t he vertebral
The vessels that supply the brain stem are branches of the artery.
vertebrobasilar system ( Fig 7- 1 0 ; see also Chapter 1 2 ) . Lateral medullary, or Wallenberg's, syndrome involves
Those classified a s circumferential vessels are the posterior some (or all) of the following structures in the open medulla
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90 SECTION IV Anatomy of the Brain
on the dorsolateral side (see Fig 7- 1 1 ) : inferior cerebellar pe Cerebellopontine angle syndrome may involve nerve
duncle, vestibular nuclei, fibers or nuclei of nerve IX or X, VIII or VII or deeper structures. It is most often caused by a
spinal nucleus and tract of V, spinothalamic tract, and sympa tumor that begins by affecting the Schwann cells of a cranial
thetic pathways. (Involvement of the sympathetic pathways nerve in that region (eg, a tumor at nerve VIII; see Fig 7-3) .
may lead to Horner's syndrome.) The affected area is supplied A tumor i n the pineal region may compress the upper
by branches of the vertebral artery or, most commonly, the quadrigeminal plate and cause vertical gaze palsy, loss of
posterior inferior cerebellar artery. An example is provided in pupillary reflexes, and other ocular manifestations. There may
Clinical Illustration 7- 1 . be accompanying obstructive hydrocephalus.
Vertical gaze palsy, also called Parinaud's syndrome, is
an inability to move the eyes up or down. It is caused by com
Lesions Near t h e Bra i n Stem pression of the tectum and adjacent areas (eg, by a tumor of
Space-occupying processes ( eg, tumors, aneurysms, brain the pineal gland; see Figs 7- 1 3 and 7- 14).
herniation) in the area surrounding the brain stem can affect Other tumors near the brain stem include medulloblas
the brain stem indirectly. Several disorders, discussed next, toma, ependymoma of the fourth ventricle, glioma, menin
are typically caused by extrinsic (extra-axial) lesions. gioma, and congenital cysts. Medulloblastoma, a cerebellar
A 49-year-old landsca pe a rtist, who had visited many cou ntries sm a l l b ra i n stem, occ l u s i o n of even re latively sma l l a rteries,
i n E u rope, Asia, and Africa, was a d m itted to the hospita l be such as the posterior i nferior cerebe l l a r arteries, can have pro
cause of a s u d d e n o n set of fa c i a l n u m b ness, ataxia, vertig o, fou n d effects.
nausea, a n d vo miting. Exa m i nation revealed impaired sensa In this case, vasc u l a r occlusion was due to syph i l itic a rteritis,
tion over the left half of the face. The arm and leg on the left a form of tertia ry neurosyp h i l i s. Although neurosyph i l i s i s now
side were c l u m sy, a n d there was an intention tremor on the ra re, meningovascu l a r syp h i l is was a common cause of b ra i n
left. A l eft-sided H o r n er's syn d rome-myosis (a con stricted stem strokes i n t h e prea nti biotic e r a . I n eva l uating strokes, it i s
pupil), ptosis (a wea k, d roopy eyelid), and decreased sweating essential to consider a l l o f the disorders t h a t can l e a d to cere
over the forehead-was a p pa re nt. There was s u bjective n u mb brovascular com promise. In this case, treatment with penici l l i n
ness of the right a rm, although no abnormalities cou l d be de a rrested t h e patient's neurosyphilis and m a y have prevented
tected on exami nation. Over the ensuing 1 2 hou rs, the patient fu rther cereb rovascu l a r events. A s ignifica nt degree of fu nc
had d iffi cu lty swa l l owing and com p l a i ned of intra cta b l e h ic tional recovery, a s seen i n this patient, can occ u r after bra i n
cu ps. Vi bratory a n d position sen ses were now impaired i n the stem strokes and presumably reflects reorg a n ization o f neura l
left arm, the voca l cord was pa ra lyzed, and the gag r eflex was circuits contro l l i n g swa l lowing as we l l a s related activities.
d i m i n ished. O n t h e right s i d e, t h e re was i m p a i red pain a n d Basal pont i n e synd romes can i nvolve both the corti
tem perat u re sensibil ity. Magnetic resonance imaging demon cospinal tract and a cra n i a l nerve (VI, VII, or V) in the affected re
strated a n a b n o r m a l ity, p res u m a b l y i nfa rction, i n the l atera l g i o n , depe n d i n g on the extent and l evel of the l e s i o n
med u l l a on the left side, and a pres u m ptive diagnosis of Wa l ( F i g 7- 1 2) . T h e synd rome is cal led alternati ng abducens (VI),
lenberg's syn d rome (latera l med u l l a ry syn d ro me) on the basis facial (V), or trigeminal hemi plegia (V). If the lesion is l a rge, it
of occ l u s i o n of t h e posterior i nfe rior cerebe l l a r a rte ry was may include the medial lemniscus. The vascul ar supply comes
made. from the perforators, or pontine branches, of the a nterior infe
Arteriog ra phy revea led occlusion of the posterior i nferior rior cerebel l a r a rtery.
cerebe l l a r artery with "bead i ng" (evi dence of i nfla m mation) of The locked-in syndrome res u lts from l a rge lesions of the
vertebral arteries and a nterior i nferior cerebe l l a r arteries. Lu m basal pons that i nterrupt the cortico b u l b a r and corticospinal
bar pu nct u re revea led 40 wh ite blood ce l l s (mostly lympho pathways b i l ate ra l ly, t h u s i nterfering with speech, fac i a l ex
cytes) per m i l l i l iter of cerebrospinal fl uid (CSF). Serologic test pression, a n d the capacity to activate m ost m u sc l es. These
i n g was pos itive fo r syp h i l i s. The patient was treated with pontine lesions a re usually d u e to infa rcts o r hemorrhages. So
penici l l i n . Over the ensuing 6 months, many of h i s deficits re matosen s o ry pathways a n d the reti c u l a r system a re u s u a l ly
solved, and he resumed his activities, including painting. spared so that patients remain awa ke and awa re of their s u r
Th i s case i l l u strates the deve l o p m ent of the l ateral ro u n d i ngs. Eye movements a re often s p a red. Patients c a n
med u l l ary syndrome ( Wallen berg's synd rome) as a result of oc sometim es, therefore, com m u n icate via a c r u d e c o d e i n this
cl usion of the posterior i nferior cerebe l l a r a rtery. Beca use so tragic syndrome and can su rvive i n this state for yea rs. An ex
many structu res a re packed closely together i n the relatively a m p le is provided in C l i n ical I l l u stration 7-2.
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CHAPTER 7 The Brain Stem and Cerebellum 91
VI I I
G ross Structu re
The cerebellum is located behind the dorsal aspect of the pons
tumor (usually of the vermis) that occurs in childhood, may and the medulla. It is separated from the occipital lobe by the
fill the fourth ventricle and block the CSF pathway. Although
tentorium and fills most of the posterior fossa. A thinner
compression of the brain stem is rare, the tumor has a ten midline portion, the vermis, separates two lateral lobes, or
dency to seed to the subarachnoid space of the spinal cord and cerebellar hemispheres (Fig 7- 1 5 ) . The external surface of the
the brain. cerebellum displays a large number of narrow, r idge-like folds
termed folia, most of which are oriented t ransversely.
The cerebellum consists of the cerebellar cortex and the
underlying cerebellar white matter (see Cerebellar Cortex s ec
Dorsa l
tion). Four paired deep cerebellar nuclei are located within the
pontine
syndrome
white matter of the cerebellum, above the fourth ventricle. (Be
cause they lie in the roof of the ventricle, they are sometimes re
ferred to as roof nuclei.) These nuclei are termed, from medial
to lateral, the fastigial, globose, emboliform, and dentate.
Because of the location of the fourth ventricle, ventral to
the cerebellum, mass lesions or swelling of the cerebellum ( eg,
because of edema after an infarct) can cause obstructive
hydrocephalus.
Divisions
The cerebellum is divided into two symmetric hemispheres; they
are connected by the vermis, which can be further subdivided
(see Fig 7- 15). The phylogenetically old archicerebellum con
Alternating
inferior (middle)
sists of the flocculus, the nodulus (nodule of the vermis), and in
cerebellar VI abducens terconnections (flocculonodular system ); it is concerned with
Basilar
artery artery hemiplegia equilibrium and connects with the vestibular system. The pale
ocerebellum consists of the anterior portions of the hemi
FIGURE 7-1 2 C l i n ica l syndromes associated with pontine le spheres and the anterior and posterior vermis and is involved
sions (compare with Fig 7-70). with propulsive, stereotyped movements, such as walking. The
remainder of the cerebellum is considered the neocerebellum
and is concerned with the coordination of fine movement.
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92 SECTION IV Anatomy of the Brain
A 53-yea r-old a rch itect led a prod uctive life until, over severa l l i mited eye movement that was used for com m u n ication. Sen
hours, weakness in his arms and legs developed, t ogether with sation was preserved, probably because the i nfa rction did not
double vision and d ifficu lty swa l l owing. He was taken to the hos i nvolve the medial lemniscus and spi notha lamic tracts, which
pital, where exami nation revea led wea kness and hyperreflexia a re located dorsa l ly within the pons.
of the arms and legs, bilatera l Babinski's responses, facial weak Th is case also illustrates that consciousness can be maintained
ness on both sides, and dysphagia. Latera l gaze was l i mited and even when there is significant damage in the bra i n stem if the
nystagmus was present. A provisional diagnosis of basi lar a rtery reticular system is spared. In patients with larger infarcts, coma
thrombosis was made. Arteriography confirmed this diagnosis. may resu lt from ischemia of the r eticular system in the brain stem.
Over the next 2 days, despite aggressive treatment, the pa Dorsal pons syndrome affects nerve VI or VII or their re
tient's deficits progressed. Tota l paralysis of all extremities and spective n u c l ei, with o r without i nvo l ve m e nt of the m e d i a l
ma rked wea kness of the face developed. As a res ult of wea k lemniscus, spinothalamic tract, or lateral lemniscus. The " l ate ra l
ness of the b u l bar musculature, swa l l owing was i m pa i red, and gaze center" is often i nvolved (see Fig 8-7). At a more rostral
the patient co u l d not protrude his tongue. Latera l eye move level, nerve V a n d its nuclei may no longer be fu nctioning. The
ments were i m paired, but vertica l eye movements were main affected a rea i s s u p p l i ed by various perfo rators (ponti n e
tained. The patient remai ned awake, with apparently preserved branches) o f t h e circu mferential a rteries.
mentation. He was able to com m u n icate using eye b l i n ks and Ped uncular syndrome, also ca l led alternating oculomo
vertica l eye m ovements. Sensation, tested via s i m p l e yes-no tor hemiplegia and Weber's syndrome in the basal midb rain,
q u esti ons a n swered with eye b l i n ks, a p peared to be i ntact. i nvo l ves n e rve Ill and port i o n s of t h e cere b ra l ped u n c l e
Magnetic resona nce imaging demon strated a l a rge infa rct in (Fig 7- 1 3) . There is a nerve I l l pa l sy o n t h e s i d e o f t h e lesion and
volving the base of the pons. The patient remai ned i n this state, a contra lateral hemipa resis (because the lesion is a bove the py
com m u n icating with friends a n d fa m i ly via eye b l i n ks, for the ra m i d a l decussation). The a rteri a l s u p p ly is by the posterior
next 5 months. He d i ed after a cardiopul monary arrest. perforators and b ra nches of the posterior cerebral artery.
Th is tragic case i l l u strates the l ocked-in syn d rome. The in Bened i kt's syndrome, situ ated in the teg mentum of the
farction, i n the base of the pons, d estroyed the corticospi n a l mid bra i n, may damage the medial lemn iscus, the red nucleu s,
a n d cortico b u l b a r tracts a n d t h u s p rod u ced p a r a l y s i s of t h e a n d n e rve I l l a n d its n u c l e u s a n d associated tracts (see
limbs a n d b u l ba r m uscu l ature. Preservation o f the oculomotor Fig 7- 1 3). This a rea is suppl ied by perforators and b ra nches of
a n d troch l e a r n u clei a n d of t h e i r n e rves perm itted some circu mferentia l a rteries.
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CHAPTER 7 The Brain Stem and Cerebellum 93
Cerebellar tonsil
Functions
The cerebellum has several main functions : coordinating FIGURE 7-1 6 Cerebellar homunculi. Proprioceptive and tactile
skilled voluntary movements by influencing muscle activity, sti m u l i a re projected as shown i n the u pper (inverted) homunculus
and controlling equilibrium and muscle tone through connec and the l ower (spl it) h o m u n c u l us. The striped a rea represents the re
tions with the vestibular system and the spinal cord and i ts gion from which evoked responses to a u d itory and visual sti m u l i a re
gamma motor neurons. There is a somatotopic organization observed. (Redrawn and reproduced, with permission, from Snider R: The cerebel
lum. Sci Am 1 958;1 99:84.)
of body parts within the cerebellar cortex ( Fig 7 - 1 6 ) . In
addition, the cerebellum receives collateral input from the
sensory and special sensory systems.
section). These afferents end in either climbing fibers or mossy
As might be predicted from the cerebellar homunculi,
fibers in the cerebellar cortex, both of which are excitatory (Table
the vermis tends to control coordination and muscle t one of
7-4). Climbing fibers originate in the inferior olivary nucleus
the trunk, whereas each cerebellar hemisphere controls mo
and synapse on Purkinje cell dendrites. Mossy fibers are formed
tor coordination and muscle tone on the same side of the body.
by afferent axons from the pontine nuclei, spinal cord, vestibular
nuclei, and reticular formation: They end in specialized
Ped u ncles glomeruli, where they synapse with granule cell dendrites.
Three pairs of p eduncles, lo cated above and around the There are also several arninergic inputs to the cerebellum.
fourth ventricle, attach the cerebellum to the brain stem and Noradrenergic inputs, from the locus ceruleus, project widely
contain pathways to and from the brain stem (see Fig 7-5 and within the cerebellar cortex. Serotonergic inputs arise in t he
Table 7-3) . The inferior cerebellar peduncle contains many raphe nuclei and also project to the cerebellar cortex. These
fiber systems from the spinal cord (including fibers from the inputs appear to have a modulatory effect on cerebellar activ
dorsal spinocerebellar tracts and cuneocerebellar tract; see ity. Most afferent fibers (both mossy and climbing fibers) send
Fig 5- 1 7) and lower brain stem (including t he olivocerebellar collateral branches that provide excitatory inputs to the deep
fibers from the inferior olivary nuclei, which give rise to the cerebellar nuclei.
climbing fibers within the cerebellar cortex). The inferior
cerebellar peduncle also contains inputs from the vestibular
nuclei and nerve and efferents to the vestibular nuclei. Cerebel l a r Cortex
The middle cerebellar peduncle consists of fibers from The cerebellar cortex consists of three layers: the subpial,
the contralateral pontine nuclei. These nuclei receive input outer molecular layer; the Purkinje cell layer; and the gran
from many areas of the cerebral cortex. ular layer, an inner layer composed mainly of small granule
The superior cerebellar peduncle, composed mostly of cells (Figs 7- 1 7 and 7 - 1 8 ) .
efferent fibers, contains axons that send impulses to both the The cerebellar cortex is arranged a s a highly ordered ar
thalamus and spinal cord, with relays in the red nuclei (see ray, consisting of five primary cell types (Figs 7- 1 9 and 7-20):
Chapter 13). Afferent fibers from the ventral spinocerebellar
• Granule cells, with cell bodies located in the granular layer of
tract also enter the cerebellum via this peduncle.
the cerebellar cortex, are the only excitatory neurons in the
cerebellar cortex. The granule cells send their axons upward,
Afferents to the Cerebel l u m into the molecular layer, where they bifurcate in a T-like man
Afferents to the cerebellum are carried primarily via the inferior ner to become the parallel fibers. The nonmyelinated parallel
and middle cerebellar peduncles, although some afferent fibers fibers run perpendicular through the Purkinje cell dendrites
are also present in the superior cerebellar peduncles (see prior (like the wires running between telephone poles) and form
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94 SECTION IV Anatomy of the Brain
TABLE 7-3 Functions and Major Terminations of the Principal Afferent Systems to the Cerebel l u m.*
Peduncle of Entry
Afferent Tracts Transmits Distribution Into Cerebellum
Dorsal spi nocerebellar Proprioceptive and exteroceptive Folia I-VI, pyramis and paramedian I nferior
i m pulses from body lobule
Ventral spinocerebellar Proprioceptive and exteroceptive Folia I-VI, pyra mis and paramedian Su perior
impu lses from body lobule
Cuneocerebellar Proprioceptive impu lses, especially Folia I-VI, pyramis and paramedian I nferior
from head and neck lobule
Tectocerebellar Auditory and visual i m p u l ses via Fol ium, tuber, ansiform lobule Superior
i nferior and su perior col liculi
Vestibu locerebel lar Vestibular i m p ulses from labyrinths, Pri ncipally flocculonodular lobe I nferior
d i rectly and via vesti bular nuclei
Pontocerebel lar I m p u l ses from motor and other parts All cerebel lar cortex except Middle
of cerebra l cortex via ponti ne nuclei floccu lonod ular lobe
Ol ivocerebel lar Proprioceptive i n put from whole body All cerebellar cortex and deep nuclei I nferior
via relay i n i nferior o l ive
• Several other pathways transmit impulses from nuclei in the brain stem to the cerebel lar cortex and to the deep nuclei.
Data from Ganong WF: Review of Medical Physiology, 22nd ed. Appleton & Lange, 2005.
excitatory synapses on these dendrites. Glutamate appears to • Stellate cells are located in the molecular layer and receive
be the neurotransmitter at these synapses. excitatory inputs, primarily from the parallel fibers. Like the
• Purkinje cells provide the primary output from the cerebel basket cells, these cells give rise to inhibitory synapses on
lar cortex. These unique neurons have their cell bodies in Purkinje cells.
the Purkinje cell layer and have dendrites t hat fan out in a
single plane like the ribs of a Japanese fan or the crossbars Deep Cerebellar N uclei
on a telephone pole. The axons of Purkinje cells project i psi
Four pairs of deep cerebellar nuclei are embedded in the white
laterally to the deep cerebellar nuclei, especially t he dentate
matter of the cerebellum: fastigial, globose, emboliform, and
nucleus, where they form inhibitory synapses.
dentate. Neurons in these deep cerebellar nuclei project out of
• Basket cells are located in the molecular layer. These cells the cerebellum and thus represent the major efferent pathway
receive excitatory inputs from the parallel fibers and project
back to Purkinje cells, which they inhibit.
• Golgi cells are also located in the molecular layer and with
in the granule cell layer. They r eceive excitatory inputs from
parallel fibers and mossy fibers. The Golgi cells send their
axons back to the granule cells, which they inhibit.
G ray
matter
TABLE 7-4 Excitatory and Inhibitory Effects.
Excitation Inhibition
Mossy fi bers --7 gran ule cell Basket cel l --7 Purkinje cel l
body
Ol ive (via climbing fibers) --7 Stel late cell --7 Purkinje cel l
Purkinje cel l dend rite
Gra n u l e cel l --7 Pu rkinje cel l Purkinje cel l --7 roof nuclei
(including dentate)
Granule cel l --7 Golgi cell Pu rkinje cell --7 lateral FIGURE 7-1 7 Photomicrog ra ph of a portion of the cerebe l l u m .
vestibular nuclei Each l o b u l e contains a core o f wh ite matter and a cortex consisting
Gra n u l e cel l --7 basket cel l Pu rkinje cell --7 Purkinje cel ls of t h ree layers-gra n u l a r, Purkinje, and molecu lar-of g ray matter.
H&E stain, X 28. (Reproduced, with permission, from Junqueira LC, Carneiro J ,
Gra n u l e cel l --7 stellate cell Pu rkinje cell --7 Golgi cells
Kelley RO: Basic Histology, 8th ed. Appl eton & Lange, 1 995.)
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CHAPTER 7 The Brain Stem and Cerebellum 95
Pu rkinje cel l
Granule
cells
Granule
cel l layer
G o l g i cell
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96 SECTION IV Anatomy of the Brain
nucleus and other deep cerebellar nuclei modulates activity in cause cerebe l l a r dysfu nction a nd, i f large, m a y b e accompa
the contralateral motor cortex. This crossed connection, to the nied by edema that, again, can compress the fou rth ventri
contralateral motor cortex, helps to explain why each cerebel cle, thus producing hyd rocephal us. A n u m ber of meta bolic
lar hemisphere regulates coordination and muscle tone on the d i sorders (especia lly those i nvo lving abnormal meta bolism
ipsilateral side of the body. of a m i n o acids, a m m o n i a , pyruvate, and lactate) and de
generative diseases (including the olivopontocerebellar
In addition, neurons in the fastigial nucleus proj ect via
the inferior cerebellar peduncle to the vestibular nuclei bilat atrophies) can a l so cause cerebel l a r degeneration.
A 43-yea r-old woman com plained of g rad u a l ly i n creasing oc w a s asked t o rapidly supinate, t h e n pronate, t h e n supinate the
cipital h eadaches. She was righthanded and was not s u re, but hand) and left lower extremity (when she attempted to tap the
thought that her left hand might have been less facile when floor rapidly with her left foot).
knitting. She had fa l len a few ti mes, to the left side. I m a g i n g revealed a g l i o m a i nvolving the left cerebe l l a r
Examination was normal except for signs of cerebel lar dys hemisphere.
fu nction. She displayed an intention tremor on the left side, and This case i l l u strates that, in contrast to the cerebral cortex
coordi nation of movements of the left u pper and lower extremi which controls movement on the contralateral side of the body,
ties was poor. The patient did poorly when atte m pti ng ra pid cerebe l l ar lesions affect m ovement on the ipsilateral side of the
alternating movements of the left u pper extremity (eg, when she body.
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CHAPTER 7 The Brain Stem and Cerebellum 97
Ventrolateral
nucleus of
thalamus
nuclei:
Dentate Cerebellar cortex
Globose
Emboliform
Fastigial
Inferior olivary
Dorsal spinocerebellar tract
nucleus
Ventral
spi nocerebellar
FIGURE 7-2 1 Schematic i l l u stration of some
tract
cerebe l l a r afferents and outflow pathways.
FIGURE 7-22 Mag netic resonance i mages showing tumor (med u l loblastoma), shown by wh ite arrow, originating from m i d l i n e cerebel lar
structu res, i n a 29-year-old m a n who had experienced headaches upon awakening f or a month. On exa m i nation, he was unable t o ta ndem wa l k
d u e t o cerebellar dysfu nction, a n d h i s deep t endon stretch reflexes were brisk, probably d u e t o compression o f t h e corticosp i n a l tracts within
the bra i n stem. As a result of p rom pt diagnosis, there was com p l ete r ecovery after craniospinal irradiation and chemotherapy. (Courtesy o f Joach im
M. Baehring, MD, DSc, Yale U n iversity School of Medicine.)
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98 SECTION IV Anatomy of the Brain
C A S E 7
FIGURE 7-23 Mag netic resonance image of a coronal sectio n eral gaze, and mild weakness of the left central facial
through the h e a d at the l eve l o f the f o u rth ventricle. muscles. All other muscles had normal strength. The
deep tendon reflexes were normal on the right and live
lier on the left, and there was a left extensor plantar re
C A S E 6 sponse. The sensory system was unremarkable.
The patient was admitted to the hospita1 4 months later
A 60-year-old technician with a history of hypertension because he noticed difficulty in walking and his speech
had a sudden onset of double vision and dizzines s . had become thickened. Neurologic examination showed
Three days later ( 1 day before admission), she noticed the following additional findings: wide-based ataxic gait,
a sudden drooping of her right eyelid. minor slurring of speech, bilateral tremor in the finger-to
Neurologic examination showed unequal pupils (right nose test, and disorganization of rapid alternating move
smaller than left, both responding to light and accommo ments. A computed tomography scan was within normal
dation), ptosis of the right eyelid, mild enophthalmos and limits, but magnetic resonance imaging revealed numer
decreased sweating on the right side of the face, and nys ous lesions. Lumbar puncture showed 56-mg protein with
tagmus on left lateral gaze. The corneal reflex was dimin a relatively increased level of gamma globulin, and elec
ished on the right but normal on the left. Although pain trophoresis showed several oligoclonal bands in the CSF.
sensation was decreased on the right side of the face, All other CSF findings were normal. Treatment with b-in
touch sensation was normal; there was minor right pe terferon was begun.
ripheral facial weakness. The uvula deviated to the left, What is the differential diagnosis?
and mild hoarseness was noted. Muscle strength was in Cases are discussed further in Chapter 25 .
tact, but the patient could not execute a right finger-to
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was an intention tremor of the right arm, and further ex
amination revealed ataxia in the right lower extremity. Chan-Palay V: Cerebellar Dentate Nucleus: Organization, Cytology
and Transmitters. Springer-Verlag, 1 977.
All reflexes were normal. Pain sensation was decreased
DeArmand SJ: Structure of the Human Brain: A Photographic Atlas,
on the left side of the body; senses of touch, vibration, 3rd ed. Oxford Univ Press, 1989.
and position were intact. DeZeeuw C, Cicirata F (editors): Creating Coordination in the Cere
What is the differential diagnosis? What is the most bellum. Elsevier, 2004.
Ito M: The Cerebellum and Motor Control. Raven, 1 984.
likely diagnosis?
Montemurro DG, Bruni JE: The Human Brain in Dissection. WB
Saunders, 1 98 1 .
Raymond JL, Lisberger SG, Mauk MD: The cerebellum: A neuronal
learning machine? Science 1 996;272:1 126.
Riley HA: An Atlas of the Basal Ganglia, Brain Stem and Spinal
Cord. Williams & Wilkins, 1 943.
Wall M: Brain stem syndromes. In: Neurology in Clinical Practice,
2nd ed. Bradley WG, Daroff RB, Fenichel GM, Marsden CD
(editors). Butterworth-Heinemann, 1 996.
Welsh JP, Lang JP, Sugihara I, Llinas R: Dynamic organization of motor
control within the olivocerebellar system. Nature 1995;374:453.
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C H A P T E R
Cranial nerve fibers with motor (efferent) functions arise cles of the heart, lung, and bowel that are involved in
from collections of cells (motor nuclei) that lie deep within the movement and secretion; see Chapter 20) .
brain stem; they are homologous to the anterior horn cells of (4) Visceral afferent fibers, also called general visceral affer
the spinal cord. Cranial nerve fibers with sensory (afferent) ent fibers, convey sensation from the alimentary tract,
functions have their cells of origin (first-order nuclei) outside heart, vessels, and lungs by way of nerves IX and X. A spe
the brain stem, usually in ganglia that are homologous to the cialized visceral afferent component is involved with the
dorsal root ganglia of the spinal nerves. Second-order s ensory sense of taste; fibers carrying gustatory impulses are pres
nuclei lie within the brain stem (see Chapter 7 and Fig 7-6). ent in cranial nerves VII, IX, and X.
Table 8 - 1 presents an overview of the cranial nerves. This
(5) Somatic afferent fibers , often called general somatic
table does not list the cranial nerves numerically; rather, i t
afferent fibers, convey sensation from the skin and the
groups them functionally:
mucous membranes of the head. They are found mainly in
• Nerves I, II, and VIII are devoted to special sensory input. the trigeminal nerve (V) . A small number of afferent
• Nerves Ill, IV, and VI control eye movements and pupil fibers travel with the facial (VII), glossopharyngeal (IX),
lary constriction. and vagus (X) nerves; these fibers terminate on trigeminal
• Nerves XI and XII are pure motor (XI: sternocleidomastoid nuclei in the brain stem.
and trapezius; XII: muscles of tongue).
• Nerves V, VII, IX, and X are mixed.
• Note that nerves III, VII, IX, and X carry parasympathet
ic fibers.
-..-..:�,.....-l:- Trigeminal
A cranial nerve can have one or more functions (as shown in
ganglion
Table 8-1 ) . The functional components are conveyed from or to
the brain stem by six types of nerve fibers: t!�S,�;:-ij- Cerebello-
IX pontine
( 1 ) Somatic efferent fibers, also called general somatic effer
x angle
ent fibers, innervate striated muscles that are derived from
XI
somites and are involved in eye (nerves III, IV, and VI) XII
and tongue (nerve XII) movements.
(2) Branchial efferent fibers , also known as special visceral
efferent fibers, are special somatic efferent components. FIGURE 8-1 Ventral view of the brain stem with cra n i a l nerves.
99
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-
0 TAB L E 8-1 Overview o f Cranial Nerves.
0
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VII Facial BE Muscles of facial Facial nucleus
express ion,
platysma,
stapedius
VA Taste, anterior Geniculate Projects to sol itary
2/3 of tongue ganglion tract and n ucleus,
(via chorda then to thalamus
tym pani) (VPM)
VE Submandibular, Su perior
sublingual, salivatory
lacrimal glands nucleus
(via nervus
intermedius)
IX Glossopharyngeal VE Parotid gland I nferior
salivatory
nucleus
VA General sensation I nferior (petrosal) Projects to solitary
from posterior and superior tract and nucleus
1 /3 of tongue, glossopharyngeal
soft palate, ganglia
auditory tube.
Sensory input
from carotid
bodies and sinus.
Taste from
posterior 1 /3 of
tongue
BE Stylopharyngeus Ambiguus
muscle nucleus
X Vag us BE Soft palate Ambiguus
and pharynx nucleus
VE Autonomic Dorsal motor
control of nucleus
thoracic and
abdominal viscera
SA External auditory Superior (j ugular) Projects to
ganglion thalamus (VPM)
meatus
VA Sensation from I nferior vagal Projects to solitary
abdominal and (nodose) and tract and nucleus
thoracic viscera superior ganglia
*
Efferent (motor) Afferent (sensory)
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1 02 SECTION IV Anatomy of the Brain
(6) Special sensory fibers are found in nerves I (involved in bulb within the cranial cavity (Fig 8-2; see also Chapter 19).
smell), II (vision) , and VIII (hearing and equilibrium). There are 9 to 1 5 of these nerves on each side of t he brain. The
olfactory bulb lies just above the cribriform plate and below
the frontal lobe (nestled within the olfactory sulcus ). Axons
Differences Between Cra n i a l
from the olfactory bulb run within the olfactory stalk,
and Spinal Nerves synapse in the anterior olfactory nucleus , and terminate in
Unlike the spinal nerves, cranial nerves are not spaced at r eg the primary olfactory cortex (pyriform cortex) as well as the
ular intervals. They differ in other aspects as well: The spinal entorhinal cortex and amygdala.
nerves, for example, contain neither branchial efferent nor
special sensory components. Some cranial nerves contain mo
tor components only (most motor nerves have at least a few Cra n i a l Nerve I I : Optic N erve
proprioceptive fibers), and some contain large visceral com The optic nerve contains myelinated axons that arise from the
ponents. Other cranial nerves are completely or mostly sen ganglion cells in the retina. As noted above, axons within t he
sory, and still others are mixed, with both types of compo optic nerve are myelinated by oligodendrocytes. The optic nerve
nents. The motor and sensory axons of mixed cranial nerves passes through the optic papilla to the orbit, where it is con
enter and exit at the same point on the brain stem. This point tained within meningeal sheaths. The nerve changes its name to
is ventral or ventrolateral except for nerve IV, which exits from optic tract when the fibers have passed through the optic chiasm
the dorsal surface (see Fig 8 - 1 ) . (Fig 8-3). Optic tract axons project to the superior colliculus
The optic nerve is unique i n that it connects the retina and to the lateral geniculate nucleus within the thalamus, which
(which some nerves scientists consider a specialized outpost relays visual information to the cortex (see Chapter 15).
of the brain) with the brain. The optic nerve is essentially a
white matter tract that connects the retina to the brain. Ax:ons
within the optic nerve are myelinated by oligodendrocytes, in Cra n i a l Nerve I l l : Ocu lomotor Nerve
contrast to axons within peripheral nerves that are myelinated Cranial nerves III, IV, and VI work together to control eye
by Schwann cells. movements and are therefore discussed together. In addition,
cranial nerve III controls pupillary constriction.
The oculomotor nerve (cranial nerve III) contains axons
Ganglia Related to Cra n i a l Nerves that arise in the oculomotor nucleus (which innervates all of
Two types of ganglia are related to cranial nerves. The fust the oculomotor muscles except the superior oblique and lat
type contains cell bodies of afferent (somatic or visceral) ax eral rectus) and the nearby Edinger-Westphal nucleus (which
ons within the cranial nerves. (These ganglia are somewhat sends preganglionic parasympathetic axons to the ciliary gan
analogous to the dorsal root ganglia that contain the cell bod glion). The oculomotor nerve leaves the brain on the medial
ies of sensory axons within peripheral nerves.) The second side of the cerebral peduncle, behind the posterior cerebral ar
type contains the synaptic terminals of visceral efferent axons, tery and in front of the superior cerebellar artery. It then
together with postsynaptic (parasympathetic) neurons that passes anteriorly, parallel to the internal carotid artery in the
project peripherally (Table 8-2). lateral wall of the cavernous sinus, leaving the cranial cavity by
Sensory ganglia of the cranial nerves include the semilu way of the superior orbital fissure.
nar (gasserian) ganglion (nerve V), geniculate ganglion The somatic efferent portion of the nerve innervates the
(nerve VII), cochlear and vestibular ganglia (nerve VIII), in levator palpebrae superioris muscle; the superior, medial,
ferior and superior glossopharyngeal ganglia (nerve IX), su and inferior rectus muscles; and the inferior oblique mus
perior vagal ganglion (nerve X), and inferior vagal (nodose) cle (Fig 8-4) . The visceral efferent portion innervates two
ganglion (nerve X). smooth intraocular muscles: the ciliary and the constrictor
The ganglia of the cranial parasympathetic division of the pupillae.
autonomic nervous system are the ciliary ganglion (nerve III),
the pterygopalatine and submandibular ganglia (VIII), otic
ganglion (IX), and intramural ganglion (X). The first four of CLI N I CAL CORRELATIONS
these ganglia have a close association with branches of V; the
trigeminal branches may course through the autonomic ganglia. Anosmia (absence o f the sense o f s m e l l ) can res ult from d is
o rders (eg, viral infecti o n s, such as the co m m o n cold) i n
vo l v i n g the n a s a l m ucosa. The t i ny o l factory ne rves a n d
ANATOMIC RELATIONSHI PS b u l bs can be i nj u red as a res ult o f h e a d traum a. T h e location
of the o lfactory b u l b and sta l k, below the frontal lobe, pre
OF THE CRANIAL NERVES
d i s poses them to com pression fro m fro ntal l o b e t u m o rs
Cra n i a l Nerve 1: Olfactory Nerve and olfactory groove men i ng iomas.
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CHAPTER 8 Cranial Nerves and Pathways 103
Cra n i a l Nerve IV: Troch lear Nerve Cra n i a l Nerve VI: Abducens Nerve
The trochlear nerve is the only crossed cranial nerve. It orig A. Anatomy
inates from the trochlear nucleus, which is a group of spe The abducens nerve arises from neurons of the abducens nu
cialized motor neurons located j ust caudal to (and actually cleus located within the dorsomedial tegmentum within the
constituting a subnucleus of) the oculomotor nucleus within caudal pons. These axons proj ect through the body of the
the lower midbrain. Trochlear nerve axons arise from t hese pons and leave it as the abducens nerve. This nerve emerges
neurons, cross within the midbrain, and then emerge con from the pontomedullary fissure, passes through the cav
tralaterally on the dorsal surface of the brain stem. The ernous sinus close to the internal carotid, and exits from the
trochlear nerve then curves ventrally between the posterior cranial cavity via the superior orbital fissure. Its long intracra
cerebral and superior cerebellar arteries (lateral to the ocu nial course makes it vulnerable to pathologic processes in the
lomotor nerve). It continues anteriorly in the lateral wall of posterior and middle cranial fossae. The nerve innervates the
the cavernous sinus and enters the orbit via the superior or lateral rectus muscle (see Fig 8-4).
bital fissure. It innervates the superior oblique muscle (see A few sensory (proprioceptive) fibers from the muscles
Fig 8-4). of the eye are present in nerves III, IV, and VI and in some
Note: B ecause nerves III, IV, and VI are generally other nerves that innervate striated muscles. The central
grouped together for discussion, nerve V is discussed after
nerve VI.
nerves
Nasal
conchae
Hard palate FIGURE 8-3 Horizontal section through the head at the l evel of
the orbits.
FIGURE 8-2 Latera l view of the olfactory b u l b, tract, m ucous
membra ne, and nerves.
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1 04 SECTION IV Anatomy of the Brain
Abducens
nucleus
To striated
(extraocular) muscles VI
Levator
palpebrae Nerves
Superior rectus
Medial rectus
Constrictor pupillae
termination of these fibers is in the mesencephalic nucleus C. Control of Ocu lar Muscle Movements
of V (see Chapter 7 and Fig 7-8) . The oculomotor system activates the various extraocular mus
cles in a highly coordinated manner (Fig 8-6) . When the eyes
B. Action of the External Eye Muscles scan the environment, they do so in short, rapid movements
The actions of eye muscles operating singly and in t andem are called saccades. When a target moves, a different form of oc
shown in Tables 8-3 and 8-4 (Fig 8-5). The levator palpebrae ular movement-smooth pursuit-is used to keep the image
superioris muscle has no action on the eyeball but lifts the up in sharp focus. When the head or body moves unexpectedly
per eyelid when contracted. Closing the eyelids is performed
by contraction of the orbicular muscle of the eye; this muscle
is innervated by nerve VII. TAB L E 8-4 Yoke Muscle Combi nations.
Cardinal
Direction of Gaze Yoke Muscles
TABLE 8-3 Functions of the Ocular Muscles.
Eyes u p, right Right s u perior rectus and left i nferior
Muscle Primary Action Secondary Action oblique
I nferior rectus Depression Adduction, extorsion Eyes down, left Right s u perior oblique and l eft inferior
rectus
Superior oblique Depression I ntorsion, abduction
Eyes left Right medial rectus and left lateral
I nferior oblique Elevation Extorsion, abd uction rectus
Reproduced, with permission, from Vaughan D, Asbury T, Riordan-Eva P: General Eyes u p, left Right i nferior oblique and left superior
Ophthalmology, 7 7th ed. Appleton & Lange, 2008. rectus
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CHAPTER 8 Cranial Nerves and Pathways 105
Medial
rectus
Lateral
rectus ._-+--� 1---1-..... • ++---1 Lateral
I---+-_. rectus
R i ght Left
(eg, when one is j olted) , reflex movements of the head and eye which requires a different set of muscles, including the in
muscles compensate and maintain fixation on the visual tar traocular muscles. Each of the extraocular muscles is brought
get. This compensatory function is achieved by the vestibula into play in conjugate gaze movements or vergence.
ocular reflex (see Chapter 17).
The six individual muscles that move one eye normally 1. Gaze and vergence centers-Conjugate gaze and ver
act together with the muscles of the other eye in controlled gence are controlled from three areas in the brain stem. There
movement. Both eyes move in the same direction to follow an are two lateral gaze centers in the paramedian pontine retic
object in space, but they move by simultaneously contracting ular formation near the left and right abducens nuclei and a
and relaxing different muscles; this is called a conjugate gaze vergence center in the pretectum just above the superior col
movement. Fixating on a single point is called vergence, liculi. Each of these three areas can be activated during head
movement by the vestibular system via t he medial longitudi
�
nal fasciculus (see Chapter 1 7) . Activation of t he lateral gaze
center on the right produces conjugate gaze to t he right and
vice versa. Regions in the contralateral frontal lobe (the eye
� -Mio field area) influence voluntary eye movements via polysynap
system tic connections to the lateral gaze centers, whereas regions in
5
�
the occipital lobe influence visual pursuit and also have con
0 nections with the vergence center (Fig 8-7) .
Activity in each of the lateral gaze centers (located in t he
'Rf
20 Smooth
paramedian pontine reticular formation on each side, adj a
�
pursuit
system cent to the abducens nuclei) controls eye movements to the ip
Q)
5 silateral side. Thus, the lateral gaze center on the right is con
5 ��
i
� ________
0
nected, via excitatory proj ections, to the right abducens
[ 1
Convergence
system
nucleus that activates the lateral rectus muscle responsible for
abduction of the right eye. The right -sided lateral gaze center
also sends projections, via the medial longitudinal fasciculus,
�
w
0 1 to the contralateral (left-sided) oculomotor nucleus, where
they form excitatory synapses on oculomotor neurons inner
v'"' '"'"
vating the medial rectus muscle. (This muscle is responsible
20
system for movement of the left eye across the midline to the right.)
5
As a result of this arrangement, activation of t he right-sided
lateral gaze center results in movement of both eyes to the
0
right (see Fig 8-7) .
Time (seconds)
This arrangement also provides an anatomic basis for re
FIGURE 8-6 Types of eye movement control. (Modified and repro· flexes involving eye movements, such as the vestibula-ocular
duced, with permission, from Robinson DA: Eye movement control i n primates. reflex. Sudden rotation of the head to the left results in move
Science 1 968; 1 6 1 : 1 2 1 9. Copyright © 1 968 by the American Association for the ment of endolymph within the semicircular canals, whose
Advancement of Science.) neurons project to the vestibular nuclei (see Fig 8-7) . These
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1 06 SECTION IV Anatomy of the Brain
Left frontal
eye field Volu ntary gaze
to right
R
Abducens (VI)
nerve
Abducens (VI)
nucleus
FIGURE 8-7 B ra i n circu itry contro l l i n g right conj ugate gaze. The command for vol u ntary conjugate movements i n right latera l gaze origi
nates i n the frontal eye fields in the left fronta l lobe. This com mand excites a latera l gaze control center, adjacent to the abducens nucleus,
within the pa ramedian pontine reticular formation on the right side. This, in turn, activates the abducens nucleus on the rig ht, turning the right
eye to the rig ht, and projects via the med i a n longitud i n a l fascic u l u s to the ocu lomotor nucleus o n the left, which turns the left eye t o the rig ht.
(Reprod uced, with permission, from Ami noff ML, Green berg DA, Simon RP: Clinical Neurology, 6th ed. McGraw-Hill, 2005.)
nuclei, in turn, send excitatory projections via the medial lon The pathways for the reflex include optic nerve fibers (or their
gitudinal fasciculus to the right-sided lateral gaze center (and collaterals) to the pretectum, a nuclear area between thalamus
also send inhibitory projections to the left-sided lateral gaze and midbrain (Fig 8-9). Short fibers go from the pretectum to
center) . Increased activity in the right-sided lateral gaze cen both Edinger-Westphal nuclei (the visceral components of t he
ter triggers eye movements to the right, stabilizing the image oculomotor nuclei) by way of the posterior commissure and to
on the retina. both ciliary ganglia by way of the oculomotor nerves. Postgan
2. Control of pupillary size- The diameter of the pupil is af glionic parasympathetic fibers to the constrictor muscles are ac
fected by parasympathetic efferent fibers in the oculomotor tivated, and the sympathetic nerves of the dilator muscle are in
nerve and sympathetic fibers from the superior cervical gan hibited. The interaction between these components of the
glion (Fig 8-8). Constriction (miosis) of the pupil is caused autonomic nervous system can be used to localize a lesion in the
by the stimulation of parasympathetic fibers, whereas dilation reflex pathways.
(mydriasis) is caused by sympathetic activation. Both pupils The accommodation reflex involves pathways from the
are normally affected simultaneously by one or more of such visual cortex in the occipital lobe to the pretectum. From here,
causes as emotion, pain, drugs, and changes in light intensity fibers to all nuclei of nerves III, IV, and VI cause vergence of
and accommodation. the extraocular muscles as well as parasympathetic activation
3. Reflexes-The pupillary light reflex is a constriction ofboth
of the constrictor and ciliary muscles within each eye.
eyes in response to a bright light. Even if the light hits only one
eye, both pupils usually constrict; this is a consensual response.
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CHAPTER 8 Cranial Nerves and Pathways 107
Constrictor pupi l l ae
and ciliary muscles
Ciliary
ganglion
I
Ill
Retina
ganglion
cel l
Superior cervical
(sympathetic) ganglion
Oculomotor
FIGURE 8-8 I n nervation of the eye. nucleus
I nferior oblique Ill Downward and outward U pward and i nward Oblique
* Diplopia is noted only when the affected eye attempts these movements.
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108 SECTION IV Anatomy of the Brain
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CHAPTER 8 Cranial Nerves and Pathways 1 09
--
Supraorbital nerve
Frontal branch
of frontal nerve
Supratrochlear nerve Anterior ethmoidal nerve Main sensory
Posterior ethmoidal nerve
nucleus of V
V,
N asoci liary nerve
Main motor
l nfratrochlear nerve nucleus of V
Ciliary ganglion
Nucleus of
spinal tract of V
rami
Infraorbital nerve
External nasal
t---+--- Anterior and posterior
rami
deep temporal nerves
Nasal and labial __ ,;...__.
.. __.; (to temporal muscle)
rami of infraorbital
nerve
Au ricu lotemporal nerve
Anterior superior
External pterygoid muscle
alveolar nerves
Chorda tympani nerve
Internal pterygoid muscle
Submaxillary
ganglion
Submaxillary and
sublingual g lands
Ophthalmic division
Ophthalmic ----+- Area of skin labeled i n Figure 8- 1 2
division Cornea, conjunctiva, and i ntraocu lar structures (the sclera is
innervated by fibers of the anterior branches of the ciliary plexus)
M ucosa of paranasal sin uses (frontal, sphenoid, and ethmoid)
M ucosa of u pper and a nterior nasal septum and latera l wal l of nasal
cavity
Lacrimal duct
Maxillary division
Area of skin labeled i n Figure 8- 1 2
Maxi llary --"' M ucosa of maxi l l a ry sinus
division M ucosa of posterior part of nasal septum and lower part of nasal
cavity
Upper teeth and gum
Hard palate
Mandibular
Soft palate and tonsil (via sphenopalatine ganglion, g reater petrosal
division
nerve, and nervus i ntermedius)
Mandibular division
Area of skin labeled i n Figure 8- 1 2
M ucosa of the cheek, lower jaw, floor of the mouth, t ongue
Proprioception from jaw muscles
FIGURE 8-1 2 S e n s ory d istri bution of n e rve V. Lower teeth and g u m
Mastoid cel l s
M uscles o f mastication
Modified from Haymaker W: Bing's Local Diagnosis in Neurological Disease, 75th ed.
CV Mosby, 7 969.
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l lO SECTION IV Anatomy of the Brain
Because the spinal tract of V is located near the lateral Cra n ia l Nerve VI I : Facial Nerve
spinothalamic tract in the medulla and lower pons, laterally
A. Anatomy
placed lesions at these levels produce a crossed picture of pain
and temperature insensibility on the ipsi lateral face and on the The facial nerve consists of the facial nerve proper and the
contra lateral side of the body below the face. This occurs, for nervus intermedius (Fig 8 - 1 3 ) . Both parts pass through the
example, in Wallenberg's syndrome , in which there is dam internal auditory meatus, where the geniculate ganglion for
age to the lateral medulla, usually because of occlusion of the the taste component lies. The facial nerve proper contains ax
posterior inferior cerebellar artery. ons that arise in the facial (VII) nucleus. The nerve exits
Trigeminal neuralgia is characterized by attacks of se through the stylomastoid foramen; it innervates the muscles
vere pain in the distribution of one or more branches of the of facial expression, the platysma muscle, and the stapedius
trigeminal nerve. Although the cause is not always clear, it is muscle in the inner ear.
known that excruciating paroxysmal pain of short duration The nervus intermedius sends parasympathetic pregan
can be caused by pressure from a small vessel on the root en glionic fibers to the pterygopalatine ganglion to innervate
try zone of the nerve. Trigeminal neuralgia is also seen in the lacrimal gland and, via the chorda tympani nerve to the
some patients with multiple sclerosis. Pain may follow even submaxillary and sublingual ganglia in the mouth, to inner
gentle stimulation of a trigger zone, a point on the lip, face, or vate the salivary glands.
tongue that is sensitive to cold or pressure. Involvement is The visceral afferent component of the nervus inter
usually unilateral. Carbamazepine can be helpful in alleviating medius, with cell bodies in the geniculate ganglion, carries
the pain of trigeminal neuralgia. taste sensation from the anterior two-thirds of the tongue via
the chorda tympani to the solitary tract and nucleus. The so
matic afferent fibers from the skin of the external ear are car
ried in the facial nerve to the brain stem. These fibers connect
Nervus i ntermed i u s
Frontal is muscle
\ (Branchial efferent)
Nucleus of
sol itary tract
Zygomatic branch
'
Obicularis oris occipital is muscle
Cervicofacial branch
1'
/
...
Mootall' /______.-.,
Motor nerve
Platysma muscle ---- Sensory nerve
Parasympathetic nerve
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CHAPTER 8 Cranial Nerves and Pathways 111
there to the trigeminal nuclei and are, in fact, part of the eyelids, the eyeball on the affected side may turn upward
trigeminal sensory system. (Bell's phenomenon; Fig 8-14).
The superior salivatory nucleus receives cortical impulses The symptoms and signs depend on the location of the le
from the nucleus of the solitary tract via the dorsal longitudi sion. A lesion in or outside the stylomastoid foramen results
nal fasciculus and reflex connections. Visceral efferent axons in flaccid paralysis (lower-motor-neuron type) of all the mus
run from the superior salivatory nucleus via nerve VII to the cles of facial expression in the affected side; t his can occur
pterygopalatine and submandibular ganglia. They synapse from a stab wound or from swelling of the parotid gland ( eg,
there with postganglionic parasympathetic neurons that in as seen in mumps) . A lesion in the facial canal involving the
nervate the submandibular and sublingual salivary glands. chorda tympani nerve results in reduced salivation and loss of
The taste fibers run through the chorda tympani and taste sensation from the ipsilateral anterior two-thirds of t he
nervus intermedius to the solitary nucleus, which is con tongue. A lesion higher up in the canal can paralyze the
nected with the cerebral cortex through the medial lemnisci stapedius muscle. A lesion in the middle ear involves all com
and the VPM nucleus of the thalamus and with the salivatory ponents of nerve VII, whereas a tumor in the internal auditory
nucleus and motor nucleus of VII by reflex neurons. The cor canal ( eg, a schwannoma) can cause dysfunction of nerves VII
tical taste area is located in the inferior central (face) region; it and VIII. (Lesions in and near the brain stem are discussed in
extends onto the opercular surface of the parietal lobe and ad Chapter 7.)
jacent insular cortex.
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1 12 SECTION IV Anatomy of the Brain
the vestibular nerve is part of t he system of equilibrium (posi Cra n i a l N erve X: Vag u s N e rve
tion sense) . The functional anatomy of the auditory system
A. Anatomy
(and its clinical correlations) is discussed in Chapter 16; t he
Branchial efferent fibers from the ambiguus nucleus con
vestibular system is discussed in Chapter 17.
tribute rootlets to the vagus nerve and the cranial compo
nent of the accessory nerve (XI ) . Those of the vagus nerve
Cra n i a l N erve IX: G l ossopharyngeal Nerve pass to the muscles of the soft palate and pharynx
A. Anatomy (Fig 8 - 1 9 ) . Those of the accessory nerve j oin the vagus out
side the skull and pass, via t he recurrent laryngeal nerve, to
Cranial nerve IX contains several types of fibers (Fig 8 - 1 6) .
the intrinsic muscles of t he larynx.
Branchial efferent fibers from the ambiguus nucleus pass to
Visceral efferent fibers from the dorsal motor nucleus of
the stylopharyngeal muscle.
the vagus course to the thoracic and abdominal viscera. Their
Visceral efferent (parasympathetic preganglionic) fibers
postganglionic fibers arise in the terminal ganglia within or
from the inferior salivatory nucleus pass through the tym .
near the viscera. They inhibit heart rate and adrenal s ecretion
panic plexus and lesser petrosal nerve to the otic ganglion,
and stimulate gastrointestinal peristalsis and gastric, hepatic,
from which the postganglionic fibers pass to the parotid
and pancreatic glandular activity (see Chapter 20).
gland. The inferior salivatory nucleus receives cortical im
Somatic afferent fibers of unipolar cells in the superior
pulses via the dorsal longitudinal fasciculus and reflexes from
(formerly called the jugular) ganglion send peripheral
the nucleus of the solitary tract.
branches via the auricular branch of nerve X to the external
Visceral afferent fibers arise from unipolar cells in the in
auditory meatus and part of the earlobe. They also send pe
ferior (formerly petrosal) ganglia. Centrally, they terminate
ripheral branches via the recurrent meningeal branch to the
in the solitary tract and its nucleus, which in turn projects to
dura of the posterior fossa. Central branches pass with nerve
the thalamus (VPM nucleus) and t hen to the cortex. Peripher
X to the brain stem and end in the spinal tract of the trigemi
ally, the visceral afferent axons of nerve XI supply general sen
nal nerve and its nucleus.
sation to the pharynx, soft palate, posterior third of the
Visceral afferent fibers of unipolar cells in the inferior
tongue, fauces, tonsils, auditory tube, and tympanic cavity.
(formerly nodose) ganglion send peripheral branches to the
Through the sinus nerve, they supply special receptors in the
pharynx, larynx, trachea, esophagus, and thoracic and ab
carotid body and carotid sinus that are concerned with r eflex
dominal viscera. They also send a few special afferent fibers to
control of respiration, blood pressure, and heart rate. Special
taste buds in the epiglottic region. Central branches run to the
visceral afferents supply the taste buds of the posterior third of
solitary tract and terminate in its nucleus. The visceral affer
the tongue and carry impulses via the superior ganglia to the
ent fibers of the vagus nerve carry the sensations of abdomi
gustatory nucleus of the brain stem. A few somatic afferent
nal distention and nausea and the impulses concerned with
fibers enter by way of the glossopharyngeal nerve and end in
regulating the depth of respiration and controlling blood pres
the trigeminal nuclei.
B. Clin ical Correlations Lesions of the vagus nerve may be intramedullary or periph
eral. Vagus nerve lesions near the skull base often involve the
The glossopharyngeal nerve is rarely involved alone by disease
glossopharyngeal and accessory nerves and s ometimes the hy
processes (eg, by neuralgia); it is generally involved with the
poglossal nerve as well. Complete bilateral transection of t he
vagus and accessory nerves because of its proximity to them.
The pharyngeal (gag) reflex depends on nerve IX for its sen
vagus nerve is fatal.
Unilateral lesions of the vagus nerve, within the cranial
sory component, whereas nerve X innervates the motor com
vault or close to the base of the skull, produce widespread dys
ponent. Stroking the affected side of the pharynx does not
function of the palate, pharynx, and larynx. The soft palate is
produce gagging if the nerve is injured. The carotid sinus re
flex depends on nerve IX for its sensory component. Pressure
weak and may be flaccid so the voice has a nasal twang. Weak
ness or paralysis of the vocal cord may result in hoarseness.
over the sinus normally produces slowing of the heart rate and
There can be difficulty in swallowing, and cardiac arrhyth
a fall in blood pressure.
mias may be present.
Damage to the recurrent laryngeal nerve , which arises
from the vagus, can occur as a result of invasion or compres
sion by tumor or as a complication of thyroid surgery. It may
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CHAPTER 8 Cranial Nerves and Pathways 113
Genicu lotympanic
nerve Pterygopalati ne
Inferior salivatory nucleus Facial G reat petrosal ganglion
(parasympathetic)
Ambiguus nucleus
(motor)
/:
branch of X
Carotid sinus
nerve
and nerve plexus
Stylopharyngeal muscle
.. . . . - · -
posterior third of tongue
FIGURE 8-1 6 The g l ossopharyngeal nerve. TP, tym panum plexus; FR, fora men rotundum; FO, foramen ova le.
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1 14 SECTION IV Anatomy of the Brain
Thalamus
(VPM nuclei)
Postcentral
gyrus
Medial
Nerve V I I
(via chorda
tympani, nervus
intermedius)
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CHAPTER 8 Cranial Nerves and Pathways l lS
Meningeal branch to
posterior fossa VII
Sensation to
lower pharynx
{
Trapezius muscle
Epiglottic and
Arytenoid, thyroarytenoid, lingual rami
and cricoarytenoid muscles
Cardiac plexus
Diaphragm
Left kidney
11 11 11 11 Sensory nerves
Parasympathetic nerves
Motor nerves
FIGURE 8-1 9 The vag u s nerve. J, jugular (superior) ganglion; N, n odose (inferior) ganglion.
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1 16 SECTION IV Anatomy of the Brain
C A S E 9
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CHAPTER 8 Cranial Nerves and Pathways 1 17
Styloglossus muscle
/ Vertical muscle of tongue
/ -::::.,_..,..- Superior longitudinal
_
muscle of tongue
--- Transverse muscle
of tongue
I nternal jugular vein
I nferior longitudinal
/
muscle of tongue
Descendens cervicalis
! _,...:.. \�
I To
�
hyoglossus
Gen ioglossus muscle
Descendens hypoglossi 1
muscle
n
Gen iohyoid muscle
, ... ...
......._ -,
I \
� ,' \\ \
- ..
Ansa hypoglossi , , Hyoid bone
\ I
\
Thyrohyoid muscle
I '
'
I
Posterior belly of '.., .-- Sternohyoid muscle
omohyoid muscle
-- Sternothyroid muscle
Anterior belly of omohyoid
Central connections of the hypoglossal nucleus include Lesions of the medulla produce characteristic symptoms
the corticobulbar (corticonuclear) motor system (with that are related to the involvement of the nuclei of the last four
crossed fibers, as shown in Fig 7-9), as well as reflex neurons cranial nerves that lie within the medulla and the motor and
from the sensory nuclei of the trigeminal nerve and the nu sensory pathways through it. Extramedullary lesions of the
cleus of the solitary tract (not shown). posterior fossa may involve the roots of the last four cranial
nerves between their emergence from the medulla and their
B. Clin ical Correlations exit from the skull.
Peripheral lesions that affect the hypoglossal nerve usually
come from mechanical causes. Nuclear and supranuclear
lesions can have many causes (eg, tumors, bleeding, demyeli
nation).
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l l8 SECTION IV Anatomy of the Brain
REFERENCES Harding AE, Deufel T (editors): The Inherited Ataxias. Raven, 1 994.
Horn AK, Leigh RJ: Anatomy and physiology of t he ocular motor
Bradley WG, Daroff RB, Fenichel GM, Marsden CD (editors): system. Handbook Clin Neural. 20 1 1 ; 1 02:21-69.
Neurology in Clinical Practice, 2nd ed. Butterworth Samii M, Jannetta PJ (editors): The Cranial Nerves. Springer-Verlag,
Heinemann, 1996. 1 98 1 .
DeZeeuw Cl, Strata P, Voogol J (editors): The Cerebellum: From Sears ES, Patton JG, Fernstermacher MJ: Diseases o f t he cranial
Structure to Control. Elsevier, 1 998. nerves and brain stem. In: Comprehensive Neurology.
Foley JM: The cranial mononeuropathies. N Engl ] Med 1 969; Rosenberg R (editor). Raven, 1991.
281 :905. Wilson-Pauwels L, Akesson EJ, Stewart PA, Spacey SD: Cranial
Hanson MR, Sweeney PJ: Disturbances of lower cranial nerves. I n: Nerves in Health and Disease, 2nd ed. BC Decker, 2002.
Neurology in Clinical Practice, 2nd ed. Bradley WG, Daroff RB,
Fenichel GM, Marsden CD (editors). Butterworth-Heinemann,
1 996.
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C H A P T E R
Diencep halon
The diencephalon includes the thalamus and its geniculate B. Nuclei of the Midline
bodies, the hypothalamus, the subthalamus, and the epithala These groups of cells are located j ust beneath the lining of the
mus (Fig 9- 1 ) . The third ventricle lies between the halves of third ventricle and in the interthalamic adhesion. They con
the diencephalon. The development of the diencephalon is re nect with the hypothalamus and central periaqueductal gray
viewed in Chapter 10 (see Figs 1 0- 1 , 1 0-3, and 1 0-4) . matter. The centromedian nucleus connects with the cerebel
A small groove on the lateral wall of the slim third lum and corpus striatum.
ventricle-the hypothalamic sulcus-separates the thalamus
dorsally and the hypothalamus and subthalamus inferiorly. C. Medial N uclei
These include most of the gray substance medial to the inter
nal medullary lamina: the intralaminar nuclei as well as the
THALAMUS dorsomedial nucleus, which projects to the frontal cortex.
1 19
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1 20 SECTION IV Anatomy of the Brain
Thalamus receives acoustic fibers from the lateral lemniscus and inferior
Roof of third
Fornix ventricle with colliculus. It projects fibers via the acoustic radiation to the
temporal cortex. The lateral geniculate nucleus is a major
way station along the visual pathway. I t receives most of the
fibers of the optic tract and projects via the geniculocalcarine
radiation to the visual cortex around the calcarine fissure. The
geniculate nuclei or bodies appear as oval elevations below the
posterior end of the thalamus (Fig 9-5).
Fu nctional Divisions
T h e thalamus can be divided into five functional nuclear
groups: sensory, motor, limbic, multimodal, and intralaminar
(see Table 9- 1 ) .
FIGURE 9- 1 M idsagitta l section through the d iencepha lon.
The sensory nuclei (ventral posterior group including
VPL and VPM, and the lateral and medial geniculate bodies)
are involved in relaying and modifying sensory signals from
(VPM) nucleus , which relays sensory input from the face. the body, face, retina, cochlea, and taste receptors (see Chap
The ventral posterior nuclei project information via the inter ter 14). The thalamus is thought to be the crucial structure for
nal capsule to the sensory cortex of the i psilateral cerebral the perception of some types of sensation, especially pain, and
hemisphere (see Chapter 10). the sensory cortex may give finer detail to the sensation.
The thalamic motor nuclei (ventral anterior and lateral)
E. Posterior Nuclei convey motor information from the cerebellum and globus
These include the pulvinar nucleus, the medial geniculate nu pallidus to the precentral motor cortex. The nuclei have also
cleus, and the lateral geniculate nucleus. The pulvinar nu been called motor relay nuclei (see Chapter 1 3 ) .
cleus is a large posterior nuclear group that connects with the Three anterior limbic nuclei are interposed between the
parietal and temporal cortices. The medial geniculate nu marnill ary nuclei of the hypothalamus and the cingulate gyrus
cleus, which lies lateral to the midbrain under the pulvinar, of the cerebral cortex. The dorsomedial nucleus receives input
�� \
Interventricular
foramen and
Lentiform
choroid plexus
nucleus
Stria
terminalis -...--�-
�·}.:%0::.&:...-r==---=::.-
... superior colliculus
Pulvinar (posterior and pi neal gland
thalamus)
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CHAPTER 9 Diencephalon 121
Internal with cortical motor areas, the caudate nucleus, the putamen,
Anterior medul lary and the cerebellum has been demonstrated.
nuclei lamina
HYPOTHALAMUS
La n d m a rks
Ventral
anterior The hypothalamus, which serves a number of autonomic, appet
nucleus itive, and regulatory functions, lies below and in front of the thal
amus; it forms the floor and lower walls of the third ventricle (see
nucleus Fig 9- 1 ) . External landmarks of the hypothalamus are the optic
chiasm; the tuber cinereum, with its infundibulum extending to
the posterior lobe of the hypophysis; and the mamillary bodies
Ventral Genicu late
nucleus lying between the cerebral peduncles (Fig 9-6).
posterolateral bodies
nuclei The hypothalamus can be divided into an anterior portion,
the chiasmatic region, including the lamina terminalis; the cen
FIGURE 9-3 Diagrams of the thalam us. Oblique latera l and me tral hypothalamus, including the tuber cinereum and the in
dial views. fundibulum (the stalk connecting the pituitary to the hypothal
amus); and the posterior portion, the mamillary area (Fig 9-7).
from the olfactory cortex and amygdala regions and projects The right and left sides of the hypothalamus each have a
reciprocally to the prefrontal cortex and the hypothalamus medial hypothalamic area that contains many nuclei and a
(see Chapter 19). lateral hypothalamic area that contains fiber systems ( eg, the
T h e multimodal nuclei (pulvinar, posterolateral, and medial forebrain bundle) and diffuse lateral nuclei.
dorsolateral) have connections with the association areas in
the parietal lobe (see Chapter 10). Other diencephalic r egions
may contribute to these connections. Med i a l Hypotha l a m i c N u clei
Other, nonspecific thalamic nuclei include the intralam Each half of the medial hypothalamus can be divided into
inar and reticular nuclei and the centrum medianum; the three parts (Fig 9-8) : the supraoptic portion, which is far
projections of these nuclei are not known in detail. I nteraction thest anterior and contains t he supraoptic, suprachiasmatic,
Lentiform ----+--
nucleus
nucleus
Hypothalamus Trigeminal
lemniscus
FIGURE 9-4 Schematic lateral view of the thalamus with afferent fi ber systems.
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1 22 SECTION IV Anatomy of the Brain
C L I N ICAL CORRELATIONS
and paraventricular nuclei; the tuberal portion, which lies FIGURE 9-5 Horizonta l section through the thalam u s.
immediately behind the supraoptic portion and contains the
ventromedial, dorsomedial, and arcuate nuclei in addition
to the median eminence; and the mamillary portion, which is thalamus from nuclei in the septal region, parolfactory area,
the farthest posterior and contains the posterior nucleus and and corpus striatum; thalamohypothalarnic fibers from the
several mamillary nuclei. There is also the preoptic area, a medial and midline thalamic nuclei; and the fornix, which
region that lies anterior to the hypothalamus, between t he op brings fibers from the hippocampus to the marnill ary bodies.
tic chiasm and the anterior commissure. These connections also include the stria terminalis, which
brings fibers from the amygdala; pallidohypothalamic fibers,
which lead from the lentiform nucleus to the ventromedial
Afferent Con nections hypothalamic nucleus; and the inferior marnillary peduncle,
Consistent with its autonomic and regulatory functions, the which sends fibers from the tegmentum of the midbrain. A
hypothalamus receives inputs from limbic structures, thalamus small number of ganglion cells from throughout the retina
and cortex, visceral and somatic afferents, and sensors such as (less than 1% of the total number of retinal ganglion cells) send
osmoreceptors, which permit it to monitor the circulation. axons that provide visual input to the suprachiasmatic nucleus
Afferent connections to the hypothalamus include part of via the retinohypothalamic tract. These and other connec
the medial forebrain bundle, which sends fibers to the hypo- tions are shown in Table 9-2.
Tuber cinereum
---7
Amygdala 1n cut su rface
'""'"""'
I nternal capsule
/ ' "' )
Pineal body
Thalam u s
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CHAPTER 9 Diencephalon 123
/
Lateral ventricle Corpus callosum Fornix
Caudate
/
;('--- Internal
nucleus
/
capsule
Globus
pallidus
basalis
Third ventricle
Hypothalamus
A B
A B C Fornix
Transverse fissure
(cistern of the
velum interpositum)
!)
commissu re
Mamillary body A B C
c D
FIGURE 9-7 Coronal sections through the d iencep halon and adjacent structu res. A: Section through the optic chiasm and the anterior
com m issure. B: Section through the tuber cinere u m and the anterior portion of the thalamus. C: Section through the m a m i l lary bodies and
middle thalamus. D : Key to the section levels.
Affective and emotional inputs from the prefrontal cortex There are rich connections between the hypothalamus
reach the hypothalamus via a polysynaptic pathway that and the pituitary gland. The pituitary has two maj or lobes: t he
passes through the dorsomedial nuclei of the thalamus. In ad posterior pituitary (neurohypophysis) and anterior pituitary
dition, visceral information from the vagal sensory nuclei, (adenohypophysis). Neurons in the supraoptic and paraven
gustatory messages from the nucleus solitarius, and somatic tricular nuclei send axons, via the hypothalamohypophyseal
afferent messages from the genitalia and nipples are relayed to tract, to the neurohypophysis. These axons transport Herring
the hypothalamus. bodies, which contain precursors of the hormones oxytocin
and vasopressin (also known as antidiuretic hormones, or
ADHs) to the posterior pituitary. Oxytocin and vasopressin
Efferent Con n ections are released from axon endings in the posterior pituitary and
Efferent tracts from the hypothalamus include the hypothala are then taken up by a rich network of vessels that transports
mohypophyseal tract, which runs from the supraoptic and them to the general circulation (Figs 9-8 and 9-9).
paraventricular nuclei to the neurohypophysis (see the next Neurons in other hypothalamic nuclei regulate the adeno
paragraph); the mamillotegmental tract (part of the medial hypophysis via the production of a group of hypophyseotropic
forebrain bundle) going to the tegmentum; and the mamil hormones that control the secretion of anterior pituitary hor
lothalamic tract (tract of Vicq d�) , from the mamillary mones (Fig 9-10). The hypophyseotropic hormones include
nuclei to the anterior thalamic nuclei. There are also the releasing factors and inhibitory hormones , which, respec
periventricular system, including the dorsal fasciculus to the tively, stimulate or inhibit the release of various anterior pitu
lower brain levels; the tuberohypophyseal tract, which goes itary hormones.
from the tuberal portion of the hypothalamus to the posterior Communication between the hypothalamus and adeno
pituitary; and fibers from the septal region, by way of the hypophysis involves a vascular circuit (the portal hypophy
fornix, to the hippocampus (see Chapter 1 9 ) . seal system) that carries hypophyseotropic hormones from
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1 24 SECTION IV Anatomy of the Brain
FIGURE 9-8 The h u m a n hypothalam us, with a superim posed diagram matic r ep resentation of the portal-hypophyseal vessels.
(Reprod uced, with permission, from Ganong WF: Review of Medical Physiology, 22nd ed. McGraw-Hill, 2005.)
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CHAPTER 9 Diencephalon 125
Medial forebrai n bundle A, E Connects l i m bic lobe and midbrain via lateral hypotha lamus, where fibers enter
and leave it; incl udes di rect amygdalohypothalamic fibers, which a re sometimes
referred to as a separate pathway
Mamil lary ped uncle A Connects bra i n stem to lateral mamil lary nuclei
Ventral noradrenergic bundle A Axon s of noradrenergic neurons projecti ng from nucleus of tractus solitarius and
ventrolatera l med u l l a to paraventricular nuclei and other parts of hypotha lamus
Dorsal noradrenergic bundle A Axon s of noradrenergic neurons projecti ng from locus ceruleus t o dorsal
hypothalamus
Serotonergic neurons A Axon s of serotonin-secreti ng neurons projecting from dorsal and other raphe
nuclei to hypothalamus
Retinohypothalamic fi bers A Optic nerve fi bers to suprachiasmatic nuclei from optic chiasm
Tha lamohypothalamic and A Connects thalamus and lenticu lar nucleus to hypothalamus
pal l idohypothalamic fibers
Periventricular system (including A, E I nterconnects hypotha lamus and midbrain; efferent projections to
dorsal longitudinal fasciculus of spinal cord, afferent from sensory pathways
Schutz)
Mamillothalamic tract of Vicq d'Azyr E Connects mamil lary nuclei to a nterior thalamic nuclei
Mamil lotegmental tract E Connects hypothalamus with reticular portions of mid brain
Hypothalamohypophysea l tract E Axon s of neurons i n supraoptic and paraventricular nuclei that end i n
(supraopticohypophyseal and median eminence, pitu itary stal k, and posterior pitu itary
paraventriculohypophyseal tracts)
Neurons containing vasopressin, E Run from paraventricular nucleus to nucleus of tractus sol itari us, other
oxytocin bra i n stem nuclei, i ntermed iolateral col u m n of spinal cord; also from para
ventricular nucleus to central nucleus of amygdala
Neurons containing hypophyseotropic E Run from va rious hypothalamic nuclei t o med ian eminence
hormones
stress, and certain emotional states also stimulate vasopressin sity changes that have a circadian (day-to-day) rhythm .
secretion. Lack of secretion of vasopressin caused by hypothal Within the hypothalamus, a specific cell group, t he suprachi
amic or pituitary lesions can result in diabetes insipidus, which asmatic nucleus, functions as an intrinsic clock. Within
is characterized by polyuria (increased urine excretion) and these cells, there are "clock genes;' including two genes called
polydipsia (increased thirst). clock and per, that turn on and off with a circadian, once
per-day; rhythm (Fig 9- 1 2 ) . Thus, cells within the suprachi
E. Anterior Pituitary Function asmatic nucleus show circadian rhythms in metabolic and
The hypothalamus exerts a direct influence on s ecretions of the electrical activity, and in neurotransmitter synthesis, and
anterior pituitary and an indirect influence on secretions of appear to keep the rest of the brain on a day-night cycle. A
other endocrine glands by releasing or inhibiting hormones retinosuprachiasmatic pathway carries information about t he
carried by the pituitary portal vessels (see Fig 9-9) . It thus reg light intensity and can "entrain'' the suprachiasmatic clock in
ulates many endocrine functions, including reproduction, sex order to synchronize its activity with environmental events
ual behavior, thyroid and adrenal cortex s ecretions, and growth. (eg, the light-dark day-night cycle) . In the absence of any
sensory input, the suprachiasmatic nucleus itself can function
F. Circadian Rhythm as an independent clock with a period of about 25 hours per
Many body functions ( eg, temperature, corticosteroid levels, cycle; lesions in this nucleus cause the loss of all circadian
oxygen consumption) are cyclically influenced by light inten- cycles.
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1 26 SECTION IV Anatomy of the Brain
SUBTHALAMUS
Lan d m a rks
The subthalamus is the zone of brain tissue that lies between
Portal vessels
the dorsal thalamus and the tegmentum of the midbrain. The
hypothalamus lies medial and rostral to the subthalamus; the
internal capsule lies lateral to it (see Fig 9-?C). The subthala
mic nucleus, or body of Luys, lies dorsolateral to the upper
end of the substantia nigra; it extends posteriorly as far as the
lateral aspect of the red nucleus.
Venous
channel
sin usoids Pituitary
gland Fiber Co n nections
The subthalamus receives fibers from the globus pallidus and
FIGURE 9-9 Schematic view of the pituitary portal system of projects back to it (see Chapter 1 3 ) ; the proj ections from the
vessel s and neurohypophysea l pathways. The porta l hypophysea l ves
globus pallidus to the subthalamic nucleus form part of the
sels serve as a vascu lar cond uit that carries various hypophyseotropic
efferent descending path from the corpus striatum. Fibers
hormones from their sites of release from hypothalamic neu rons, in
from the globus pallidus also occupy the fields of Forel,
the median eminence on the p itu ita ry sta l k, to the a nterior pituitary.
In contrast, the axons of supraoptic and paraventricu lar neu rons run
which lie anterior to the red nucleus and contain cells that
all the way to the posterior pituita ry, where they release vasopressin may be a rostral extension of reticular nuclei. The ventrome
and oxytocin. dial portion is usually designated as field H, the dorsomedial
Severa l c l i n i ca l problems related t o dysfu nction o f the hypo sipidus is cha racterized by polyuria (passage of l a rge amou nts
thalamus have been discussed p reviously in this cha pter. Le of d i l ute u rine) and polydipsia (the drinking of large amounts
sions in the hypotha l a m u s a re most often ca u sed by tum ors of fluids).
that a rise fro m either t h e hypot h a l a m u s itself (eg, g l ioma, The syndrome of inappropriate secretion of antidiuretic
h a m a rtoma, germinoma) o r adjacent structu res (eg, pitu itary hormone (SIADH) resu lts fro m i n a pp rop riate hypersecretion
adenoma, cra n iopharyngioma, thalamic g l ioma). Somnol ence of vasopress i n . The syndrome i s c h a racterized by hypo na
or even coma may be the result of bi latera l lesions of the latera l tremia with low plasma osmolal ity; i ncreased u r i n a ry sod i u m
hypotha l a m u s a n d its reti c u l a r fo rmation compon e nts (see excretion; a bsence o f vo lume depletion; and normal renal, he
Chapter 1 8). Even relatively minor destruction i n the hypothal patic, and a d renal fu nction. SIADH can res ult from inappropri
amus can cause a considera b l e loss of fu nction. ate hypersecretion of vasopressin by hypotha lamic neurons a s
A vasopressin deficiency produces a syn d rome of diabetes a result o f i ntracra n i a l tra u m a, bra i n tumors, a n d central nerv
insipidus, usually in the setting of damage to the hypothala ous system infections or from the inappropriate prod uction of
m u s beca use of neoplastic invasion, tra u ma, or vasc u la r or in vasopressin by neoplastic ce l l s in a variety of tiss ues, including
fecti o u s lesions (25% of cases a re i d i o pathic). Dia betes i n- the l u ngs.
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CHAPTER 9 Diencephalon 127
Hypothalamus
Anterior
pitu itary
FIGURE 9- 1 0 Effects of hypophyseotropic hormones on the secretion of a nterior pitu itary hormones. CRH, corticotropi n-releasing
hormone; TRH, thyrotropin-releasing hormone; G n RH, gonadotropi n-releasing hormone; GRH, g rowth horm one-releasing hormone; GIH,
g rowth hormone-i n h i biting hormone; PRH, prolactin-releasing hormone; PIH, prolacti n -i n h i b iting hormone. (Reprod uced, with permission, from
Ganong WF: Review of Medical Physiology, 22nd ed. McGraw-Hill, 2005.)
portion as field H1, and the ventrolateral portion as field Hz. Haben u l a r Trigone
The fasciculus lenticularis (field Hz ) runs medially from the The habenular trigone is a small triangular area in front of the
globus pallidus and is j oined by the ansa lenticularis, which
superior colliculus. It contains the habenular nuclei, which re
bends acutely in field H. The thalamic fasciculus extends ceive fibers from the stria medullaris thalami and are joined via
through field H1 to the anterior ventral nucleus of the thala the habenular commissure. The habenulointerpeduncular
mus. The zona incerta is a thin zone of gray substance above tract extends from the habenular nucleus to the interpeduncu
the fasciculus lenticularis. lar nucleus in the midbrain. The function of these structures is
not known.
EPITHALAMUS
l l l
? Breast
1
1 7 -Hyd roxy- Somato- Thyroxine Estrogen Progesterone
corticoids medins
Aldosterone,
sex hormones
FIGURE 9- 1 1 Anterior pitu itary hormones. ACTH, adrenocorticotrop i c hormone; TS H, thyroid-st i m u lating hormone; FSH, f o l l icle
sti m u lating hormone; LH, l utei n i z i n g hormone; 13-LPH, beta-l i potro p i n (fu n ction u n k n own). I n women, FSH and LH act i n seque nce o n the
ovary to produce g rowth of the ovarian f o l l i cle, ovu l ati on, a n d formation a n d m a i ntenance of the corpus l uteu m . I n men, FSH and LH con
trol the fu nctions of the t estes. Prolactin sti m u lates l actation. (Reproduced, w i t h permission, from G a n o n g W F : Review of Medical Physiology, 2 2 n d ed.
McGraw- H i l l , 2005.)
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128 SECTION IV Anatomy of the Brain
Temperature reg ulation Cutaneous cold receptors; temperatu re Anterior hypothalamus (response to
sensitive cel l s in hypothalamus heat), posterior hypotha lamus (response to cold)
Neuroendocrine control of Emotional sti m u l i, probably via limbic system Dorsomedial and posterior hypothalamus
catecholamines
Oxytoci n Touch receptors i n breast, uterus, genitalia Supraoptic and paraventricular nuclei
Thyroid-stimulating hormone Temperature receptors, perhaps others Dorsomed ial nuclei and neighboring
(thyrotropin, TSH) via thyrotropin a reas
stim u lating hormone (TRH)
Adrenocorticotropic hormone Limbic system (emotional sti m u l i); reticular Paraventricular n uclei
(ACTH) and 13 -li potropin formation ("systemic" stim u l i); hypothalamic or
(J3-LPH) via corticotropin anterior pitu itary cel l s sensitive to circu lating
releasing hormone (CRH) blood cortisol level; su prachiasmatic nuclei
(diurnal rhythm)
Fol licle-sti mulating hormone Hypothalamic cel ls sensitive to estrogens; eyes, Preoptic a rea, other areas
(FSH) and l utei nizing hormone touch receptors in skin and genitalia
(LH) via l utei n izing-hormone
releasing hormone (LHRH)
Prolactin via prolactin-i nh ibiting Touch receptors i n breasts, other u n known Arcuate nucleus, other areas
hormone (PI H) and prolactin receptors (hypothalamus inhi bits secretion)
releasing hormone (PRH)
Growth hormone via somatostatin U n known receptors Periventricular n ucleus, arcuate n ucleus
and g rowth-hormone-releasing
hormone (GRH)
H u nger "Gi ucostat" cel ls sensitive to rate of g l u cose Ventromedial satiety center, latera l
utilization hunger center; also limbic components
Sexual behavior Cel ls sensitive to circulating estrogen and Anterior ventral hypothalamus plus
androgen, others (in the male) piriform cortex
Defensive reactions Sense organs and neocortex, paths unknown In l i m bic system and hypotha lamus
Fear, rage
Control of various endocrine Reti na via retinohypothal a m ic fi bers Suprach iasmatic nuclei
and activity rhythms
Reproduced and modified, with permission, from Ganong WF: Review o f Medical Physiology, 22nd ed. Appleton & Lange, 2005.
Mi dday Ea rly N ight the stalk is continuous with the posterior commissure and
the dorsal lamina with the habenular commissure. At their
mRNA �� proximal ends, the laminas of the stalk are separated, form
ing the pineal recess of the third ventricle. The pineal body
Protei n
CIRCUMVENTRICULAR ORGANS
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CHAPTER 9 Diencephalon 129
Subfornical organ
Habenula
C L I N ICAL CORRELATIONS
REFERENCES
Area postrema Boulant JA: Hypothalamic neurons regulating body temperature.
Pages 1 05-126 in: Handbook of Physiology. Section 4:
Environmental Physiology . Oxford Univ Press, 1 997.
FIGURE 9-1 3 Location of the c i rcumventricular organs. There Buijs RM Hermes MH, Kalsbeek A: The suprachiasmatic
,
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C H A P T E R
The cerebral hemispheres make us human. They include the large area of cortex (nearly 2 � square feet if the cortex were
cerebral cortex (which consists of six lobes on each side: unfolded) , more than 50% of which is hidden within the sulci
frontal, parietal, temporal, occipital, insular, and limbic), the and fissures. The presence of gyri and sulci, in a pattern that is
underlying cerebral white matter, and a complex of deep relatively constant from brain to brain, makes it easy to iden
gray matter masses, the basal ganglia. From a phylogenetic tify cortical areas that fulfill specific functions.
point of view, the cerebral hemispheres, particularly t he cor
tex, are relatively new. Folding of the cortex, in gyri separated
by sulci, permits a highly expanded cortical mantle to fit M a i n S u lci a n d Fissures
within the skull vault in higher mammals, including humans. The surfaces of the cerebral hemispheres contain many fis
The cortex is particularly well developed in humans. There sures and sulci that separate the frontal, parietal, occipital, and
are multiple maps (motor, somatosensory, visual) of the body temporal lobes from each other and the insula (Figs 1 0-5 and
and the external world within the cortex. The cortex is highly 1 0-6). Some gyri are relatively invariant in location and con
parcellated, with different parts of t he cortex being responsi tour, whereas others show variation. The overall plan of the
ble for a variety of higher brain functions, including manual cortex as viewed externally, however, is relatively constant
dexterity (the "opposing thumb" and the ability, eg, to move from person to person.
the fmgers individually so as to play the piano) ; conscious, The lateral cerebral fissure (Sylvian fissure) separates
discriminative aspects of sensation; and cognitive activity, in the temporal lobe from the frontal and parietal lobes. The in
cluding language, reasoning, planning, and many aspects of sula, a portion of cortex that did not grow much during devel
learning and memory. opment, lies deep within the fissure (Fig 1 0-7). The circular
sulcus (circuminsular fissure) surrounds the insula and sep
arates it from the adj acent frontal, parietal, and temporal
DEVELOPM ENT lobes.
The hemispheres are separated by a deep median fissure,
The telencephalon (endbrain) gives rise to the left and right the longitudinal cerebral fissure. The central sulcus (the fis
cerebral hemispheres (Fig 1 0- 1 ) . The hemispheres undergo a sure of Rolando) arises about the middle of the hemisphere,
pattern of extensive differential growth; in the later stages, beginning near the longitudinal cerebral fissure and extending
they resemble an arch over t he lateral fissure (Fig 1 0-2). downward and forward to about 2.5 em above the lateral cere
The basal ganglia arise from the base of the primitive te bral fissure (see Fig 1 0-5). The central sulcus separates the
lencephalic vesicles (Fig 1 0- 3 ) . The growing hemispheres frontal lobe from the parietal lobe. The parieto-occipital fis
gradually cover most of the diencephalon and the upper part sure passes along the medial surface of the posterior portion
of the brain stem. Fiber connections (commissures) between of the cerebral hemisphere and then runs downward and for
the hemispheres are formed first at the rostral portions as the ward as a deep cleft (see Fig 1 0-6). The fissure separates the
anterior commissure, later extending posteriorly as the cor parietal lobe from the occipital lobe. The calcarine fissure
pus callosum (Fig 1 0-4) . begins on the medial surface of the hemisphere near the oc
cipital pole and extends forward to an area slightly below t he
splenium of the corpus callosum (see Fig 1 0-6).
ANATOMY OF THE CEREBRAL
HEM ISPHERES
Corpus Ca l losum
The cerebral hemispheres make up the largest portion of the The corpus callosum is a large bundle of myelinated and non
human brain. The cerebral hemispheres appear as highly con myelinated fibers, the great white commissure that crosses the
voluted masses of gray matter that are organized into two longitudinal cerebral fissure and interconnects the hemi
somewhat symmetrical (but not totally symmetrical) folded spheres (see Figs 1 0-4 and 1 0-6). The body of the corpus cal
structures. The crests of the cortical folds (gyri) are separated losum is arched; its anterior curved portion, the genu, contin
by furrows (sulci) or deeper fissures. The folding of the cor ues anteroventrally as the rostrum. The thick posterior
tex into gyri and sulci permits t he cranial vault to contain a
131
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1 32 SECTION IV Anatomy of the Brain
Neural crest
Frontal lobe Y-
Temporal lobe
�� Central sulcus
Lateral fissure
Lateral ventricle
Lateral ventricles
Basal ganglia
Telencephalic vesicles
Lateral ventricle
Caudate
Lentiform
nucleus
Diencephalon
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 133
Telencephalic
hemispheres
Posterior
choroidal Pineal
arteries body
FIGURE 1 0-4 Dorsal view of developing cerebrum showi ng formation of the corpus ca llosum, which covers the s u barachnoid cistern and
vessels over the diencepha lon.
Supramarginal gyrus
Triangular portion
of inferior frontal
gyrus
Orbital portion
of inferior frontal gyrus Superior
temporal gyrus
Superior
temporal sulcus
Middle temporal gyrus
D
Parietal Occipital
..____. lobe lobe
FIGURE 1 0-5 Latera l view of the left cerebra l hemisphere, showing principal gyri and sulci.
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1 34 SECTION IV Anatomy of the Brain
Corpus callosum
Lingual gyrus
Cut diencephalon
!! Temporal
L__j lobe .._____.
Frontal Fusiform (medial
lobe occipitotemporal) gyrus
Parietal r-J Occipital
lobe L__j lobe
Frontal lobe
Circular sulcus
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 135
portion terminates in the curved splenium, which lies over ramus o f the lateral cerebral fissure. The angular gyrus arches
the midbrain. above the end of the superior temporal sulcus and becomes con
The corpus callosum serves to integrate the activity of the tinuous with the middle temporal gyrus. The precuneus is the
two hemispheres and permits them to communicate with each posterior portion of the medial surface between the parieto-oc
other. Most parts of the cerebral cortex are connected with their cipital fissure and the ascending end of the cingulate sulcus.
counterparts in the opposite hemisphere by axons that run in
the corpus callosum. The corpus callosum is the largest of the
interhemispheric commissures and is largely responsible for co Occi pita l Lobe
ordinating the activities of the two cerebral hemispheres. The occipital lobe-which most notably houses the primary vi
sual cortex-is situated behind the parieto-occipital fissure (see
Figs 1 0-5 and 1 0-6). The calcarine fissure divides the medial
Fronta l Lobe surface of the occipital lobe into the cuneus and the lingual
The frontal lobe includes not only the motor cortex but also gyrus. The cortex on the banks of the calcarine fissure (termed
frontal association areas responsible for initiative, j udgment, the striate cortex because it contains a light band of myelinated
abstract reasoning, creativity, and socially appropriate behav fibers in layer N) is the site of termination of visual afferents
ior (inhibition of socially inappropriate behavior) . These latter from the lateral geniculate body; this region of cortex thus func
parts of the cortex are the phylogenetically newest and the tions as the primary visual cortex. The wedge-shaped cuneus
most uniquely "human". The frontal lobe extends from the lies between the calcarine and parieto-occipital fissures, and the
frontal pole to the central sulcus and the lateral fissure (see lingual (lateral occipitotemporal) gyrus is between the cal
Figs 1 0-5 and 1 0-6). carine fissure and the posterior part of the collateral fissure. The
The precentral sulcus lies anterior to the precentral posterior part of the fusiform (medial occipitotemporal)
gyrus and parallel to the central sulcus. The superior and in gyrus is on the basal surface of the occipital lobe.
ferior frontal sulci extend forward and downward from the
precentral sulcus, dividing the lateral surface of the frontal lobe
into three parallel gyri: the superior, middle, and inferior Tem pora l Lobe
frontal gyri. The inferior frontal gyrus is divided into three The temporal lobe lies below the lateral cerebral fissure and ex
parts: the orbital part lies rostral to the anterior horizontal ra tends back to the level of the parieto-occipital fissure on the
mus; the triangular, wedge-shaped portion lies between the an medial surface of the hemisphere (see Figs 1 0-5 and 1 0-6) .
terior horizontal and anterior ascending rami; and the opercu The lateral surface of the temporal lobe is divided into the par
lar part is between the ascending ramus and precentral sulcus. allel superior, middle, and inferior temporal gyri, which are
The orbital sulci and gyri are irregular in contour. The separated by the superior and middle temporal sulci. The in
olfactory sulcus lies beneath the olfactory tract on the orbital ferior temporal sulcus extends along the lower surface of the
surface; lying medial to it is the straight gyrus (gyrus rectus) . temporal lobe from the temporal pole to the occipital lobe.
The cingulate gyrus i s the crescent-shaped, o r arched, convo The transverse temporal gyrus occupies the posterior part of
lution on the medial surface between the cingulate sulcus and the superior temporal surface. The fusiform gyrus is medial
the corpus callosum. The paracentral lobule is on the medial and the inferior temporal gyrus lateral to the inferior temporal
surface of the hemisphere and is the continuation of the pre sulcus on the basal aspect of the temporal lobe. The hip
central and postcentral gyri. pocampal fissure extends along the inferomedian aspect of
The prefrontal cortex includes higher order association the lobe from the area of the splenium of the corpus callosum
cortex involved in j udgment, reasoning, initiative, higher or to the uncus. The parahippocampal gyrus lies between the
der social behavior, and similar functions. The prefrontal cor hippocampal fissure and the anterior part of the collateral fis
tex is located anterior to the primary motor cortex within the sure. Its anterior part, the most medial portion of the temporal
precentral gyrus and the adjacent premotor cortex. lobe, curves in the form of a hook; it is known as the uncus.
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136 SECTION I V Anatomy o f the Brain
M I CROSCOPI C STRUCTURE
OF THE CORTEX
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 137
C. Columns
Although the cortex is arranged in layers, its constituent
groups of neurons with similar functions are interconnected
in vertically oriented columns that extend, in column-like
fashion, from the superficial cortical layers to the deep layer.
The columns are about 30 to 1 00 j.Lm in diameter.
Each cortical column app ears to be a functional unit,
consisting of cells with related properties. For example, in the
somatosensory cortex, all of the neurons in a column are ac
tivated by a single type of s ensory receptor, and all r eceive in
puts from a similar part of the body. Similarly, within t he vi
Inferior longitudinal sual cortex, all of the cells within a column receive input from
fasciculus the same part of the retina ( and hence from the same part of
(temporo-occipital bundle)
the visual world) and are tuned to respond to stimuli with
FIGURE 1 0-9 Diagram of the major associatio n systems. similar orientations. Each column acts as a small computa
tional unit. The columns interact like multiple computes
within a network or cloud. It is the vast number of such local
surface of the cortex). The axons of pyramidal and fusiform neu circuits that gives the brain its complex functions.
rons form the projection and association fibers, with large layer V
pyramidal neurons projecting their axons to the spinal cord and D. Classification of Principal Areas
brain stem, smaller layer II and layer III pyramidal cells s ending Division and classification of the cerebral cortex have been at
association axons to other cortical areas, and fusiform neurons tempted by many investigators. The most commonly used c las
giving rise to corticothalamic projections. Stellate neurons are in sification system is Brodmann's, which is based on cytoarchi
terneurons whose axons remain within the cortex. tectonics (the precise shapes and arrangements of t he neurons
within a given part of the cortex). The Brodmann classification
A. Types of Cortices
uses numbers to label individual areas of the cortex that Brad
The cortex of the cerebrum comprises two types: allocortex mann believed differed from others (Figs 1 0- 1 1 and 1 0 - 1 2 ) .
and isocortex. The allocortex (archicortex) is found predom These anatomically defined areas have been used a s a r eference
inantly in the limbic system cortex and contains fewer layers base for the localization of physiologic and pathologic
than the isocortex (three in most regions) (see Chapter 1 9) . processes. Ablation and stimulation have led to functional lo
The isocortex (neocortex) i s more commonly found i n most calizations. More recently, functional brain imaging (see Chap
of the cerebral hemisphere and contains six layers. The juxtal ter 22) has been used to localize various functions to particu
locortex (mesocortex) forms the transition between t he allo lar cortical areas. Some principal cortical areas and their
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138 SECTION I V Anatomy o f the Brain
10
1a
1b
1c
2
II
5a
5b
6a 1
VIa
6a2
Vlb
6b 1
6b2
A B c D
FIGURE 1 0-1 0 Diagram of the structu re of the cerebra l cortex. A: Golgi neuronal sta i n . B: N i ssl cel l u l a r sta i n . C: Weigart mye l i n sta i n .
D: Neuronal con n ections. R o m a n and Arabic n u merals indicate the layers of t h e i socortex (neocortex); 4 , external l i n e of Bail larger (line of Gen
nari i n the occipital lobe); S b, i nternal line of Ba i l larger. (A, B, and c reproduced, with permission, from Ranson SW, Clark SL: The Anatomy ofthe Nervous System,
1 Oth ed. Saunders, 1 959. D reproduced, with permission, from Ganong WF: Review of Medical Physiology, 22nd ed. Appleton & Lange, 2005.)
-- �
Area 4:
Area 6: Principal
Premotor area motor area Areas 3-1 -2 :
---
-
Postcentral principal
Area 8: '\ sens reas
' /
Frontal eye field _ _, 6
4
I� 3
/ 2
(
Sensory association areas
5
r
9
40
43
10 Areas 1 8-1 9 :
44
Visual association areas
22
"" 44,
Motor speech .7J
�.... . %�t·
22
42
FIGURE 1 0- 1 1 Latera l aspect of the cerebrum. The cortica l a reas a re shown accord i n g t o Brod m a n n with fu nctional localizations.
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 139
Area 4:
Area 6: Principal Areas 3-1 -2 :
�
Premotor area motor area
./'/ Postcentral principal
sensory areas
�/.
Area S :
Frontal eye field Areas 5 and 7 :
6 ory association areas
3
1
5
2 7
32
24
33 �-
,.,
23 Areas 1 8-1 9 :
Visual association areas
11
Area 1 7 :
Principal visual
34 27 cortex (striate)
28
35
37
36 -
20
...- Areas 1 8-1 9 :
Visual association areas
FIGURE 1 0- 1 2 Medial aspect of the cerebrum. The cortica l a reas a re shown accord i n g to Brod m a n n with fu nctional localizations.
Premotor
area � Pri mary motor
area
Pri mary sensory
Language comprehension
(Wernicke's) area
FIGURE 1 0- 1 3 Latera l view of the left hemisphere showi ng the functions of the cortical a reas.
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1 40 SECTION IV Anatomy of the Brain
Brodmann's
Area Name Function Connections
Frontal lobe: 4 Pri mary motor cortex Vol u nta ry m uscle activation Contri butes to corticospinal tract
6 Premotor cortex
8 Frontal eye field Eye movements Sends projections to lateral gaze center
{paramed i u m ponti ne reticular
formation)
44, 45 Broca's a rea Motor aspects of speech Projects to Wernicke's a rea via a rcuate
fasciculus
Parieta l lobe: 3, 1 , 2 Primary sensory cortex Somatosensory I n put from VPL, VPM
Occipital lobe: 17 Striate cortex = Processing of visual I n put from latera l geniculate only
primary visual cortex sti m u l i Projects to a reas 1 8, 1 9
1 8, 1 9 Extrastriate = visual Processing o f v i s u a l sti m u l i I n put from a rea 1 7
association cortex
Temporal lobe: 41 Primary auditory Processing o f aud itory I n put from medial genicu late
cortex sti m u l i
42 Associative auditory
cortex
22 Wernicke's a rea Language I n puts from auditory association
comprehension cortex, visual association cortex, Broca's
area (via a rcuate fasciculus)
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 141
Area 6 (the premotor area) contains a second motor 3 . Occipita/ lobe-Area 1 7 i s the striate-the primary
map. Several other motor zones, including the supplementary visual-cortex. The geniculocalcarine radiation relays visual
motor area (located on the medial aspect of the hemisphere), input from the lateral geniculate to t he striate cortex. Upper
are clustered nearby. parts of the retina (lower parts of the visual field) are repre
Area 8 (the frontal eye field) is concerned with eye sented in upper parts of area 1 7, and lower parts of t he retina
movements. (upper parts of the visual field) are represented in lower parts
Within the inferior frontal gyrus, areas 44 and 45 (Broca's of area 1 7 . Areas 18 and 19 are visual association areas
area) are located anterior to the motor cortex controlling the within the occipital lobe. There are also visual maps within the
lips and tongue. Broca's area is an important area for speech. temporal and parietal lobes. Each of these maps represents the
Anterior to these areas, the prefrontal cortex has exten entire visual world, but extracts information about a particu
sive reciprocal connections with the dorsomedial and ventral lar aspect of it (forms, colors, movements) from the incoming
anterior thalamus and with the limbic system. This association visual signals. (This is further described in Chapter 15.)
area receives inputs from multiple sensory modalities and in
tegrates them. The prefrontal cortex serves a set of "executive" 4 . Temporal lobe Area 41 is the primary auditory cortex;
-
functions, planning and initiating adaptive actions and inhibit area 42 is the associative (secondary) auditory cortex. To
ing maladaptive ones; prioritizing and s equencing actions; and gether, these areas are referred to as Heschl's gyrus. Immedi
weaving elementary motor and s ensory functions into a coher ately adjacent to Heschl's gyrus lies t he planum temporale,
ent, goal-directed stream of behavior. Studies indicate that the which is located on the superior surface of the tempural lobe
prefrontal cortex, like the motor and sensory cortices, is com (Fig 1 0- 1 6), which is larger on the left in right-handed indi
partmentalized into areas that perform specific functions. viduals, and is involved in language and music. These r egions
When prefrontal areas are inj ured ( eg, as a result of receive input (via the auditory radiations) from the medial
tumors or head trauma), patients become either apathetic geniculate. The surrounding temporal cortex ( area 22) is the
(lacking initiative or, in some cases, motionless and mute) or auditory association cortex. In the posterior part of area 22 (in
uninhibited and distractible, with loss of social graces and im the posterior third of the superior temporal gyrus) is Wer
paired j udgment. nicke's area, which plays an important role in the comprehen
sion of language. The remaining temporal areas are multi
2. Parietal lobe Areas 3, 1, and 2 are the primary sensory
-
modal association areas.
areas, which are somatotypically represented (again in the form
of a homunculus) in the postcentral gyrus (Fig 10-15). This area 5. Multimodal association areas- As noted earlier, for each
receives somatosensory input from the ventral posterolateral
sensory modality, there is a primary sensory cortex as well as
(VPL) and ventral posteromedial (VPM) nuclei in the thalamus.
modality-specific association areas. A number of multimodal
The remaining areas are sensory or multimodal association areas. association areas also receive converging proj ections from
different modality-specific association areas. Within these
multimodal association areas, information about different at
tributes of a stimulus (eg, the visual image of a dog, the sound
Temporal lobe
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1 42 SECTION IV Anatomy of the Brain
of its bark, and the feel of its fur) all appear to converge, so that
higher order information processing can take place. A multi
modal association area has been found in the temporoparietal
area within the inferior parietal lobule and the area around the
superior temporal sulcus. Another multimodal association
area is located in the prefrontal region. These multimodal as
sociation regions project, in turn, to the limbic cortex.
PHYSIOLOGY OF SPECIALIZED
CORTICAL REGIONS FIGURE 1 0- 1 7 Motor activity in the cerebral cortex, visual ized
with fu nctional magnetic resonance imagi ng. Cha nges in signal
Reflecting its parcellated organization, different parts of the cor
i ntensity, measured using a method ca l led echoplanar magnetic r es
tex subserve different functions. Focal injury of various parts of
onance imaging, result from changes i n the flow, vo l u m e, and
the cortex can produce district clinical syndromes. Thus, in oxygenation of the blood. This study was performed o n a 7-year-old
many cases it is possible to predict, from the history and neuro boy. The sti m u l u s was repetitive sq u eezi ng of a foa m-rubber ba l l at
logical examination, which parts of t he cortex are damaged. the rate of two to fou r squeezes per second with the right o r left
The functions of the olfactory receptive cortex (pyriform hand. Changes in corti cal activity associated with sq ueezi ng the ba l l
and entorhinal cortex) and related areas are discussed in with t h e right hand a re shown i n black. Changes i n cortical activity
Chapter 19. associated with sq ueezing the ba l l with the left hand a re shown i n
wh ite. (Data from Novotny EJ, e t a l : Functional magnetic resonance imaging (fMRI)
i n ped iatric epilepsy. Epilepsia 1 994;35 (5upp 8):36.)
Primary Motor Cortex
A. Location and Fu nction
The primary motor projection cortex (area 4; see Chapter 1 3 )
i s located o n the anterior wall o f the central sulcus and the ad affected muscle groups. Spasticity is more apt to occur if area
jacent portion of the precentral gyrus, corresponding gener 6 is also ablated.
ally to the distribution of the giant pyramidal ( Betz's) cells.
These cells control voluntary movements of skeletal muscle on
Pri m a ry Sensory Co rtex
the opposite side of the body, with the impulses traveling over
their axons in the corticobulbar and corticospinal tracts to the A. Location and Fu nction
branchial and somatic efferent nuclei in the brain stem and to The primary sensory proj ection cortex for sensory informa
the ventral horn in the spinal cord. tion received from the skin, mucosa, and other tissues of the
A somatotopic representation within the motor areas, b ody and face is lo cated in the p ostcentral gyrus and is
mapped by electrical stimulation during brain surgery, ap called the somatesthetic area (areas 3 , 1, and 2 ; see
pears in Figure 1 0 - 1 4. Secondary and tertiary areas of motor Fig 1 0- 1 5) . From the thalamic radiations, t his area receives
function can be mapped around the primary motor cortex. fibers that convey touch and proprioceptive (muscle, joint,
Contralateral conjugate deviation of the head and eyes occurs and tendon) sensations from the opposite side of the body
on stimulation of the posterior part of the middle frontal (see Chapter 1 4 ) .
gyrus (area 8), termed the frontal eye fields. A relatively wide portion o f the adj acent frontal and pari
An alternative method for mapping the cortex is provided etal lobes can be considered a secondary sensory cortex be
by functional magnetic resonance imaging, which is described cause this area also receives sensory stimuli. The primary
in Chapter 22. Figure 1 0- 1 7 shows activation of motor cortex sensorimotor area is, therefore, considered capable of func
associated with squeezing a foam-rubber ball with the con tioning as both a motor and a s ensory cortex, with the portion
tralateral hand. of the cortex anterior to the central sulcus predominantly
motor and that behind it predominantly sensory.
B. Clin ical Correlations The cortical taste area is located close to the facial sensory
Irritative lesions of the motor centers may cause seizures that area and extends onto the opercular surface of the lateral cere
begin as focal twitching and spread (in a s omatotopic manner, bral fissure (see Fig 8-19). This cortical area receives gustatory
reflecting the organization of the homunculus) to involve large information, which is relayed from the solitary nucleus in the
muscle groups. As noted in Clinical Illustration 10- 1 , as abnor medulla via the ventral posteromedial nucleus of the thalamus.
mal electrical discharge spreads across t he motor cortex, the
seizure "marches" along the body in a ''Jacksonian march': There B. Clin ical Correlations
may also be modification of consciousness and postconvulsive Irritative lesions of this area produce paresthesias (eg, numbness,
weakness or paralysis. Destructive lesions of the motor cortex abnormal sensations of tingling, electric shock, or pins and
(area 4) produce contralateral flaccid paresis, or paralysis, of needles) on the opposite side of the body. Destructive lesions
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CHAPTER 10 Cerebral Hemlspheres/Telencephalon 143
produce subjective and objective impairments in s ensibility, such unilateral lesion in this area may cause only mild hearing loss,
as an impaired ability to localize or measure t he intensity of but bilateral lesions can result in deafness. Damage to area 22
painful stimuli and impaired perception of various forms of cuta in the dominant hemisphere produces a syndrome of
neous sensation. Complete anesthesia on a cortical basis is rare. pure word deafness (in which words cannot be understood
although hearing is not impaired) , also called Wernicke's
aphasia.
Primary Vis u a l Cortex a n d Visual
Association Cortex
A. Location and Fu nction BASAL GANGLIA
The primary visual receptive (striate) cortex (area 1 7) is located
The term basal ganglia refers to masses of gray matter deep
in the occipital lobe. It lies in the cortex of the calcarine fissure
within the cerebral hemispheres. The term "basal ganglia" is
and adjacent portions of the cuneus and the lingual gyrus.
debatable because these masses are nuclei rather than ganglia,
In primates, an extensive posterior portion of t he occipital
and some of them are not basal, but it is still widely used. Ir
pole is concerned primarily with high-resolution macular vi
respective of the name, the basal ganglia play an essential
sion; more anterior parts of the calcarine cortex are concerned
functional role in motor control. Anatomically, the basal gan
with peripheral vision. The visual cortex in the right occipital
glia include the caudate nucleus, the putamen , and the
lobe receives impulses from the right half of each retina,
globus pallidus.
whereas the left visual cortex (area 1 7) receives impulses from
Terminology used to describe the basal ganglia is sum
the left half of each retina. The upper portion of area 1 7 rep
marized in Fig 10-18. Sheets of myelinated fibers, including
resents the upper half of each retina, and the lower portion
the internal capsule, run between the nuclei comprising t he
represents the lower half. Visual association is a function of
basal ganglia, thus imparting a striped appearance (Figs 10- 1 9
areas 18 and 1 9. Area 19 can receive stimuli from the entire
and 1 0-20 ) . Thus, classical neuroanatomists termed the
cerebral cortex; area 18 receives stimuli mainly from area 1 7
caudate nucleus, putamen, and globus pallidus collectively t he
(see Chapter 1 5 ) .
corpus striatum. The caudate nucleus and putamen develop
together and contain similar cells and, collectively, are t ermed
B . Clin ical Correlations the striatum. Lateral to the internal capsule, the putamen and
Irritative lesions of area 17 can produce such visual hallucina globus pallidus abut each other to form a lens-shaped mass
tions as flashes of light, rainbows, brilliant stars, or bright termed the lenticular nuclei. Functionally, the basal ganglia
lines. Destructive lesions can cause contralateral homony and their interconnections and neurotransmitters form the
mous defects of the visual fields. This can occur without de extrapyramidal system , which includes midbrain nuclei
struction of macular vision, a phenomenon called "macular such as the substantia nigra, and the subthalamic nuclei (see
sparing:' Injury to areas 18 and 19 can produce visual disor Chapter 13).
ganization with defective spatial orientation in t he homony
mous halves of the visual field.
Ca udate N ucleus
The caudate nucleus, an elongated gray mass whose pear
Primary Aud itory Receptive Cortex shaped head is continuous with the putamen, lies adjacent to
A. Location and Fu nction the inferior border of the anterior horn of the lateral ventri
The primary auditory receptive area (4 1 ; see Chapter 16) is de. The slender end curves backward and downward as the
located in the transverse temporal gyrus, which lies in the tail; it enters the roof of the temporal horn of the lateral ven
superior temporal gyrus toward the lateral cerebral fissure. The tricle and tapers off at the level of the amygdala. The caudate
auditory cortex on each side receives t he auditory radiation nucleus and putamen (striatum) constitute the major site
from the cochlea of both ears, and there is point-to-point pro of input to the basal ganglia; the circuitry is described in
jection of the cochlea on the acoustic area (tonotopia). In hu Chapter 1 3 .
{
mans, low tones are projected or represented in the frontolateral
portion and high tones in the occipitomedial portion of area 4 1 .
Low tones are detected near the apex o f the cochlea and high
}
tones near the base. Area 22, which includes Wernicke's area (in Caudate nucleus
the posterior third of the superior temporal gyrus in the (= neostriatu m)
Striatum
dominant-usually left-hemisphere), is involved in high Corpus
striatum Putamen
order auditory discrimination and speech comprehension.
Lenticular
nuclei
B. Clin ical Correlations Globus
pallidus
Irritation of the region in or near the primary auditory recep
tive area in humans causes buzzing and roaring sensations. A
FIGURE 1 0- 1 8 Major nuclei of the basal ganglia.
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1 44 SECTION I V Anatomy o f the Brain
I nternal capsule
Caudate
Tail of caudate
Thalamus
Amygdala
A
FIGURE 1 0- 1 9 Spatial rel ationsh i ps between basal gangl ia, thalam us, and i nternal caps u l e as viewed from the l eft side. Sections through
pla nes A and B a re shown i n Fig u res 1 0-1 9A and B.
Lenticu l a r N ucleus through the internal capsule and form a bundle, the fascicu
lus lenticularis, on the medial side. Other fibers sweep the
The lenticular nucleus is situated between the insula and the
medial border of the internal capsule to form a loop, the ansa
internal capsule. The external medullary lamina divides the
lenticularis. Both of these sets of fibers have some terminals
nucleus into two parts: the putamen and the globus pallidus.
in the subthalamic and red nuclei; others continue upward to
The putamen is the larger, convex gray mass lying lateral to
the thalamus via the thalamic fasciculus (see Fig 10-2 1 ) . As
and just beneath the insular cortex. The striped appearance of
described in Chapter 1 3 , this rich system of interconnections
the corpus striatum is caused by the white fasciculi of the in
forms a basis for the control of movement and posture.
ternal capsule that are situated between the putamen and the
caudate nucleus. The globus pallidus is the smaller, triangular
median zone whose numerous myelinated fibers make it ap
INTERNAL CAPSULE
pear lighter in color. A medullary lamina divides the globus
pallidus into two portions. The globus pallidus is the major The internal capsule is a small but crucial band of myelinated
outflow nucleus of the basal ganglia. fibers that separates the lentiform nucleus from the medial
caudate nucleus and thalamus. It consists of an anterior limb
and a posterior limb. The capsule is not one of the basal gan
Claustru m a n d External Ca psu l e
glia, but a fiber bundle that runs through the basal ganglia. In
The claustrum is a thin layer o f gray substance situated j ust horizontal section, it presents a V -shaped appearance, with
beneath the insular cortex. It is separated from the more me the genu (apex) pointing medially (Figs 1 0-22 and 1 0-23).
dian putamen by the thin lamina of white matter known as the The internal capsule contains critically important path
external capsule. ways such as the corticobulbar and corticospinal tracts. Thus,
small lesions within the internal capsule (which can occur, eg,
as a result of small strokes called lacunar strokes) can produce
Fi ber Con n ections
devastating clinical deficits.
Most portions of the basal ganglia are interconnected by two The anterior limb of the internal capsule separates the
way fiber systems (Fig 1 0-2 1 ) . The caudate nucleus sends lentiform nucleus from the caudate nucleus. It contains thala
many fibers to the putamen, which in turn sends short fibers mocortical and corticothalamic fibers that j oin the lateral thal
to the globus pallidus. The putamen and globus pallidus re amic nucleus and the frontal lobe cortex, frontopontine tracts
ceive some fibers from the substantia nigra, and the thalamus from the frontal lobe to the pontine nuclei, and fibers that run
sends fibers to the caudate nucleus. Efferent fibers from the transversely from the caudate nucleus to the putamen.
corpus striatum leave via the globus pallidus. Some fibers pass
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CHAPTER 10 Cerebral Hemispheres/Telencephalon 1 45
Corpus callosum
Thalamus
Claustrum
Internal capsule
G lobus pallidus
Th ird ventricle
Frontal lobe
Corpus callosum
Lateral ventricle
G lobus pal lidus
Foramen of
Monro
External capsu le
Extreme capsu le
Occipital lobe
FIGURE 1 0-20 A: Frontal section through cerebral hemispheres showing basal ganglia and thalamus. B: Horizonta l sectio n thro u g h
cerebral hemispheres.
The posterior limb of the internal capsule, located be orly located corticospinal and corticobulbar fibers, there is a
tween the thalamus and the lentiform nucleus, contains major somatotopic organization of the sensory fibers in the poste
ascending and descending pathways. The corticobulbar and rior limb, with the face and arm (f, a) ascending in front of
corticospinal tracts run in the anterior half of t he posterior the fibers for the leg (1) (see Fig 10-22). As a result of its or
limb, with the fibers to the face and arm (see Fig 1 0-22, F, A) derly organization, small lesions of the internal capsule can
in front of the fibers to the leg (see Fig 1 0-22, L). Corticorubral compromise motor and sensory function in a selective man
fibers from the frontal lobe cortex to the red nucleus accom ner. For example, small infarcts (termed "lacunar" infarcts),
pany the corticospinal tract. owing to occlusion of small penetrating arterial branches, can
The posterior third of the posterior limb contains third selectively involve the anterior part of the posterior limb of
order sensory fibers from the posterolateral nucleus of the the internal capsule, producing " pure motor" strokes. (An ex
thalamus to the postcentral gyrus. As with the more anteri- ample is shown in Fig 1 0-24.)
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1 46 SECTION IV Anatomy of the Brain
Anterior
I
I
}
nucleus
(head)
limb
Caudate nucleus Internal
capsule
Putamen
"-- I"" U �lt,IIUI limb
Globus
pallidus
Thalam u s
I
ventricle
S ubstantia n ig ra
Globus pallidus Corticospinal tract
Posterior
FIGURE 1 0-21 Connections between the basal ganglia, the FIGURE 1 0-22 Relationships between internal capsu le, basal
thalam us, and the cortex. gangl ia, and thalamus i n horizonta l section. N otice that descending
motor fi bers for the face, a rm, and leg (F, A, L) run i n front of ascend
ing sensory fibers (f, a, I) i n the p osterior limb of the internal ca psu le.
(Modified from Simon RP, Aminoff MJ, Greenberg DA: Clinical Neurology, 4th ed.
Appleton & Lange, 1 999.)
FIGURE 1 0-23 Magnetic resonance image of a h orizonta l FIGURE 1 0-24 Magnetic resonance image showing i nfa rction
sectio n through the head. i n the posterior limb of the left internal capsule, which p rod uced a
"pure motor stroke" in an 83-yea r-old woman. The patient presented
with acute onset of weakness of the right face, arm, and leg.
(Courtesy of Joseph Schind ler, M.D., Ya l e Medical School.)
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CHAPTER 10 Cerebral Hemispheres/Telencephalon 147
C A S E 11
A 44-year-old woman was brought to a clinic by her hus gram showed an abnormal slow-wave focus in the left
band, who relayed her history of disorientation, confusion, hemisphere. Imaging showed a calcified multifocal mass
and distractibility and forgetfulness. These symptoms had in the left frontoparietal region.
become more severe in the past several months. The pa What is the differential diagnosis based on these find
tient had recently begun to complain of headaches, and ings?
after she had what she described as "a fit," her husband A brain biopsy was performed and a diagnosis made.
insisted she see a doctor. By the next day, the patient had become comatose with di
Neurologic examination showed apathy and difficulty lated fixed pupils, and she died soon afterward. At autopsy,
focusing attention, impairment of memory, left-sided pa findings included small hemorrhages in the brain stem and
pilledema, facial asymmetry, lack of movement on the extensive pathologic changes in the forebrain.
right side of the face, and general weakness but symmetric What happened after the brain biopsy? What is the most
reflexes in the remainder of the body. An electroencephalo- likely diagnosis?
c A s E 12
I
A 1 2-year-old girl began to have severe ear pain and fever. confusion of past and recent events, severe diffic ulty in
A few days later, her mother noticed a discharge from the naming objects, bilateral papilledema, normal extraocular
left ear and took her to her family physician. The doctor movements, minor left peripheral facial paralysis, and de
prescribed antibiotics. One week later, the girl had a se creased hearing ability on the left. The patient resisted
vere, constant, left frontal headache. The following week, neck flexion. An electroencephalogram showed slow-wave
she had left-sided facial weakness. activity in the left hemisphere, especially in the frontotem
What is the differential diagnosis at this point? poral region. Computed tomography scanning revealed a
The girl was then referred to a neurologist. At the time lesion in the left frontotemporal area.
of admission, she was lethargic and confused, spoke unin What is the most likely diagnosis?
telligibly, displayed silly behavior, and had a temperature Cases are discussed further in Chapter 25.
of 1 00 op (37 . 8 °C). Neurologic examination showed
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C H A P T E R
Ventricles and
Coverings of the Brain
VENTRICULAR SYSTEM border are the stria terrninalis and the tail of the caudate nu
cleus. The amygdaloid nuclear complex bulges into the upper
Within the brain is a communicating system of cavities that terminal part of the inferior horn, whose floor and medial
are lined with ependyma and filled with cerebrospinal fluid wall are formed by the fimbria, hippocampus, and collateral
(CSF): There are two lateral ventricles, the third ventricle (be eminence.
tween the halves of the diencephalon), the cerebral aqueduct, The two interventricular foramens, or foramens of
and the fourth ventricle within the brain stem (Fig 1 1 - 1 ) . Monro, are apertures between the column of the fornix and
the anterior end of the thalamus. The two lateral ventricles
communicate with the third ventricle through these foramens
Latera l Ventricles a n d Choroid Plexus
(see Fig 1 1 - 1 ) .
The lateral ventricles are the largest. They each include two
central portions (body and atrium) and three extensions
(horns). Th i rd Ventricle
The choroid plexus is the site where cerebrospinal fluid The third ventricle is a narrow vertical cleft between t he two
( CSF) is produced. It is a fringe-like vascular process of pia mater halves of the diencephalon (see Figs 1 1 - 1 to 1 1 -4). The roof
containing capillaries of the choroid arteries. It projects into the of the third ventricle is formed by a thin tela choroidea (a layer
ventricular cavity and is covered by an epithelial layer of ependy of ependyma) and pia mater from which a small choroid
mal origin (Figs 1 1 -2 and 1 1 -3). The attachment of the plexus plexus extends into the lumen of the ventricle (see Fig 9- 1 ) .
to the adjacent brain structures is known as t he tela choroidea. The lateral walls are formed mainly b y the medial surfaces of
The choroid plexus extends from the interventricular foramen, the two thalami. The lower lateral wall and the floor of the
where it joins with the plexuses of the third ventricle and oppo ventricle are formed by the hypothalamus; the anterior com
site lateral ventricle, to the end of the inferior horn. (There is no missure and the lamina terminalis form the rostral limit.
choroid plexus in the anterior and posterior horns.) The optic recess is an extension of the third ventricle be
The anterior (frontal) horn is in front of the interven tween the lamina terminalis and the optic chiasm. The hy
tricular foramen. Its roof and anterior border are formed by pophysis is attached to the apex of its downward extension,
the corpus callosum; its vertical medial wall, by the septum the funnel-shaped infundibular recess . A small pineal recess
pellucidum; and the floor and lateral wall, by the bulging head projects into the stalk of the pineal body. A large extension of
of the caudate nucleus. the third ventricle above the epithalamus is known as the
The central part, or body, of the lateral ventricle is t he suprapineal recess.
long, narrow portion that extends from the interventricular
foramen to a point opposite the splenium of the corpus callo
sum. Its roof is formed by the corpus callosum and its medial Cerebra l Aq ueduct
wall by the posterior portion of the septum pellucidum. The The cerebral aqueduct is a narrow, curved channel running
floor contains (from medial to lateral side) the fornix, the from the posterior third ventricle into the fourth. It contains
choroid plexus, the lateral part of the dorsal surface of no choroid plexus (see Figs 1 1 - 1 and 1 1 -4).
the thalamus, the stria terminalis, the vena terminalis, and
the caudate nucleus. The atrium, or trigone, is a wide area
of the body that connects with the posterior and inferior Fou rth Ventricle
horns (Fig 1 1 -4). The fourth ventricle is a pyramid-shaped cavity bounded ven
The posterior (occipital) horn extends into the occipital trally by the pons and medulla oblongata (see Figs 7- 14, 1 1 - 1 ,
lobe. Its roof is formed by fibers of the corpus callosum. On its and 1 1 -3); its floor i s also known a s the rhomboid fossa. The
medial wall is the calcar avis, an elevation of the ventricular lateral recess extends as a narrow, curved extension of the
wall produced by the calcarine fissure. ventricle on the dorsal surface of the inferior cerebellar pe
The inferior (temporal) horn traverses the temporal duncle. The fourth ventricle extends under the obex into the
lobe, whose white substance forms its roof. Along the medial central canal of the medulla.
149
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1 50 SECTION IV Anatomy of the Brain
7�
I nterventricular
foramen (of Monro) Lateral
ventricles
Anterior
Posterior
(frontal)
A\
(occi pital)
horn
hom
::::;::. Cerebral
aqueduct
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CHAPTER 1 1 Ventricles and Coverings of the Brain 151
Scalp
layers over the brain are generally fused, except where they Skull
separate to provide space for the venous sinuses and where the Dura
inner layer forms septa between brain portions. The outer Arachnoid
layer is firmly attached to the inner surface of the cranial Subarachnoid
bones and sends vascular and fibrous extensions into the bone space
itself; the inner layer is continuous with the spinal dura. Pia
One of the dural septa, the falx cerebri, extends like a
curtain, down into the longitudinal fissure between the cere FIGURE 1 1 -5 A: Schematic i l l u stratio n of a coronal section
bral hemispheres (Figs 1 1 -5 and 1 1 -6). It attaches to the inner through the bra i n and coverings. B: E n l a rgement of the a rea at the
surface of the skull in midplane, from the crista galli to the in top of A.
ternal occipital protuberance, where it becomes continuous
with the tentorium cerebelli.
The tentorium cerebelli separates the occipital lobes
from the cerebellum. It is a roughly transverse, shelflike mem
Right lateral brane that attaches at the rear and side to the skull at the trans
ventricle verse sinuses; at the front, it attaches to the petrous portion of
the temporal bone and to the clinoid processes of the sphe
noid bone. Toward the midline, it fuses with the falx cerebri.
The free, curved anterior border leaves a large opening, the
Superior
sagittal
sinus
Third
ventricle/ Straight
Cerebral sinus
aqueduct Inferior horn Atrium of left Left half
of left lateral lateral ventricle of tentorium
ventricle
Diaphragma sellae
FIGURE 1 1 -4 Drawing of the ventricles showing their relation
ship to the d u ra, tentorium, and sku l l base. FIGURE 1 1 -6 Schematic i l l u stration of the d u ra l folds.
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1 52 SECTION IV Anatomy of the Brain
incisura tentorii (tentorial notch), for passage of the upper lies a wide space between the two temporal lobes. This space
brain stem, aqueduct, and vessels. is divided into the chiasmatic cisterna above the optic chi
The falx cerebelli projects between the cerebellar hemi asm, the suprasellar cistern above the diaphragma sellae, and
spheres from the inner surface of the occipital bone to form a the interpeduncular cistern between the cerebral peduncles.
small triangular dural septum. The space between frontal, parietal, and temporal lobes is
The diaphragma sellae forms an incomplete lid over the called the cistern of the lateral fissure (cistern of Sylvius) .
hypophysis in the sella turcica by connecting the clinoid at
tachments of the two sides of the tentorium cerebelli. The pi
tuitary stalk passes through the opening in the diaphragma. Pia
The pia is a thin connective tissue membrane that covers the
brain surface and extends into sulci and fissures and around
Arachnoid blood vessels throughout the brain (see Fig l l -5). It also ex
T h e arachnoid, a delicate avascular membrane, covers the tends into the transverse cerebral fissure under the corpus
subarachnoid space, which is filled with CSF. The inner sur callosum. There it forms the tela choroidea of the third and
face of the arachnoid is connected to the pia by fine (but in lateral ventricles and combines with the ependyma and
constantly present) arachnoid trabeculae (see Fig l l -5). The choroid vessels to form the choroid plexus of these ventri
cranial arachnoid closely covers the inner surface of the dura cles. The pia and ependyma pass over the roof of the fourth
mater but is separated from it by the subdural space, which ventricle and form its tela choroidea for the choroid plexus
contains a thin film of fluid. The arachnoid does not dip into there.
the sulci or fissures except to follow the falx and the tento
rium.
Arachnoid granulations consist of many microscopic CSF
villi (see Fig l l -5B). They have the appearance of berry-like
clumps protruding into the superior sagittal sinus or its asso Function
ciated venous lacunae and into other sinuses and large veins. The CSF acts like a protective water jacket around t he brain. It
The granulations are sites of absorption of CSF. controls brain excitability by regulating the ionic composition,
The subarachnoid space between the arachnoid and the carries away metabolites (because t he brain has no lymphatic
pia is relatively narrow over the surface of the cerebral hemi vessels), and provides protection from pressure changes (ve
sphere, but it becomes much wider in areas at t he base of the nous volume versus CSF volume).
brain. These widened spaces, the subarachnoid cisterns, are
often named after neighboring brain structures (Fig l l -7).
They communicate freely with adj acent cisterns and the gen
eral subarachnoid space.
The cisterna magna results from the bridging of the C L I N ICAL CORRELATIONS
arachnoid over the space between the medulla and the cerebel
lar hemispheres; it is continuous with the spinal subarachnoid
Several t y p e s of h e r n i ation of t h e b ra i n c a n occ u r
space. The pontine cistern on the ventral aspect of t he pons
(Fig 1 1 -8). T h e tento ri u m sepa rates t h e s u p ratentorial a n d
contains the basilar artery and some veins. Below the cerebrum
t h e infratento rial co m pa rtments, a n d t h e two spaces com
m u n icate by way of the incisura that conta i n s the midbrain.
Both the fa lx a n d the tentori u m form i nco m p l ete sepa ra
tions, and a mass or expa n d i n g lesion may d isplace a por
Subarachnoid
I
Suprasellar space over tion of the bra i n aro u n d these septa, res u lting in either a
cistern cerebral convexity subfalcial or a tra n stentorial herniation. In s u bfalcial h er
n iation, the c i n g u l ate gyrus is d i s p laced i nto or under the
fa lx. In transtentorial hern iation, the uncus (of the medial
te m p o r a l l o be) i s d i s p l aced t h ro u g h t h e tentori u m, a n d
co m p resses t h e b ra i n stem a n d t h e adjacent ocu l o m otor
nerve (causing a n ipsi latera l d i l ated p u p i l and third nerve
paresis). Hern iation of the cerebe l l a r to n s i l s i nto the f ora
men m a g n u m by a l esion is often ca l l ed coning. Tra nsten
j•
I nterpeduncular Supracerebellar
c1stern cistern beca use they can d i stort or com p ress the brain ste m and
d a m a g e its vita l reg u l atory centers fo r res p i ration, con
Pontine cistern Cisterna magna
sciousness, bl ood pressu re, a n d other fu n ctions (see Chap
FIGURE 1 1 -7 Schematic i l l u stration of the bra i n showi ng ters 1 8 and 20).
spaces that contai n CSF.
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CHAPTER 1 1 Ventricles and Coverings of the Brain 153
Area Appearance Pressure (mm H 20) Cells (per j.LL) Protein Miscellaneous
Lumbar Clear and colorless 70- 1 80 0-5 <SO mg/d l Glucose 50-75 mg/dl
Composition a n d Vol u me with tumors or with some massive infarcts which cause brain
swelling), blood volume (with hemorrhages), or CSF volume
Normal CSF is clear, colorless, and odorless. Its more impor
(with hydrocephalus), because the adult skull is a rigid box of
tant normal values are shown in Table 1 1 - 1 . Alterations in the
bone that cannot accommodate the increased volume without
composition of the CSF in various disorders are summarized
a rise in pressure (Fig 1 1 -9).
in Chapter 24 and Table 24- 1 .
The CSF i s present, for the most part, i n a system that
comprises two communicating parts. The internal portion of C i rc u l ation
the system consists of two lateral ventricles, the interventricu
Much of the CSF originates from the choroid plexuses within
lar foramens, the third ventricle, the cerebral aqueduct, and the
the lateral ventricles. The fluid passes through the interven
fourth ventricle. The external part consists of the subarachnoid
tricular foramens into the midline third ventricle; more CSF is
spaces and cisterns. Communication between the internal and
produced here by the choroid plexus in the ventricle's roof
external portions occurs through the two lateral apertures of
(Fig 1 1 - 1 0). The fluid then moves through the cerebral aque
the fourth ventricle (foramens of Luschka) and the median
duct within the midbrain and passes into the rhombus-shaped
aperture of the fourth ventricle (foramens of Magendie) . In
fourth ventricle, where the choroid plexus adds more fluid.
adults, the total volume of CSF in all the spaces combined is
The fluid leaves the ventricular system through the midline
normally about 1 50 mL. Between 400 and 500 mL of CSF is
and lateral apertures of the fourth ventricle and enters the
produced and reabsorbed daily.
subarachnoid space. From here it may flow over the cerebral
convexities or into the spinal subarachnoid spaces. Some of it
Pressu re is reabsorbed (by diffusion) into the small vessels in the pia or
The normal mean CSF pressure is 70- 1 80 mm of water; peri
odic changes occur with heartbeat and respiration. The pres
sure rises if there is an increase in intracranial volume ( eg,
upratentorial
Lateral ---for--"!-�
ventricles
U ncus --��--��� �� �
-
tonsil
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1 54 SECTION IV Anatomy of the Brain
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CHAPTER 1 1 Ventricles and Coverings of the Brain 155
Narrowing of
subarachnoid
space
-<\lll•�::::
l -....;..---+-+-
:.. l nterventricular
foramen
Outflow foramens
Noncommun icating
(obstructive) Obstruction of interventricular fora men Enlargement of latera l ventricle
Obstruction of cerebral aqueduct Enlargement of latera l and third ventricles
Obstruction of outflow foramens of fourth ventricle Enlargement of a l l ventricles
Com m u n icati ng Obstruction of peri mesencephalic cistern Enlargement of all ventricles; widening of
(occlusion of incisura tentorii) posterior fossa cisterns
Obstruction of subarachnoid CSF flow over the Enlargement of all ventricles, widening of all
cerebral convexities basal cisterns
differs markedly from that of cell plasma. The blocking Blood - N erve Barrier
function is achieved by tight j unctions between endothelial
Large nerves consist of bundles of axons embedded in an
cells. There is evidence that neither the processes of astrocytes
epineurium. Each bundle is surrounded by a layer of cells
nor the basal laminas of endothelial cells prevent diffusion,
called the perineurium; connective tissue within each bundle
even for molecules as large as proteins.
is the endoneurium. Blood vessels of the epineurium, which
are similar to those of the dura, are permeable to macromole
C. Arachnoid Barrier
cules, but the endoneuria! vessels, similar to those of the arach
Blood vessels of the dura are far more permeable than those of noid, are not.
the brain; however, because the outermost layer of cells of the
arachnoid forms a barrier, substances diffusing out of dural
vessels do not enter the CSF of the subarachnoidal space. The SKULL
cells are joined by tight junctions, and their permeability char
acteristics are similar to those of the blood vessels of the brain The skull (cranium) , which is rigid in adults but pliable in
itself. newborn infants, surrounds the brain and meninges com
pletely and forms a strong mechanical protection. In adults,
the volume of the brain can increase beyond the capacity of
Ependyma the intact cranium as a result of swelling after injury, and t his
The ependyma lining the cerebral ventricles is continuous with can further compress the already injured brain and cause her
the epithelium of the choroid plexus (Fig 1 1 - 1 5) . Except for niation. Increased cranial pressure in infants may cause the
the ependyma of the lower third ventricle, most ependymal fontanelles to bulge or the head to begin to enlarge abnor
cells do not have tight junctions and cannot prevent the move mally (see Fig 1 1 - 1 2).
ment of macromolecules between ventricles and brain tissue. Essential structures (eg, cranial nerves, blood vessels)
travel to and from the brain through various openings (fis
sures, canals, foramens) in the skull and are especially subject
Dura to compression as they traverse these small passageways.
Arachnoid villus Thus, a good knowledge of their anatomy is important for the
��::;=��·�:
Arachnoid
clinician.
Subarachnoid
space
\. Pia Basa l View of the Sku l l
Ependyma
The anterior portion of the base of the skull, the hard palate,
Choroid artery projects below the level of the remainder of the inferior skull
in choroid surface. The choanae, or posterior nasal apertures, are behind
plexus
and above the hard palate. The pterygoid plates lie lateral t o
the choanae (Fig 1 1 - 16).
Ventricle At the base of the lateral pterygoid plate is the foramen
Perivascular ovale, which transmits the third branch of the trigeminal
space Brain substance nerve, the accessory meningeal artery, and (occasionally) the
FIGURE 1 1 -1 5 Schematic i l l u stration of the r elations h i ps and superficial petrosal nerve. Posterior to the foramen ovale is
the barriers between the b ra i n, the meninges, and the vessels. the foramen spinosum, which transmits the middle
meningeal vessels. At the base of the styloid process is the sty
lomastoid foramen, through which the facial nerve exits.
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CHAPTER 1 1 Ventricles and Coverings of the Brain 1 57
Incisive foramen
Mandibular fossa
Carotid canal
Jugular foramen
Occipital condyle
FIGURE 1 1 - 1 6 Basal view of the sku l l, external aspect. Major bones a re labeled in bl ue.
The foramen lacerum is a large irregular aperture at the the intermediate compartment contains t he glossopharyngeal,
base of the medial pterygoid plate. Within its superior aspect vagus, and spinal accessory nerves; and the posterior compart
is the carotid canal . The internal carotid artery, which ment contains the sigmoid sinus and meningeal branches from
emerges from this aperture, crosses only the superior part of the occipital and ascending pharyngeal arteries.
the foramen lacerum. Posterior to the basilar portion of the occipital bone is the
Lateral to the foramen lacerum is a groove, the sulcus foramen magnum, which transmits the medulla and its
tubae auditivae, that contains the cartilaginous part of the au membranes, the spinal accessory nerves, the vertebral arteries,
ditory (eustachian) tube. It is continuous posteriorly with the and the anterior and posterior spinal arteries. The foramen
canal in the temporal bone that forms the bony part of the au magnum is bounded laterally by the occipital condyles.
ditory tube. Lateral to the groove is the lower orifice of the Behind each condyle is the condyloid fossa, perforated on
carotid canal, which transmits the internal carotid artery and one or both sides by the posterior condyloid canal (which
the carotid plexus of the sympathetic nerves. may transmit an emissary vein from the transverse sinus ) .
Behind the carotid canal is the large jugular foramen, Farther forward is the anterior condylar canal, o r hypoglos
which is formed by the petrous portion of the temporal and oc sal canal , which transmits the hypoglossal nerve and a
cipital bones and can be divided into three compartments. The meningeal artery.
anterior compartment contains the inferior petrosal sinus;
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158 SECTION I V Anatomy o f the Brain
I nterior of the S ku l l
A . Calvaria
The inner surface of the calvaria (skull cap) is concave, with
depressions for the convolutions of the cerebrum and furrows
for the branches of the meningeal vessels. Along the midline
is a longitudinal groove, narrow anteriorly and posteriorly
wide, that contains the superior sagittal sinus. The margins of
the groove provide attachment for the falx cerebri. At the rear
are the openings of the parietal emissary foramens (when
these are present) . The sutures of the calvaria (sagittal, coro
nal, lambdoid, and others) are meshed lines of union between
adjacent skull bones.
TABLE 1 1 -3 Structu res Passing Through Open ings in the Cranial Floor.
Foramens Structures
Superior orbital fissure Ocu lomotor, trochlear, and abducens nerves; ophtha lmic division of trigeminal nerve; superior
ophthalmic vein
Fora men rotundum Maxil l a ry d ivision of trigem inal nerve, small a rtery and vei n
I nternal acoustic meatus Facial and vestibu locochlear nerves, interna l aud itory artery
Jugular foramen Glossopharyngeal, vag us, and spinal accessory nerves; sigmoid sinus
Fora men magnum Med u l la and meni nges, spinal accessory nerve, vertebral a rteries, a nterior and posterior spinal a rteries
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CHAPTER 1 1 Ventricles and Coverings of the Brain 1 59
Crista galli
Cribriform plate of eth moid
Tuberculum sellae
Foramen rotundum
Anterior clinoid process
Carotid groove
Foramen lacerum
Foramen ovale
Foramen spinosum
Carotid canal
Dorsum sellae
Arcuate eminence
Clivus of sphenoid
FIGURE 1 1 - 1 8 Basal view of the skull, i nternal aspect. Major openings a re h i g h l i g hted i n color.
The narrow medial portion of the fossa presents the chi contains the internal carotid artery, surrounded by a plexus of
asmatic groove and the tuberculum sellae anteriorly; the sympathetic nerves.
chiasmatic groove ends on either side at the optic canal, The lateral segments of the middle fossa are deeper than
which transmits the optic nerve and ophthalmic artery. its middle portion; they support the temporal lobes of the
Behind the optic canal, the anterior clinoid process is di brain and show depressions that mark the convolutions of the
rected posteriorly and medially and provides attachment for brain. These segments are traversed by furrows for the ante
the tentorium cerebelli. In back of the tuberculum sellae is a rior and posterior branches of the middle meningeal vessels,
deep depression, the sella turcica; this structure, whose name which pass through the foramen spinosum.
means "Turkish saddle" (which it resembles), is especially The superior orbital fissure is situated in the anterior
important because it contains the hypophyseal fossa in which portion of the middle cranial fossa. It is bounded above by the
the hypophysis (pituitary) lies. The sella t urcica is bounded lesser wing, below by the greater wing, and in the middle by
posteriorly by a quadrilateral plate of bone, the dorsum sel the body of the sphenoid. The superior orbital fissure trans
lae, whose sides project anteriorly as the posterior clinoid mits into the orbital cavity the oculomotor nerve, the
processes. These attach to slips of the tentorium cerebelli. trochlear nerve, the ophthalmic division of the trigeminal
Below each posterior clinoid process is a notch for the ab nerve, the abducens nerve, some filaments from the cavernous
ducens nerve. plexus of the sympathetic nerves, the ophthalmic veins, and
On either side of the sella turcica is the broad and shallow the orbital branch of the middle meningeal artery.
carotid groove, curving upward from the foramen lacerum to The maxillary division of the trigeminal nerve passes
the medial side of the anterior clinoid process. This groove through the foramen rotundum, which is located behind the
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1 60 SECTION IV Anatomy of the Brain
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CHAPTER 1 1 Ventricles and Coverings of the Brain 161
FIGURE 1 1 -1 9 A n 8 1 -year-old woman was adm itted with shortness o f breath and f ever. She was fou n d t o have a right middle lobe
pneumon ia, the third pneumonia i n three months. Neurologic exa m ination r evea led a voca l cord paralysis on the right side; the gag r eflex was
a bsent and there was loss of bulk of the trapezius and sternocleidomastoid m uscles o n the right side; the t ongue appeared slightly atrophic o n
the r i g h t and deviated to the r i g h t upon protrusion; there w a s asymmetric elevation of t h e s o ft pa late (deviation t o the l eft due to paralysis o n
the r i g h t side). T h e patient aspi rated during a swa l lowi ng eva l uatio n . Mag netic r esonance imaging of the bra i n demonstrated a m a s s lesion
with i n the j u g u l a r foramen and the petrous bone o n the right side [left image, a rrow heads] . Computed t omography of the base of the skull
showed osteolytic changes with i n the right petrous t em poral and occipita l bone [rig ht: a rrow heads; asterisk: j u g u l a r foramen]. A biopsy
confi rmed the c l i n ical l y suspected d iagnosis of glomus j u g u l a re tumor which had i m p a i red fu nction of the n i nth, t enth, eleventh and t welfth
cra n i a l nerves. The patient was treated with rad iation. (Courtesy of Dr. Joachim Baehring.)
C A S E 14
A 2 1 -year-old motorcyclist was brought into the emer logic deficits . Other findings included a blood pressure of
gency room. He had been found lying unconscious, with 1 20/80 mrn Hg, a pulse rate of 75/min, and a respiratory
out a helmet, in the street, having apparently slipped going rate of 17 /min.
around a curve. It appeared that his head had probably hit What is the differential diagnosis at this time? What im
the curb. He had facial abrasions and a swelling above his aging or other diagnostic procedures are indicated?
right ear. While in the emergency room he regained con The patient was kept for observation in the emergency
sciousness. He appeared dazed and complained of room. Several hours later the patient had become stuporous
headache but did not speak clearly. and his right pupil was dilated. His blood pressure was
Neurologic examination showed no papilledema. His 1 5 0/90 mrn Hg; pulse rate, 55/min; and respiratory rate,
pupils were equal, round, and reactive to light (PERRL), 1 2/min. Emergency surgery was undertaken.
extraocular movements were normal, and there was ques What is the most likely diagnosis?
tionable left facial weakness. There were no other neuro- Cases are discussedfurther in Chapter 25.
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1 62 SECTION IV Anatomy of the Brain
nerves and vessels running through these foramens. An exam Rosenberg GA: Brain edema and disorders of cerebrospinal fluid
ple is shown in Figure 1 1 - 1 9. circulation. In: Neurology in Clinical Practice, 5th Ed. Bradley
WG, Daroff RB, Fenichel GM, Jankovic J (editors). Butterworth
Heinemann-Elsevier, 2008.
REFERENCES Seehusen DA, Reeves MM, Fomin DA: CSF analysis. Amer. Family
Physician 2003;68: 1 1 03- 1 108.
Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous System. Sharma HS (editor): Blood-Spinal Cord and Brain Barriers in Health
WB Saunders, 1 992. and Disease. Elsevier, 2004.
Heimer L: The Human Brain and Spinal Cord. Springer-Verlag, Waddington MM: Atlas of the Human Skull. Academic Books, 1 983.
1 983.
Romanes GJ: Cunningham's Textbook of Anatomy, 12th ed. Oxford
Univ Press, 1 983.
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C H A P T E R
Vascular Supply of
the Brain
The brain and spinal cord are critically dependent on an unin region. The arteries course in the subarachnoid space, often
terrupted supply of oxygenated blood, and thus are dependent for a considerable distance, before entering the brain i tself;
on unimpeded flow through the cerebral vessels. About 18% of rupture of a vessel ( eg, from an aneurysm that has burst) tends
the total blood volume in the body circulates in the brain, to cause a subarachnoid hemorrhage.
which accounts for about 2% of the body weight. The blood Each major artery supplies a certain territory, separated
transports oxygen, nutrients, and other substances necessary by border zones (watershed areas) from other territories;
for proper functioning of the brain and carries away metabo sudden occlusion in a vessel affects its territory immediately,
lites. Loss of consciousness occurs in less than 15 seconds after sometimes irreversibly.
blood flow to the brain has stopped, and irreparable damage to
the brain tissue occurs within 5 minutes.
Cerebrovascular disease, or stroke, occurs as a result of Principal Arteries
vascular compromise or hemorrhage and is one of the most fre The arterial blood for the brain enters the cranial cavity by way
quent sources of neurologic disability. Because t he cerebral ves of two pairs oflarge vessels (Figs 12-1 and 12-2): the internal
sels each tend to irrigate specific territories in the brain, their oc carotid arteries, which branch off the common carotids, and
clusion results in highly stereotyped syndromes that, even prior the vertebral arteries , which arise from the subclavian arteries.
to imaging studies, can suggest the site of the vascular lesion. The vertebral arterial system supplies the brain stem, cerebel
Nearly half of the admissions to many busy neurologic lum, occipital lobe, and parts of the thalamus, and the carotids
services are because of strokes. Cerebrovascular disease is the normally supply the remainder of the forebrain. The carotids
third most common cause of death in industrialized societies. are interconnected via the anterior cerebral arteries and the
Because thrombolysis-if accomplished in the initial hours af anterior communicating artery; the carotids are also con
ter a stroke occurs-can sometimes restore blood flow and im nected to the posterior cerebral arteries of the vertebral sys
prove clinical status, early recognition and treatment of stroke tem by way of two posterior communicating arteries, part of
are essential. the circle of Willis.
Left posterior
cerebral artery
Left middle
cerebral artery
Posterior
GIWIJ!�--'---t- Carotid siphon communicating
artery
FJ��iiir---f-- Basi lar artery
6'-����,....----::---1"- Posterior
Left vertebral cerebral artery
Superior
cerebellar artery
Basilar artery
with pontine
branches
Posterior inferior
cerebellar artery
-1---- Left subclavian Left vertebral artery
Anterior spinal artery
artery
FIGURE 1 2-2 Circle of Wi l l i s and principal a rteries of the
brain stem .
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CHAPTER 12 Vascular Supply of t he Brain 165
Ophthalmic artery
FIGURE 1 2-3 Principal a rteries on the floor of the cra nial cavity (brain r em oved) .
cortical area is accompanied by a shift in blood volume to that dural sinuses. Communication exists between most of these
area. channels. Unlike systemic veins, cerebral veins have no
valves and seldom accompany the corresponding cerebral
arteries.
VENOUS DRAINAGE
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1 66 SECTION IV Anatomy of the Brain
I l l -----,M:::�
ST ---af#!-�1
:0...�
M L --,tllf---'!
RN --H<"-1�-+
B. Pons
Basal branch
V l l l ----..�10111'
Xll -��b.._
v --HJ'---r""l
ML -�----�1
ST -lor.J.--�
ON -""";.-or·� Basal branch
FIGURE 1 2-4 Arterial supply of the bra i n stem . A: M i d bra i n . The bas i l a r artery gives off paramed ian branches that supply the ocu lomotor
(Ill) nerve n ucleus and the r ed nucleus (RN). A larger branch, the posterior cerebral artery, cou rses latera l l y around the m idbrain, giving off a
basal branch that suppl ies the cerebral pedu ncle ( CP) and a dorsolateral bra nch supplying the spi n othalamic tract (ST), medial lemn iscus (M L),
and superior cerebel lar ped u ncle. The posterior cerebra l a rtery conti n ues ( u pper arrows) to supply the thalam u s, occi pital lobe, and medial
temporal lobe. B: Pons. Pa ramedian branches of the basi lar a rtery supply the a bd ucens ( VI) nucleus and the medial l e m n iscus ( M L). The a nterior
i nferior cerebe l l a r a rtery g ives off a basal branch to the descending m otor pathways i n the basis pontis (BP) and a dorso latera l branch t o the
trigem i n a l (V) nucleu s, the vesti bular (VIII) n u cl eus, and the spi notha lamic tract (ST) before passing to the cerebe l l u m (u pper a rrows). C:
M ed u l l a . Paramedian branches of the vertebra l a rteries supply descending m otor pathways in the pyra m i d (P), the m ed i a l l e m n iscus ( M L), and
the hypog lossal (XII) n ucleus. Another vertebral branch, the posterior i nferior cerebellar a rtery, gives off a basa l branch t o the o l iva ry n u clei (ON)
and a dorsolateral branch that supp lies the trige m i n a l ( V) n ucleus, the vesti b u l a r (VIII) nucleus, and the spinothalamic tract (ST) on its way to
the cerebe l l u m ( u pper arrows). (Reprod uced, with permission, from Simon RP, Aminoff MJ, Greenberg DA: Clinical Neurology, 4th ed. Appleton & Lange, 1 999.)
right and one left) around the side of the midbrain, draining the Cortica l Vei n s
base of the forebrain. The precentral vein from the cerebellum
Venous drainage o f the brain surface i s generally into the
and veins from the upper brain stem also empty into the great
nearest large vein or sinus, from there to the confluence of
vein, which turns upward behind the splenium and j oins the in
the sinuses, and ultimately to the internal j ugular vein (see
ferior sagittal sinus to form the straight sinus. The venous
Fig 1 2-8) .
drainage of the base of the cerebrum is also into the deep middle
The veins of the cerebral convex surfaces are divided into
cerebral vein (coursing in the lateral fissure) and then to the cav
superior and inferior groups. The 6 to 12 superior cerebral
ernous sinus.
veins run upward on the hemisphere's surface to the superior
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CHAPTER 12 Vascular Supply of t he Brain 1 67
Motor Sensory
(precentral gyrus) (postcentral gyrus)
Leg
Foot
ongue
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168 SECTION IV Anatomy of the Brain
Motor Sensory
(precentral gyrus) (postcentral gyrus)
Trunk
Arm
Hand '"'H M d
Arm
/
Face
Tongue Tongue
Emissary vein
Rectus sinus
Frontal vein
Transverse sinus
Cavernous sinus
.,._-�- Superior petrosal sinus
FIGURE 1 2-8 Organ ization of vei n s and s i n u ses of the bra i n . Figure 1 2- 1 1 p rovides a frontal view, cut along the plane shown by the
vertical l i ne.
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CHAPTER 12 Vascular Supply of t he Brain 1 69
veins
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1 70 SECTION IV Anatomy of the Brain
Optic ch iasm
Trigeminal
ganglion and
ophthalmic
Sphenoid sinus
division of V
FIGURE 1 2-1 1 The cavernous sinus and associated structu res. A: Relationship t o skull and bra i n . B: The cavernous s i n u s wraps a round
the p itu itary. Several i m porta nt structures run throu g h the cavernous sinus: the internal carotid a rtery; the ocu lomotor, trochlear, and abducens
nerves; and the o phtha l m i c branch of the trigem i n a l nerve and trigeminal ganglion.
neuroprotective strategies that interfere with calcium influx are this type are termed transient ischemic attacks ( TIAs). As
being experimentally studied. with occlusive cerebrovascular disease, the neurologic
abnormalities often permit the clinician to predict the
vessel that is involved.
Classification
Hemorrhage: The rupture of a blood vessel is often asso
Diseases involving vessels of the brain and its coverings have ciated with hypertension or vascular malformations or
characteristic clinical profiles and can be classified as follows with trauma.
(Table 1 2- 1 ) . Vascular malformations and developmental abnormal
ities: These include aneurysms or arteriovenous malfor
Occlusive cerebrovascular disorders: These result from
mations (AVMs), which can lead to hemorrhage.
arterial or venous thrombosis, or embolism, and can lead
Hypoplasia or absence of vessels occurs in some brains.
to infarction of well-defined parts of the brain. Because
each artery irrigates a specific part of t he brain, it is often Degenerative diseases of the arteries: These can lead to
possible, on the basis of the neurologic deficit, to identify occlusion or to hemorrhage.
the vessel that is occluded. Inflammatory diseases of the arteries: Inflammatory dis
eases, including systemic lupus erythematosus, giant cell
Transient cerebral ischemia: Transient ischemia,
arteritis, and syphilitic arteritis, can result in occlusion of
if brief enough, can occur without infarction. Episodes of
cerebral vessels, which, in turn, can produce infarction.
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TABLE 1 2- 1 Clinical Profi le o f Cerebrovasc u l a r Disorders.
Vascular
Hypertensive Malformations
Intracerebral Cerebral Infarct Cerebral Infarct Subarachnoid (can Include Su bdural Epidural
Variable Hemorrhage (Thrombotic) (Embolic) Hemorrhage bleeding) Hemorrhage Hemorrhage
Pathology Hemorrhage in I nfarct i n territory Infarct in territory Bleeding i nto sub- Bleeding or infarct Hemorrhage i nto Hemorrhage into
deep structures of large o r small of large or medium- arachnoid space near AVM; subdura l space, epidural space
(putamen, artery sized a rteries from aneurysm localization variable often over cerebral Often seen in asso-
thalamus, May be located at Hemorrhage into convexity ciation with skull
cerebe l lum, pons) periphery of hemi- parenchyma may May see rupture of fracture over
or lobar wh ite sphere (gray-white occur meningeal or middle meningeal
matter matter junction) bridging vein a rtery
Onset and Rapid (min utes to Sudden, gradual, Sudden onset Sudden severe Can present with Variable time course Rapid
course hours) onset of or stepwise onset (usually within headache repeated seizures May see slow deterioration,
hemiplegia or of focal deficits seconds or Possible loss of (because of deterioration often after a
other signs and Often preceded min utes) consciousness ischemia),or "lucid i nterval"
sym pto ms sudden onset of Depressed level of
by TIAs (eg, fol l owing head
Focal neurologic consciousness,
transient monocular deficit caused by trauma
signs may be bleed sometimes with
blindness, present hemiparesis
hemiparesis)
Can occur after
even trivial trauma
Blood pressu re Hypertension Hypertension often Normal Hyperten sion often Normal Normal at onset Normal at onset
Special findings Cardiac hyper- Arteriosclerotic Cardiac Subhyaloid (pre- Subhyaloid hemor- Trauma, bruises Severe trauma
trophy; hyperten- cardiovascu lar arrhythmias or retinal) hemor- rhages and retinal may be present often present
sive retinopathy d isease frequently infarction (source rhages;n uchal angioma
present of emboli often in rigid ity
heart)
CT scan findings I ncreased density Less dense in Less dense in I ncreased density Abnormal vessels, Dense (later, Dense segment
su rrou nded by avascular area avascular area caused by blood in sometimes with lig hter) zone under sku l l
hypodensity from basal cisterns calcifications (high over fracture (low over
edema; may see Dense cisterns may convexity) convexity)
bl ood in ventricles be seen after
Commonly see bleeding
mass effect
M R image MRI very sensitive. Decreased Decreased Often normal May see May see May see
May see blood clot density on T, ; density on T1; Less sensitive than hemorrhage hemorrhage hemorrhage
Signal increased density increased density CT for subarachnoid
characteristics on T2 on T2 blood
change with time
after bleed
CSF May be bloody Clear Clear Grossly bloody or Bloody if May be bloody or Clear
xanthochromic hemorrhage has xanthochromic
occu rred
-
'-.)
-
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1 72 SECTION IV Anatomy of the Brain
I nternal
carotid
artery
External
carotid
artery
Spared by anastomosis
��-- circulation through the anterior communicating artery and
posterior communicating arteries may permit sufficient blood
flow to prevent infarction. Similarly, in some cases in which
" "��� nfarct of the internal carotid artery is occluded in the neck, anasto
internal motic flow in the retrograde direction via the ophthalmic ar
carotid
artery tery, from the external carotid artery, may provide adequate
circulation, thus preventing infarction.
Although sudden occlusion can lead to irreparable dam
age, slowly developing local ischemia may be compensated for
by increased flow through anastomoses involving one or more
routes: the circle of Willis, the ophthalmic artery (whose
FIGURE 1 2-1 3 Coronal section through the cerebrum show branches communicate with external carotid vessels) , or cor
ing a l a rge i nfarct caused by occl usion of the i nternal carotid a rtery. ticomeningeal anastomoses from meningeal vessels.
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CHAPTER 12 Vascular Supply of the Brain 1 73
Stenosis of internal
carotid arteries
Atherosclerosi s of the B ra i n Atheromatous changes in the arterial system are found rel
atively frequently at postmortem examination among those who
The principal pathologic change i n the arteries o f the brain oc
have reached middle age (Fig 12-15). They are particularly com
curs in the vasculature of the neck and brain, although similar
mon in patients with untreated hypertension or with unfavor
changes may also be present in other systemic vessels. Distur
able lipid profiles. Vessels of all sizes may be affected. A combi
bances in metabolism, especially of fats, are believed to be a
nation of degenerative and proliferative changes can be seen
prominent associated change. Hypertension accelerates the
microscopically. The muscularis is the main site of proliferation;
progression of atherosclerosis and is a treatable risk factor for
the intima may be absent. The areas most often involved are near
stroke.
branchings or confluences ofvessels (Fig 12- 1 6 and Table 12-2).
The most common and severe atherosclerotic lesions are in the
carotid bifurcation. Others occur at the origin ofthe vertebral ar
teries, in the upper and lower parts of the basilar artery, and in
the internal carotid artery at its trifurcation, the first third of the
middle cerebral artery, and the first part of the posterior cerebral
artery: Narrowing of vessels s evere enough to cause vascular in
sufficiency is more frequent in older persons.
Stenosis
Brach iocephalic 4
Internal carotid (near bifurcation) 34 34
Anterior cerebral 3 3
Proximal vertebral 22 18
Distal vertebral 4 5
Occlusion
Brach iocephalic
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1 74 SECTION IV Anatomy of the Brain
C L I N ICAL I L LU STRATION 1 2- 1
A 48-yea r-ol d attorney was to l d h e was hypertensive but d i d resu lt of col l atera l fl ow from other vessel s (eg, via the a nterior
n o t take h i s b l ood p ressure medications. He w a s a p p a rently co m m u n icati n g a rtery) . The patie nt's fu n cti o n a l deficit was
we l l until 4 d ays after his b i rthd ay, when he h a d several nevertheless deva stati ng beca use much of the motor cortex
episodes of b l u rred vision, " l i ke a shade com i n g down;' involv and the speech a reas in the left hemisphere were destroyed by
ing his left eye. These attacks each la sted less than an hour. He the infa rction.
was referred for n e u ro l o g i c eva l u ation but canceled the ap Th is case rem i n d s u s that hypertension represents a n i m
pointment becau se of a busy sched u le. Several weeks later, he porta nt r i s k factor for stroke, and a l l patients with hypertension
complai ned to h i s wife of a left-sided headache. She found h i m should be ca refu l ly eva l u ated a n d treated if appropriate. I t is
a h a lf hour later s l u m ped i n a chair, apparently confused and not enoug h to prescribe medication; the physician m ust fol low
paralyzed on the right side. Neurologic exa m i nation i n the hos u p and m a ke sure the patient takes the medici ne. Th is patient
pita l revea led tota l pa ra lysis of the rig ht arm and severe wea k exh i b ited seve ra l episodes of a m a u rosis fugax, o r tra n s i e nt
ness of the right face. The leg wa s o n ly m i l d ly affected. Deep monocu l a r b l i n d ness. These episodes, w h i c h a re d u e to is
tendon reflexes were i n itially depressed on the right side but chemia of the retina, ofte n occu r i n the context of atheroscle
within severa l days beca me hyperactive; there was a Babi nski rotic d i sease of the carotid a rte ry. I ndeed, a n g iogra phy after
response on the right. The patient was globally aphasic; he was this patient's stroke revea led occl usion of the ca rotid a rtery. I t
unable to produce a ny intelligible speech and a ppeared t o un h a s become clear that, in patients with sign ificant stenosis of
dersta nd only very s i m p l e p h rases. A comp uted tomogra p hy the carotid a rtery, enda rterectomy (remova l of the atheroscle
(CT) sca n revealed an infa rct in the territory of the middle cere rotic materia l within the artery) may prevent stroke. The prob
bral artery of the left side (see Fig 4-3). Ang iography revea led a b i l ity of a stroke a p pea rs to be hig hest i n the period after TIA
occlusion of the i nternal ca rotid artery. The patient recovered on set. Any patient with TIAs of recent on set should be eva l u
only m i n i m a l ly. ated on an u rgent basis.
Th i s tra g i c case i l l u strates several poi nts. Alth o u g h the The recent advent of throm bolysis with tPA has made acute
carotid a rtery o n the left was tota l l y occ l u d ed, the patient's stro ke a treatb l e e ntity if therapy i s beg u n early e n o u g h .
cerebral infa rct was l i m ited to the territory of the middle cere Stro kes, and sus pected strokes, s h o u l d be reg a rded as "brain
bral a rtery. Even though the a nterior cerebral a rtery arises (to attacks;' a n d patients should be tra nsported to the emergency
gether with the m i d d l e cerebra l a rtery) from the ca rotid, the room without delay.
a nte rior cerebral a rtery's territory was s p a red, proba bly a s a
TABLE 1 2-3 Brain Stem Syndromes Resu lting from Vascular Occlusion.
Medial syndromes
Med u l la Paramedian branches Emerging fi bers of twelfth nerve I psi latera l hemipara lysis oftongue
I nferior pons Paramedian branches Pontine gaze center, near or i n Paralysis of gaze to side of lesion
nucleus o f sixth nerve
Emerging fibers of sixth nerve I psilateral abd uction paralysis
Superior pons Paramedian branches Medial longitudinal fascicu l u s I ntern uclear ophthal moplegia
Lateral syndromes
Med u l la Posterior i nferior cerebel lar Emerging fi bers o f n i nth and Dysphagia, hoarseness, ipsi latera l
tenth nerves paralysis of vocal cord; ipsilatera l
loss of pharyngeal reflex
Vestibular n uclei Vertigo, nystagmus
Descending tract and nucleus of I psi latera l facial analgesia
fifth nerve
Sol itary n ucleus and tract Taste loss on ipsilatera l half of
tongue posteriorly
I nferior pons Anterior i nferior cerebellar Emerging fibers of seventh nerve Ipsi latera l facial paralysis
Sol itary nucleus and tract Taste loss on ipsilatera l half of
tongue anteriorly
Coch lear nuclei Deafness, ti n n itus
Midpons Motor nucleus of fifth nerve Ipsilateral jaw weakness
Emerging sensory fi bers of fifth nerve I psi lateral facial n u mbness
Modified with permission from Rowland LP: Clin ical syndromes of the brain stem. IN Kandel ER, Schwartz JH (editors): Principles of Neural Science, 2nd edition. Elsevier, 1 985.
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1 76 SECTION IV Anatomy of the Brain
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CHAPTER 12 Vascular Supply of the Brain 1 77
that is ischemic due to impaired blood flow, but not yet in
farcted) can sometimes be seen. Visualization of a s alvageable
ischemic penumbra can be clinically helpful in identifying pa
tients who are candidates for thrombolysis and/or stenting,
and can guide therapy (Fig 1 2 - 1 8 ) .
C A S E 15
A 44-year-old woman was admitted after a seizure. She normal. Reflexes appeared normal. The right plantar exten
was lethargic, with a right facial droop, right hemiparesis, sor response was equivocal, but the left was normal.
and right hyperreflexia. She complained of headache and a The blood pressure was 1 20/8 5 ; pulse rate, 60; and tem
painful neck. A few days later, she seemed slightly more perature, 38 oc ( 1 00.4 °F). The white blood count was
alert and made purposeful movements with her left hand 1 1 ,200/fl.L, and the erythrocyte sedimentation rate was 30
but not her right hand. She was still unresponsive to spo mmlh.
ken commands and had a rigid neck. Other findings in Where is the lesion? What is the cause of the lesion?
cluded papilledema, a right pupil that was smaller than the What is the differential diagnosis?
left, incomplete extraocular movements on the left side A CT scan showed a high-density area in the cisterns,
(nerve V1 function was normal), decreased right corneal especially on the right side. What is the diagnosis now ?
reflex, and right nasolabial droop. The patient's right arm Would you request a lumbar puncture with analysis of the
was hypertonic and paretic, but the other extremities were cerebrospinal fluid?
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1 78 SECTION IV Anatomy of the Brain
Congenital berry aneurysms are seen most frequently in Vascular malformations, especially AVMs, often occur in
the circle of Willis or in the middle cerebral trifurcation; younger persons and are found on the surface of the brain,
they are especially common at sites of arterial branching. deep in the brain substance, or in the meninges (dural AVMs).
Aneurysms are seen infrequently in vessels of the posterior Bleeding from such malformations can be intracerebral, sub
fossa. A ruptured aneurysm generally bleeds into the sub arachnoid, or subdural.
arachnoid space or, less frequently, into the brain substance
itself.
C A S E 16
A 5 5 -year-old salesman exhibiting signs of confusion nerves. When the left hand was extended, it showed a slow
was brought to the hospital. The history elicited from his downward drift. The reflexes were normal and symmetric,
landlady indicated that he drank alcohol excessively. His and there was a left-sided plantar extensor response.
landlady had entered the apartment on the day of admis Vital signs, complete blood count, and urinalysis were
sion because he did not respond to her calls. She found within normal limits. A lumbar puncture showed an open
him lying on the floor, incontinent and appearing bewil ing press ure of 1 80 mm H20, xanthochromia, a protein
dered; he had also bitten his lip . The landlady remem level of 80 mg/dL, and a glucose level of 70 mg/dL. Cell
bered that he had been involved in a bar fight 2 months counts in all tubes showed red blood cells, 800/fLL; lym
earlier, and 3 weeks previously he had fractured his wrist phocytes, 20/fLL; and polymorphonuclear neutrophils,
falling down stairs. 4/mL. A CT scan of the head was obtained.
On examination, the patient was unconcerned and di Over the next 36 hours, the patient became deeply ob
sheveled. Bruises on his head and legs were consistent tunded, and a left-sided hemiparesis seemed to develop.
with recent trauma. The liver was palpable 4 em below the What is the differential diagnosis? What is the most
right costal margin. The patient appeared to fall asleep likely diagnosis?
when left alone. Neurologic examination showed normal Questions and answers pertaining to Section IV (Chap
optic fundi, normal extraocular movements, and no abnor ters 7 through 1 2) can be found in Appendix D.
malities that would result from dysfunction of other cranial Cases are discussed further in Chapter 25.
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CHAPTER 12 Vascular Supply of the Brain 1 79
S u bd u ra l Hemorrhage
Tearing of the bridging veins between brain surface and dural
sinus is the most frequent cause of subdural hemorrhage
(Figs 1 2-24 and 1 2-25; see Table 1 2- 1 ) . It can occur as the re
sult of a relatively minor trauma, and some blood may be pres
ent in the subarachnoid space. Children (because they have
thinner veins) and aged adults with brain atrophy (because FIGURE 1 2-2 1 Computed tomography image of a horizontal
they have longer bridging veins) are at greatest r isk. section through the h ead, showi ng h i g h densities, r ep resenting a
subarachnoid hemorrhage (arrows) in the su lci.
Epid u ra l Hemorrhage
Bleeding from a torn meningeal vessel (usually an artery) may
lead to an extradural (outside the dura) accumulation ofblood
that can rapidly compress the brain, progressing to herniation
or death if not surgically evacuated. Fracture of t he skull can
cause this type of epidural, or extradural, hemorrhage
(Figs 1 2-26 and 1 2-27; see Table 1 2 - 1 ) . Uncontrolled arterial
Partially
th rom bosed
aneurysm
Middle
cerebral artery
Dorsum sellae
A B
FIGURE 1 2-22 A: Computed tomography image of a horizontal section through the head, showi ng a l a rge aneurysm of the anterior
com m u n icating a rtery. (Reprod uced, with permission, from deGroot J: Correlative Neuroanatomy of Computed Tomography and Magnetic Resonance Imaging. Lea &
Febiger, 1 984.) B: Corresponding angiogram showing the partially t h rom bosed a n eu rysm ( arrows).
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180 SECTION IV Anatomy of the Brain
Subdural
hematoma
Dura
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CHAPTER 12 Vascular Supply of t he Brain 181
REFERENCES
Bruised
scalp
Barnett HJ, Mohr JP, Stein BM, Yatsu FM: Stroke-Pathophysiology,
Air bubble Diagnosis, and Management, 3rd ed. Churchill Livingstone,
1 998.
Batjer HH, Caplan LR, Friberg L, Greenlee RG, Kopitnik TA, Young
WL: Cerebrovascular Disease. Lippincott-Raven, 1 997.
FIGURE 1 2-27 Com puted tomography image of a horizontal Choi DW: Neurodegeneration: Cellular defenses destroyed. Nature
section through the h ead, showi ng a n extradura l hematoma and i n 2005;433:696.
tracerebral contrecou p lesion. (Reprod uced, with permission, from deGroot J: Del Zoppo G: TlAs and the pathology of cerebral ischemia.
Correlative Neuroanatomy of Computed Tomography and Magnetic Resonance Neurology 2004;62:5 15.
Imaging. 2 1 st ed. Appleton & Lange, 1 99 1 .) Felberg RA, Burgin WS, Grotta JC: Neuroprotection and t he
ischemic cascade. CNS Spectr 2000;5:52.
Fisher CM: Lacunar strokes and infarcts: A review. Neurology
bleeding may lead to compression of the brain and subsequent 1 982;32:871.
herniation. Immediate diagnosis and surgical drainage are es Hemmen TM, Zivin JA: Molecular mechanisms in ischemic brain
sential. disease. In: Molecular Neurology, Waxman SG (editor) .
Elsevier, 2007.
Kogure K, Hossmann KA, Siesjo B: Neurology of Ischemic Brain
AVMs a n d S h u nts Damage. Elsevier, 1 994.
Mohr JP, Choi D, Grotta J, Weir B, Wolf PA: Stroke: Pathophysiology,
AVMs, in which cerebral arteries and veins form abnormal diagnosis, and management. Lippincott, 2004.
tangles or webs, can occur as developmental anomalies. Salamon G: Atlas of the Arteries of the Human Brain. Sandoz, 1 973.
Whereas some AVMs are clinically silent, others tend to Waxman SG, Ransom BR, Stys PK: Nonsynaptic mechanisms of
bleed or cause infarction in nearby parts of the brain. Trauma calcium-mediated injury in the CNS white matter. Trends
can also cause the rupture of adjacent vessels, allowing arte Neurosci 1 99 1 ; 14:46 1 .
rial blood to flow into nearby veins. For example, in a
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C H A P T E R
Control of Movement
183
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1 84 SECTION V Functional Systems
Basa l G a n g l i a
FIGURE 1 3-1 Schematic i l l u stration of some pathways control Pathways and nuclei: The anatomy o f the gray masses i n the
ling motor fu nctions. Arrows denote descend i n g pathways. forebrain that make up the basal ganglia has been described in
Chapter 10 (see Figs 1 0 - 1 7, 1 0 - 1 8, and 1 3-2). The striatum
(caudate and putamen) is the major site of input to the basal
ganglia (see Fig 1 3-2B) . The striatum receives afferents via the
neurons exists only for the musculature of the distal extrem corticostriate projections from a large portion of the cerebral
ity, such as the fingers that require rapid and precise control. cortex, especially the sensorimotor cortex (areas 4, 1, 2, and 3),
the more anterior premotor cortex (area 6), and the frontal eye
B. Pathways fields (area 8) in the frontal and parietal lobes. These corticos
The corticobulbar (corticonuclear) fibers originate in the re triate projections are excitatory. The striatum also r eceives in
gion of the sensorimotor cortex, where the face is represented puts from the intralaminar thalamic nuclei, substantia nigra,
(see Figs 1 0 - 1 3 and 10- 14). They pass through the posterior amygdala, hippocampus and midbrain raphe nuclei. Many in
limb of the internal capsule and the middle portion of the crus hibitory (gamma-aminobutyric acid [ GABA ] - ergic) and a
cerebri to their targets, the somatic and brachial efferent nuclei smaller number of excitatory interneurons (the latter in some
in the brain stem. The corticospinal tract originates in the re cases using acetylcholine as a transmitter) are present within
mainder of the sensorimotor cortex and other cortical areas. It the striatum.
follows a similar trajectory through the brain stem and then The caudate and putamen send inhibitory (GABA-ergic)
passes through the pyramids of the medulla (hence, the name axons to the inner part of globus pallidus (GPi) , which is the
pyramidal tract), decussates, and descends in the lateral column major outflow nucleus of the basal ganglia. These projections
of the spinal cord (see Figs 5- 13, 13-1, and 13-3). About 10% of provide a strong inhibitory input to the globus pallidus (see
the pyramidal tract does not cross in the pyramidal decussation Fig 1 3-2C).
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CHAPTER 13 Control of Movement 185
Caudate
Fornix
Thalamus
' '
c D �:
F I G U R E 1 3-2 A : Basal ganglia: major structu res. M D, medial dorsal; VA, ventra l a nterior; VL, ventral latera l n uclei o f tha l a m u s. B: Major
afferents t o basal ganglia. C: I ntrinsic connections. D: Efferent connections.
The globus pallidus, GPi (internal part) is one of t he two laris and the lenticular fasciculus, also known as the H2 field
major output nuclei of the basal ganglia. GPi sends inhibitory of Forel) before entering the thalamus (see Fig 1 3-2C). The
axons (GABA-ergic) to the ventral nuclei (ventral anterior, VA and VL thalamic nuclei complete the feedback circuit by
VA; and ventral lateral, VL) of the thalamus (which also re sending axons back to the cerebral cortex (see Fig 1 3-2D ) .
ceives input from the cerebellum, the subthalamic nucleus, The circuit thus traverses, i n order,
and substantia nigra) . Axons from the globus pallidus project
to the thalamus by passing through or around the internal Cortex � striatum � globus pa l l id u s (internal, G Pi)
capsule. They then travel in small bundles (the ansa lenticu- � tha l am us � cortex
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186 SECTION V Functional Systems
Superficial reflexes
Cornea l Crania i V Pons Cranial VII
Nasal (sneeze) Cranial V Brai n stem and upper cord Crania Is V, VII, IX, X, and
spinal nerves of expiration
Pharyngeal and uvu lar Cranial IX Med u l la Cranial X
Upper abdominal T7, 8, 9, 1 0 T7, 8, 9, 1 0 T7, 8, 9, 1 0
Lower abdominal T1 0, 1 1 , 1 2 n o, 1 1 . 1 2 T1 0, 1 1 , 1 2
Cremasteric Femoral L1 Gen itofemora l
Plantar Ti bial 51 , 2 Ti bial
Anal Pudenda l 54, 5 Pudendal
Deep reflexes
Jaw Crania i V Pons Cra n ia i V
Biceps Musculocutaneous C5, 6 M uscu locutaneous
Triceps Rad ial C6, 7 Rad ial
Periosteoradial Rad ial C6, 7, 8 Rad ial
Wrist (flexion) Median C6, 7, 8 Median
Wrist (extension) Rad ial C7, 8 Rad ial
Patellar Femoral L2, 3, 4 Femora l
Ach i lles Ti bial 51 , 2 Ti bial
Visceral reflexes
Light Cranial II Midbrain Cranial Ill
Accommodation Cranial II Occipita l cortex Cranial Il l
Ciliospinal A sensory nerve T1 , 2 Cervical sym pathetics
Ocu locardiac Crania i V Med u l la Cranial X
Carotid sinus Cranial IX Med u l la Cranial X
Bul bocavernosus Pudenda l 52, 3, 4 Pelvic a utonomic
Bladder and rectal Pudenda l 52, 3, 4 Pudenda l and autonomies
Another important feedback loop involves the second The pars reticulata of the substantia nigra (SNr) receives
major outflow nucleus of the basal ganglia, the substantia ni input from the striatum, and sends axons outside the basal
gra, which is reciprocally connected with the putamen and ganglia to modulate head and eye movements.
caudate nucleus. Dopaminergic neurons in the pars com The subthalamic nucleus (also called the nucleus of
pacta of the substantia nigra project to the striatum (the ni Luys) also receives inhibitory inputs from the globus pal
grostriatal projection), where they form inhibitory synapses lidus and from the cortex; efferents from the subthalamic
on striatal neurons that have D2 dopamine receptors, and ex nucleus return to the globus p allidus (see Fig 1 3 - 2 C ) .
citatory synapses on neurons that have D 1 dopamine recep Thus, the subthalamic nucleus participates i n t he feedback
tors (see Fig 1 3-2B). Reciprocal projections travel from the loop:
striatum to the substantia nigra ( striatonigral projection)
and are also inhibitory (see Fig 1 3 -2C) . This loop travels Cortex � globus pallidus � subthalamic nuclei
along the pathway � globus pallidus � cortex
Cortex � striatu m � su bsta ntia n i g ra � striatum Another loop involves the cerebellum. Portions of the
thalamus project by way of t he central tegmental tract to the
Neurons in the substantia nigra and GPi also send in inferior olivary nucleus; this nucleus, in turn, sends fibers to
hibitory projections to the thalamus (VA and VL), which, in the contralateral cerebellar cortex. From t he cerebellum, the
turn, sends projections to the sensorimotor cortex. Substantia loop to the thalamus is closed via the dentate and contralateral
nigra (pars compacta) also sends modulatory proj ections red nuclei.
(mesolimbic and mesocortical projections) to the limbic system Although there are no direct projections from the caudate
and cortex. This pathway involves t he following circuit: nucleus, putamen, or globus pallidus to the spinal cord, the
subthalamic region, including the prerubral field and the red
Cortex � striatum � su bsta ntia n i g ra � nucleus, is an important relay and modifying station. Projec
'-------� thalamus � cortex tions from the globus pallidus to the red nucleus converge
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CHAPTER 13 Control of Movement 187
with inputs from the motor cortex and the deep cerebellar nu
clei. Efferent fibers from the red nucleus descend in the spinal
cord as the rubrospinal tract, which modulates the tone of
flexor muscles (see the following section) .
The organizational theme for the basal ganglia involves
complex loops of neurons (including many inhibitory
neurons) feeding back to the sensorimotor cortex. These
neuronal loops play an important role in m otor control.
Electrical engineers are well acquainted with abnormal os
cillations, or "ringing;' that can occur when inhibitory feed
back circuits are damaged. Disorders of the basal ganglia are
often characterized by abnormal movements that can b e
repetitive or rhythmic.
The motor control circuits passing through the basal
ganglia that are involved in movement disorders such as
Parkinson's disease have been conceptualized as operating in
a manner summarized in Figure 1 3-6A. According to this
model, excitatory synaptic output from the precentral and
postcentral motor and sensory cortex is directed to the puta
men. The putamen also receives proj ections from the pars
compacta of the substantia nigra (SNc) . Output from the
putamen is directed toward the internal portion of the
globus pallidus (GPi) and the pars reticulata of the substan
tia nigra ( SNr) via two pathways (the direct and indirect
Lower motor
neurons pathways) . Monosynaptic inhibitory proj ections from the
putamen project via the direct pathway to GPi/SNr and tend
to enhance motor activity. A series of polysynaptic connec
tions extends from the putamen, within the indirect path
To leg way, through portions of the external part of the globus pal
muscles lidus (GPe) and the subthalamic nucleus (STN ) , with the
net outcome of suppression of motor activity. In addition,
Dorsal horn mutual inhibitory connections exist b etween GPe and
GPi/SNr. Outputs from GPi/SNr proj ect t oward the ventro
lateral nuclear group of the thalamus (VL), and the VL in
turn proj ects back to the cortex. Importantly, most of the
FIGURE 1 3-3 Diagram of the corticospinal tract, including de intrinsic connections within the basal ganglia, and the
scending fi bers that p rovide sensory modu lation to thalam us, dorsal
col u m n n u clei, and dorsal horn.
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188 SECTION V Functional Systems
A. Normal B. Pa rkinsonism
A. Pathways
Brain stem Subcortical descending systems originate in the red nucleus
Spinal cord
and tectum of the midbrain, in the reticular formation, and in
FIGURE 1 3-6 A: Conceptual model of activity i n the basal the vestibular nuclei of the brain stem.
ganglia and associated thalamocortica l regions under normal The rubrospinal tract arises in the red nucleus. The red
circumsta nces. Dark a r rows ind icate i n h i bitory con nections, and nucleus receives input from the contralateral deep cerebellar
o p e n arrows indicate excitatory con n ections. B: Changes i n activity nuclei (via the superior cerebellar peduncle) and the motor
i n Pa rkinso n's d isease. As a result of degeneration of the pars cortex bilaterally. Axons descend from the red nucleus in
com pacta of the su bsta ntia nigra, differential changes occu r in the the crossed rubrospinal tract that descends in the lateral
two striatopa l lidal projections (as ind icated by altered th ickness of column and then synapses on interneurons in the spinal
the a rrows), including i ncreased output from GPi t o the thalam us.
cord.
D, d i rect pathway; I, i n d i rect pathway; GPe, external seg ment of
The sensorimotor cortex projects to several nuclei in the
g lobus pallidus; GPi, i nternal segment of globus pa l l id us; SNc, s u b
sta ntia n ig ra (pa rs compacta); S N r, su bsta ntia n ig ra (pars reticu l ata);
reticular formation of the brain stem, which then sends fibers
STN, su btha l a m i c n ucleus; VL, ventrolatera l t h a l a mus. (Reprod uced with to the spinal cord in the form of the reticulospinal tract in
permission from Wichmann T, Vitek J L, Delong MR: Parkinson's disease and the the lateral column. Descending axons in this tract terminate
basal ganglia: Lessons from the laboratory and from neurosurgery, Neuroscientist on interneurons in the spinal cord and on gamma motor
1 995;1 :236-244.) neurons.
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CHAPTER 1 3 Control o f Movement 189
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190 SECTION V Functional Systems
Cerebellar cortex
FIGURE 1 3-7 Schematic i l l u stration of some
cerebel l a r afferents and outflow pathways.
Lower motor Weak {paretic or May be present Hypoactive or Hypotonic Fascicu lations*
neuron {includes paralyzed) absent {flaccid)
peri pheral nerve,
neuropathy)
* Fasciculations are spontaneous, grossly visible contractions {twitches) of entire motor un its.
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CHAPTER 1 3 Control o f Movement 191
or peripheral nerves to the motor end-plates of the muscles Damage to the cerebral cortex incurred i n utero, during
(see Fig 5-22). The lower motor neuron is called the "final birth, or in early postnatal life may result in cerebral palsy.
common pathway" for two reasons. It is under the influence This is a heterogeneous group of disorders that often include
of the corticospinal, rubrospinal, olivo spinal, vestibu a form of spastic paralysis; however, the disease may be char
lospinal, reticulospinal, and tectospinal tracts as well as the acterized by other signs, such as rigidity, tremor, ataxia, or
segmental or intersegmental reflex neurons, and it is the ul athetosis. The disorder may be accompanied by defects such
timate pathway through which neural impulses reach the as speech disorders, apraxia, and mental retardation in some
muscle. (but by no means all) patients.
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1 92 SECTION V Functional Systems
Normal
Substantia Corpus
nigra striatum
0 oopamine A
o--<o-----<
Acetyl- GABA
choline
Pa rkinsonism
0 - - - - - - - - - - - - - :t.
o--<o---<
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CHAPTER 1 3 Control o f Movement 193
C A S E 17
A 63-year-old, right-handed secretary/typist consulted her patient had difficulty initiating movements . Once seated,
family physician when her right hand and fingers "did not she did not move about much. Her posture was stooped and
want to cooperate." She also explained that her employers she walked with a small-stepped gait, with decreased arm
had become dissatisfied with her because her work habits swing. There was no muscular atrophy and no weakness.
and movements had become slow and her handwriting had Muscle tone was increased in the arms, and "cogwheel
become scribbly and illegible over the preceding several rigidity" was present. There was a fine tremor in the fingers
months. She was in danger of losing her job even though of the right hand (frequency of three to four times per sec
her intellectual abilities were unimpaired. ond). The rest of the examination and the laboratory data
Neurologic examination showed slowness of speech were within normal limits.
and mild loss of facial expression on both sides. The What is the most likely diagnosis? Where is the lesion?
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1 94 SECTION V Functional Systems
C A S E 18
A 49-year-old woman with known severe hypertension the left side of both visual fields. Complete paralysis of the
complained of a severe headache. She then had a sudden left upper and lower extremities was present. Deep tendon
loss of strength in the left leg and arm; she fell down and, reflexes were absent in the left upper extremity and in
when brought to the emergency room, seemed only par creased in the lower extremity. There was a left extensor
tially conscious. plantar response, but the response was equivocal on the
Neurologic examination on admission showed an ob right. Vital signs and the complete blood count were within
tunded woman who had difficulty in speaking. There was normal limits; blood pressure was 1 90/ 100.
no papilledema and no sensation on the left side of the face What is the preliminary diagnosis? Would a lumbar
or body. Left-central facial weakness was present. When puncture be indicated? Would imaging be useful?
aroused, the patient complained that she could not see on Cases are discussed further in Chapter 25.
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C H A P T E R
Somatosensory Systems
Input from the somatosensory systems informs the organism Fi rst-Order N e u ron
about events impinging on it. Sensation can be divided into
The cell body of a first-order neuron lies in a dorsal root gan
four types: superficial, deep, visceral, and special. Superficial
glion or a somatic afferent ganglion (eg, trigeminal ganglion)
sensation is concerned with touch, pain, temperature, and
of cranial nerves.
two-point discrimination. Deep sensation includes muscle
and joint position sense (proprioception), deep muscle pain,
and vibration sense. Visceral sensations are relayed by auto Second-Order N e u ron
nomic afferent fibers and include hunger, nausea, and visceral
The cell body of a second-order neuron lies within the neu
pain (see Chapter 2 0 ) . The special senses -smell, vision,
raxis (spinal cord or brain stem; examples are provided by t he
hearing, taste, and equilibrium-are conveyed by cranial
dorsal column nuclei, ie, the gracile and cuneate nuclei, and
nerves (see Chapters 8, 1 5, 1 6, and 1 7). In addition, nocicep
by neurons within the dorsal horn of the spinal cord) . Axons
tive sensation or pain-signaling serves to warn the organism
of these cells usually decussate and t erminate in the thalamus.
when there is contact with noxious or potentially damaging
elements in the environment, or when tissue is damaged.
Th i rd-Order N e u ron
The cell body of a third-order neuron, which lies in the thala
RECEPTORS
mus, projects rostrally to the sensory cortex. The networks of
Receptors are specialized cells for detecting particular changes in neurons within the cortex, in turn, process information re
the environment. Exteroceptors include receptors affected layed by this type of neuron; they interpret its location, qual
mainly by the external environment: Meissner's corpuscles, ity, and intensity and make appropriate r esponses.
Merkefs corpuscles, and hair cells for touch; Krause's end-bulbs
for cold; Ruffini's corpuscles for warmth; and free nerve endings
for pain (Fig 14- 1 ) . Receptors are not absolutely specific for a SENSORY PATHWAYS
given sensation; strong stimuli can cause various sensations, even
Multiple neurons from the same type of receptor often form a
pain, even though the inciting stimuli are not necessarily painful.
bundle (tract), creating a sensory pathway. Sensory pathways as
Proprioceptors receive impulses mainly from pacinian corpus
cending in the spinal cord are described in Chapter 5; their con
cles, joint receptors, muscle spindles, and Golgi t endon organs.
tinuation within the brain stem is discussed in Chapter 7. The
Painful stimuli are detected at the free endings of nerve fibers.
main sensory areas in the cortex are described in Chapter 10.
Each efferent fiber from a receptor relays stimuli that
One major system-the lemniscal (dorsal column) sys
originate in a receptive field and gives rise to a component of
tem (see Fig 14-2) -carries touch, j oint sensation, two-point
an afferent sensory system. Each individual receptor fires
discrimination, and vibratory sense from receptors to the cor
either completely or not at all when stimulated. The greater
tex. The other important system-the ventrolateral system
the intensity of a stimulus, the more end-organs that are stim
relays impulses concerning nociceptive stimuli (pain, crude
ulated, the higher the rate of discharge is, and the longer the
touch) or changes in skin temperature (see Fig 14-3). Signifi
duration of effect is. Adaptation denotes the diminution in
cant anatomic and functional differences characterize these
rate of discharge of some receptors on repeated or continuous
two pathways: the size of the receptive field, nerve fiber diam
stimulation of constant intensity; the sensation of sitting in a
eter, course in the spinal cord, and function (Table 1 4- 1 ) .
chair or walking on even ground is suppressed.
Each system i s characterized by somatotopic distribution,
with convergence in the thalamus (ventroposterior complex)
and cerebral cortex (the sensory proj ection areas; see Figs
CONNECTIONS
1 0 - 1 3 and 1 0 - 1 5 ) , where there is a map-like representation of
A chain of three long neurons and a number of interneurons the body surface. The sensory trigeminal fibers contribute to
conducts stimuli from the receptor or free ending to the so both the lemniscal and the ventrolateral systems and provide
matosensory cortex (Figs 14-1 to 1 4-3). the input from the face and mucosal membranes (see Figs 7-8
and 8- 12).
195
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196 SECTION V Functional Systems
Corticospinal tract
FIGURE 1 4- 1 Schematic i l l u stration o f a s p i n a l cord segment with its dorsa l r oot, ganglion cel l s, a n d sensory organs.
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CHAPTER 14 Somatosensory Systems 197
Leg area
FIGURE 1 4-2 Dorsal col u m n system for discri m i native touch FIGURE 1 4-3 Spi notha lamic tracts for pain and tem perature
and position sense (lemniscus system).
(ventrol ateral system).
Course in spinal cord Dorsa l and dorsolateral fu niculi Ventra l and ventrolatera l fu niculi
Specificity of signal Each sensation carried sepa rately; precise M ulti modal (several sensations carried in one
conveyed local ization of sensation fi ber system)
Dia meter of nerve fiber Large-diameter primary afferents Smal l-diameter primary afferents
Sensation transmitted Fine touch, joint sensation, vibration Pa in, tem peratu re, crude touch, visceral pain
Tests for fu nction Vibration, two-point discri m i nation, stereognosis Pinprick, heat and cold testing
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198 SECTION V Functional Systems
-': L : s
,,
T '•
Line of incision
Ventral spinothalamic tract Ventral corticospinal tract
FIGURE 1 4-4 Major spinal pathways. The solid l i n e on the right represents the l i n e of incision in performing an a nterolateral cordotomy.
Notice the l a m i nation of the tracts. 5, sacral; L, l u m ba r; T. thoracic. (Reproduced, with permission, from Ganong WF: Review of Medical Physiology, 1 6th ed. Apple
ton & Lange, 1 993.)
Following nerve injury, dorsal root ganglion neurons, in sensitization may contribute to allodynia (perception of an
cluding nociceptors, turn off certain genes and turn on others. innocuous stimulus as painful) or hyperpathia (perception of
As a result, they produce a type of sodium channel that is not a mildly unpleasant stimulus as very painful).
normally present within them, and this can result in sponta The central ascending pathway for sensation consists of
neous firing (even when a noxious stimulus is not present) or two systems: the spinothalamic tract and the phylogeneti
hyper-responsiveness (firing at a pathologically increased, ab cally older spinoreticulothalamic system. The first pathway
normally high frequency in response to peripheral stimula conducts the sensation of sharp, stabbing pain; the second
tion) . This abnormal hyperexcitability of dorsal root ganglion conveys deep, poorly localized, burning pain. Both pathways
neurons contributes to neuropathic pain (pain associated are interrupted when the ventrolateral quadrant of the spinal
with nerve injury) . cord is damaged by trauma or in surgery, such as a cordotomy,
Nociceptive dorsal root ganglion neurons can also be deliberately performed to relieve pain; contralateral loss of all
come hyperexcitable, sending pain signals t oward the brain pain sensation results below the lesion (Fig 14-4). These path
even when a painful stimulus is not present, as a result of ways project rostrally to a network of circuits termed as the
mutations of the sodium channels within them . In inher pain matrix within the brain.
ited erythromelalgia (the "man on fire" syndrome), for ex
ample, gain-of- function mutations of sodium channels
within nociceptive dorsal root ganglion neurons lower the The Pa i n Matrix
threshold for activation for these sodium channels (making Pain elicits emotional and autononomic responses and is
it easier to turn them "on") and keep t hem "on'' longer once consciously appreciated as a result of activations of the pain
they are activated. As a result, t he nociceptors became hy matrix, which includes the thalamus, primary and second
perexcitable, generating pain signals even in the absence of ary somatosensory cortex, insular cortex, prefrontal cortex,
painful stimuli. anterior cingulate cortex, supplementary motor area, poste
Because these disorders involve altered ion channel func rior parietal cortex, periaqueductal gray matter, and amyg
tion, they are referred to as channelopathies. dala, as well as the cerebellum (Fig 1 4- 5 ) .
There is also some evidence for long-lasting changes,
which may underlie chronic pain syndromes, in the dorsal
horn after nerve injury. For example, after injury to C fibers, Referred Pa i n
these fibers may degenerate and vacate their synaptic target The cells i n lamina V o f the posterior column that receive
sites on superficial second-order neurons within the dorsal noxious sensations from afferents in the skin also receive
horn. Sprouting of larger primary afferent axons may cause input from nociceptors in the viscera (Fig 14-6) . When vis
nonnociceptive inputs to excite these superficial dorsal horn ceral afferents receive a strong stimulus, the cortex may
neurons (which normally do not signal pain) . This central misinterpret the source. A common example is referred
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CHAPTER 14 Somatosensory Systems 1 99
C A S E 1 9
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200 SECTION V Functional Systems
C A S E 2 0
A 4 1 -year-old man was admitted to the hospital with pro Neurologic examination showed conspicuous atrophy in
gressive weakness and unsteadiness of his legs . His dis the calves, forearms, and intrinsic muscles of the hands.
ability had begun more than a year earlier with tingling There was weakness of movement at both ankles and wrists
("pins and needles") feelings in his feet. Gradually, these and slightly weakened movement of the knees and elbows.
sensations had become more disagreeable, and burning The patient's gait was unsteady and of the high-stepping
pains developed on the soles of his feet. The rest of his feet type. There was loss of touch and pain sensation on the feet
had become numb, and his legs had become weak. For and distal thirds of the legs and on the hands and distal
about 6 months, he had had tingling feelings in his fingers halves of the forearms, giving a "stocking-and-glove" distri
and hands; his fingers felt clumsy, and he often dropped bution of sensory loss. Vibration sensibility was absent at the
things. He had lost more than 6 kg (about 14 lbs) during toes and ankles and diminished in the fingers. The soles of
the previous 6 months. The patient had smoked about 30 the feet and the calf muscles were hyperalgesic when
cigarettes daily for many years and drank eight glasses of squeezed. Ankle and biceps reflexes were absent, and knee
beer and half a bottle of whiskey (or more) each day. After jerks and triceps reflex were diminished.
losing his j ob a year before, the patient had worked at sev What is the differential diagnosis? What is the most
eral unskilled j obs. likely diagnosis?
Cases are discussedfurther in Chapter 25.
Serotonergic -----"1..
pathway .,....-+-��- Pain inhibitory
pathways
Afferent
pain fiber
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C H A P T E R
T he Visual System
Mammals are visual animals: The visual system conveys more Ret i n a l Rods
information to the brain than any other afferent system. This
Rods, which are more numerous than cones, are photorecep
information is processed within the brain so as to form a set
tors that are sensitive to low-intensity light and provide visual
of maps of the visual world. A relatively large proportion of
input when illumination is dim (eg, at twilight and at night) .
brain tissue is devoted to vision. The visual system includes
Cones are stimulated by relatively high-intensity light; they
the eye and retina, the optic nerves, and the visual pathways
are responsible for sharp vision and color discrimination.
within the brain, where multiple visual centers process infor
Rods and cones each contain an outer segment, consisting of
mation about different aspects (shape and form, color, mo
stacks of flattened disks of membrane that contain photosen
tion) of visual stimuli.
sitive pigments that react to light. In addition, they each have
an inner segment, which contains the cell nucleus and mito
chondria and forms synapses with the second-order bipolar
THE EYE
cells. The transduction of light into neural signals occurs
The functions (and clinical correlations) of the cranial nerves when photons are absorbed by photosensitive molecules (also
(III, IV, VI) involved in moving the eyes have been discussed called visual pigments) in the rods and cones.
in Chapter 8, along with the gaze centers and pupillary re The visual pigment within retinal rods is rhodopsin, a
flexes. The vestibulo-ocular reflex is briefly explained in specialized membrane receptor that is linked to G-proteins.
Chapter 1 7. This chapter discusses the form, function, and le When light strikes the rhodopsin molecule, it is converted, first
sions of the optic system from the retina to the cerebrum. to metarhodopsin II and then to scotopsin and retinene1 •
This light-activated reaction activates a G-protein known as
transducin, which breaks down cyclic guanosine monophos
Anatomy a n d P hysiology phate (GMP). Because cyclic GMP acts within t he cytoplasm
The optical components of the eye are the cornea, the pupil of the photoreceptors to keep sodium channels open, the light
lary opening of the iris, the lens, and the retina (Fig 1 5 - 1 ) . induced reduction in cyclic GMP leads to a closing of sodium
Light passes through the first four components, the anterior channels, which causes a hyperpolarization (see Chapter 3 ) .
chamber, and the vitreous to reach the retina; the point of fix Thus, a s a result o f being struck b y light, there i s hyperpolar
ation (direction of gaze) normally lines up with t he fovea. The ization within the retinal rods. This results in decreased release
retina (which develops as a portion of the brain itself, and is of synaptic transmitter onto bipolar cells, which alters their
considered by some neuroscientists to be a specialized part of activity (Fig 1 5-5).
the brain, located within the eye) transforms light into electri
cal impulses (Fig 1 5-2).
Ret i n a l Cones
The retina, organized into 1 0 layers, contains two types of
photoreceptors ( rods and cones) and four types of neurons Cones within the retina also contain visual pigments, which
(bipolar cells, ganglion cells, horizontal cells, and amacrine respond maximally to light at wavelengths of 440, 535, and
cells) (Figs 1 5-2 and 1 5- 3 ) . The photoreceptors (rods and 565 nm (corresponding to the three primary colors: blue,
cones, which are first-order neurons) synapse with bipolar green, and red) . When cones are struck by light of t he appro
cells (Fig 1 5-4) . These, in turn, synapse with ganglion cells; priate wavelength, a cascade of molecular events, similar to
the ganglion cells are third-order neurons whose axons con that in rods, activates a G-protein t hat closes sodium chan
verge to leave the eye within the optic nerve. nels, resulting in hyperpolarization.
Within the outer plexiform layer of the retina, horizontal
cells connect receptor cells with each other. Amacrine cells,
Bipolar, Amacri ne, a n d Ret i n a l
within the inner plexiform layer, connect ganglion cells to one
another (and in some cases also connect bipolar cells and gan G a n g l ion Cel l s
glion cells) . Transmission from photoreceptors (rods and cones, frrst-or
der sensory neurons) to bipolar cells (second-order sensory
neurons) and then to retinal ganglion cells (third-order
201
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202 SECTION V Functional Systems
Temporal
visual
field
ELM ILM
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CHAPTER 15 The Visual System 203
Pigment epithelium
Inner segments
FIGURE 1 5-3 Neura l components of the retina. C, cone; R, rod; M B, RB, FB, bipolar cel l s (of the m idget, r od, and flat types, respectively);
DG and MG, ganglion cel l s (of the d iffu se and midget types, respectively); H, horizonta l cel l s; A, a macrine cells. (Reproduced, with permission from
Dowling JE, Boycott BB: Organization of the primate r etina: Electron microscopy. Proc Roy Soc Lond Ser 8 [Bio/] 1 966;1 66:80.)
illumination and the visual threshold rises. This adaptation Young-Helmholtz theory postulates that the retina contains
occurs over a period of about 5 minutes and is called light three types of cones, each with a different photopigment maxi
adaptation. The pupillary light reflex, which constricts the mally sensitive to one of the primary colors (red, blue, and
pupils, is normally a protective accompaniment to sudden green) . The sensation of any given color is determined by t he
increases in light intensity (see Chapter 8). relative frequency of impulses from each type of cone. Parvocel
Light and dark adaptation depend, in part, on changes lular ganglion cells receive color-specific signals from the three
in the concentration of cyclic GMP in photoreceptors. In types of cones and relay them to the brain via the optic nerve.
sustained illumination, there is a reduction in the concentra Each of the three photopigments has been identified. The
tion of calcium ions within the photoreceptor, which leads to amino acid sequences of all three are about 4 1 % homologous
increased guanylate cyclase activity and increased cyclic GMP with rhodopsin. The green-sensitive and red-sensitive pig
levels. This, in turn, tends to keep sodium channels open so as ments are very similar (about 40% homologous with each
to desensitize the photoreceptor. other) and are coded by the same chromosome. The blue
sensitive pigment is only about 43% homologous with the
B. Color Vision other two and is coded by a different chromosome.
The portion of the spectrum that stimulates the retina to pro In normal color (trichromatic) vision, the human eye can
duce sight ranges from 400 to 800 nm. Stimulation of the nor perceive the three primary colors and can mix these in suit
mal eye, either by this entire range of wavelengths or by mix able portions to match white or any color of the spectrum.
tures from certain different parts of t he range, produces the Color blindness can result from a weakness of one cone sys
sensation of white light. Monochromatic radiation from one tem or from dichromatic vision, in which only two cone sys
part of the spectrum is perceived as a specific color or hue. The tems are present. In the latter case, only one pair of primary
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204 SECTION V Functional Systems
Rod
Outer
segment
Inner
segment
} terminal
Synaptic
FIGURE 1 5-6 The normal fu ndus as seen through an ophthal
moscope. (Photo by Diane Beeston; Reproduced, with permission, from Riordan
FIGURE 1 5-4 Schematic diagra m of a rod and cone in the Eva P. Whitcher J P: Vaughan & Asbury� General Ophthalmology, 1 7th ed. McGraw-Hill,
retina. 2008.)
colors is perceived; the two colors are complementary to each dated state, these elastic fibers are taut and keep the lens some
other. Most dichromats are red-green blind and confuse red, what flattened. In the accommodated state, contraction of the
yellow, and green. Color blindness tests use special cards or circular ciliary muscle slackens the tension on the elastic
colored pieces of yarn. fibers, and the lens, which has an intrinsic capacity to become
rounder, assumes a more biconvex shape. The ciliary muscle is
C. Accom modation a smooth muscle that is innervated by the parasympathetic
The lens is held in place by fibers between the lens capsule and system (cranial nerve Ill; see Chapter 8); it can be paralyzed
the ciliary body (Figs 1 5 - 1 and 1 5-7). In the unaccommo- with atropine or similar drugs.
D. Refraction
When one views a distant object, the normal (emmetropic)
eye is unaccommodated and the object is in focus. A normal
eye readily focuses an image of a distant object on its retina,
24 mm behind the cornea; the focal length of t he optics and
the distance from cornea to retina are well matched, a state
Conformational change
of photopigment known as emmetropia (Fig 1 5-8). To bring closer objects into
focus, the eye must increase its refractive power by accommo
I Activation_tof transducin dation. The ability of the lens to do so decreases with age as
the lens loses its elasticity and hardens. The effect on vision
usually becomes noticeable at approximately 40 years of age;
by the 50s, accommodation is generally lost ( presbyopia) .
- - - -
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CHAPTER 15 The Visual System 205
Emmetropia
(normal eye)
Plus lens
Hyperopia Corrected
Minus lens
Myopia Corrected
FIGURE 1 5-8 E m m etropia (norma l eye) and hyperopia and myopia (common defects of the eye). I n hyperopia, the eyeba l l is too short,
and l i g ht rays come to a focus beh ind the r etina. A biconvex lens corrects this by adding to the r efractive power of the lens of the eye. I n
myopia, the eyeba l l is t o o long, and light rays focus i n front of the retina. Placing a biconcave lens i n front of the eye causes the light rays to
dive rge s l i g htly before stri king the eye, so that they a re broug ht t o a focus on the r etina. (Reproduced, with permission, from Ganong WF: Review of Medical
Physiology, 22nd ed. McGraw-H i l l, 2005.)
FIGURE 1 5-9 Visual field charts. Small wh ite objects su btending FIGURE 1 5- 1 0 Monocu lar and b i n ocular visual fields. The
1 o are moved slowly t o chart fields o n the perimeter. The smaller the d otted l i n e encl oses the visual field of the left eye; the solid l i n e en
object, the more sensitive the t est is (with a g ross error of r efraction, closes that of the right eye. The com m o n a rea (heart-sha ped clear
1 o is rel iable). Red has the smal lest normal field and g ives the m ost zone i n the center) i s viewed with binocular vision. The shaded a reas
sensitive field t est. (Reproduced, with permission, from Riordan-Eva P, Whitcher JP: a re viewed with monocular vision. (Reproduced, with permission, from
Vaughan & Asbury's General Ophthalmology, 1 4th ed. McGraw-Hill, 1 995.) Ganong WF: Review ofMedical Physiology, 22nd ed. McGraw-Hill, 2005.)
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206 SECTION V Functional Systems
C L I N ICAL CORRELATIONS
to the clinician, since it can enable a careful observer to lo through the optic chiasm, retinal ganglion cell axons travel
calige lesions in many parts of the visual system on the basis centrally in the optic tract, which carries t he axons to the lat
of history and clinical examination. eral geniculate body (also termed the lateral geniculate nu
The optic nerve consists of about a million nerve fibers cleus) as well as the superior colliculus.
and contains axons arising from the inner, ganglion cell layer The lateral geniculate bodies and the medial geniculate
of the retina. These fibers travel through the lamina cribrosa bodies constitute important relay nuclei, for vision and hearing,
of the sclera and then course through the optic canal of the respectively, within the thalamus. Each lateral geniculate nu
skull to form the optic chiasm (Fig 1 5- 1 4). The fibers from cleus is a six-layered structure. The different layers have differ
the nasal half of the retina decussate within the optic chiasm; ent roles in visual processing. Signals from magnocellular and
those from the lateral (temporal) half do not. parvocellular retinal ganglion cells (see earlier discussion of
The arrangement of the optic chiasm is such that the ax Anatomy and Physiology under The Eye section) converge on
ons from the lateral half of the left retina and the nasal half of different layers within the lateral geniculate. These signals pre
the right retina project centrally behind the chiasm within the serve the architectural principle of multiple, parallel streams of
left optic tract. As a result of the optics of the eye, these two visual information, each devoted to analyzing a different aspect
halves of the left and right retina receive visual information of the visual environment. Crossed fibers from the optic tract
from the right-sided half of the visual world. This anatomic terminate within laminas 1, 4, and 6, whereas uncrossed fibers
arrangement permits the left hemisphere to receive visual in terminate in laminas 2, 3, and 5. The optic tract axons terminate
formation about the contralateral ( right-sided) half of the vi in a highly organized manner, and their synaptic endings are
sual world and vice versa (see Fig 1 5 - 1 4 ) . After traveling organized in a map-like (retinotopic) fashion that reproduces
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CHAPTER 15 The Visual System 207
. - ..
... \
7�
' -" �;�;..' '
�
�:· . ,
;
, ·
��-
;; �i ·- ;• '
. \' ..
_ ,.
.
. ., I
-l '
'
' .
;
' . ,, '
\
/' . . \. �· ...
__
the geometry of the retina. (The central part of the visual field
has a relatively large representation in the lateral geniculate
bodies, probably providing greater visual r esolution, or sensitiv
ity to detail, in this region.) The receptive fields of neurons in
the lateral geniculate bodies usually consist of an "on'' center
associated with an "off" surround or vice versa.
From each lateral geniculate body, axons project i psilater
ally by way of the optic radiation to the calcarine cortex in t he
occipital lobe. Thus, the right halves of each retina (corre
sponding to the left halves of the visual world) project by way
FIGURE 1 5-1 1 Optic neu ritis (papill itis) with disk changes, in of the optic radiation to the right occipital lobe and vice versa.
cluding cap i l l ary hemorrhages and m i n i m a l edema. (Compare with The geniculocalcarine fibers (optic radiations) carry im
Fig 1 5-1 2.) (Reprod uced with permission from Va ughan D, Asbury T, Riordan-Eva pulses from the lateral geniculate bodies t o the visual cortex.
P: Va ughn & Asbury's General Ophthalmology, 1 4th edition, McGraw-H i l l, 1 995.)
Meyer's loop is the sweep of geniculocalcarine fibers that
curves around the lateral ventricle, r eaching forward into the
temporal lobe, before proceeding toward the calcarine cortex.
Meyer's loop carries optic radiation fibers representing the up
per part of the contralateral visual field. Within the cortex,
there is a more extensive representation for the area of central
vision (Fig 1 5 - 1 5) .
I n addition t o projecting t o the lateral geniculate bodies,
retinal ganglion cell axons in the optic tract terminate in the
superior colliculus, where they form another retinotopic
map. The superior colliculus also receives synapses from the
visual cortex. The superior colliculus proj ects to the spinal
cord via the tectospinal tracts, which coordinate reflex move
ments of the head, neck, and eyes in response to visual stimuli
(see Chapter 1 3 ) .
Still other afferents from the optic tract project, via t he
pretectal area, to parasympathetic neurons in the Edinger
Westphal nucleus (part of the oculomotor nucleus) . These
parasympathetic neurons send axons within the oculomotor
nerve and terminate in the ciliary ganglia (see Fig 1 5 - 1 4) .
Postganglionic neurons, within the ciliary ganglia, project t o
the sphincter muscles o f the iris. This loop o f neurons i s re
sponsible for the pupillary light reflex, which results in con
FIGURE 1 5-1 2 Pa p i l l edema causing moderate disk el evation
without hemorrhages. (Reprod uced with permission from Va ughan D, Asbury T,
striction of the pupil in response to stimulation of the eye with
Riordan-Eva P: Va ughn & Asbury's General Ophthalmology, 1 4th edition, McGraw-Hill, light. Visual axons in each optic tract project to the
1 995.) Edinger-Westphal nucleus bilaterally. As might be expected,
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208 SECTION V Functional Systems
� ·· .:·.o; . ".
·•
. .
�
.
� !•
. '
Optic radiation
. :.
•
.... .· : :
I
o
. . .1 .I
1 I
·
. .. . .· . .•
. .. . . · '. ..
. •
. . . .
· · · · · . ·· . · •· .··
. .
..
. . .· ·
. .. · ·
...
FIGURE 1 5-1 4 The visual pathways. The solid b l u e l i nes represent nerve fibers that extend from the r etina t o the occi pita l cortex a n d
carry afferent v i s u a l i nformation from the r i g h t h a l f o f the visua l field. T h e b roken blue l i nes s h o w the pathway from the l eft half o f the visual
fields. The black l i nes represent the efferent pathway for the pupil lary l ight reflex.
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CHAPTER 15 The Visual System 209
Upper peripheral The primary visual cortex receives its blood from the
quadrant of retina calcarine branch of the posterior cerebral artery. The re
Upper
mainder of the occipital lobe is supplied by other branches of
quadrant this artery. The arterial supply can be (rarely) interrupted by
of macula emboli or by compression of the artery between the free edge
of the tentorium and enlarging or herniating portions of t he
Lower
brain.
quadrant
of macula
C L I N ICAL CORRELATIONS
T h e accu rate exa m i nation of v i s u a l d efects i n a patient is of blind ness in the lateral or temporal half of the visual field for
co nsiderable i m porta nce in loca lizing lesions. Such lesions may each eye (Fig 1 5- 1 6B).
be i n the eye, retina, optic nerve, optic chiasm o r tracts, or vi Lesions beh ind the optic chiasm cause a field defect in the
sual cortex. tem pora l fi eld of one eye, together with a fie l d defect i n the
Impaired vision in one eye is usually d u e to a d isorder in nasal (med i a l ) fie l d of the other eye. The res ult is a homony
volving the eye, retina, or the optic nerve (Fig 1 5- 1 6A). mous hemianopsia in which the visual field defect is on the
Field defects can affect one or both visual fields. If the l e side opposite the lesion (Fig 1 5- 1 6(, 1 5- 1 6E, and 1 5- 1 7).
sion is in the optic chiasm, optic tracts, or visual cortex, both Because Meyer's loop carries optic radiation fibers represent
eyes will show field defects. ing the upper part of the contra latera l field, temporal lobe le
A chiasmatic lesion (often owi ng to a pitu itary tumor or a le sions can produce a visual field deficit involvi ng the contralateral
sion a round the sella turcica) can i nj u re the decussating axons superior ("pie in the s ky") q u a d ra nt. Th is visual field defect is
of retinal gangl ion cel l s with i n the o ptic chiasm. These axons ca l led a superior quadrantanopsia (Fig 1 5- 1 60). An example is
originate i n the nasal ha lves of the two retinas. Thus, this type discussed in Cli nical I l l ustration 1 5- 1 .
of lesion produces bitemporal hemianopsia, characterized by
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210 SECTION V Functional Systems
C L I N ICAL I L LU STRATION 1 5- 1
A 28-yea r-ol d physical ed u cation teacher, previously wel l , be mous hemianopia or q u a d ra ntanopsia on the corresp o n d i n g
gan to experience "s pell s;' which began with a feel i n g of fea r side. I n this patient, exa m i nation revea led a left-sided u pper
and epig astric d i scomfort t h a t g ra d u a l l y m oved u pward. Th is quadra nta nopsia, which was ca u sed by a slow-g rowi ng ol igo
was fol lowed by a period of u n respon siveness i n which the pa dendrog l ioma i m p i n g i n g on the optic rad iation axons travel
tient wou l d m a ke chewing m ovements with h i s mouth. Over ing i n Meyer's loop. Recog nition of the tumor at a rel atively
the ensu ing yea r, the patient had seve ra l genera lized seizures. early stage facil itated its neurosurgical removal .
A computed tomography (CT) sca n was read a s normal, but an Exa m i nation o f t h e visual fields is a n im porta nt pa rt o f the
e l ectroence p h a logram s h owed e p i l e ptiform activity in the workup of a ny patient with a sus pected lesion i n the bra i n . The
right temporal l obe. Temporal lobe epil epsy was d i a g nosed, visual pathway extends from the reti na to the calcarine cortex
and the patient was treated with a nticonvulsa nts. The seizu res in the occipita l lobe. As outlined in Figure 1 5- 1 6, lesions at a
stopped. variety of sites along this pathway prod uce cha racteristic visual
Three years later, the patient complai ned of "poor vision in field defects. Recog nition of these visual field abnormalities of
his left eye" and of a left-sided headache, which was worse in ten provides cruci a l diag nostic i nformatio n.
the morning. An ophtha lmo logist fou n d a homonymous quad Abnormal ities of pupillary size may be ca used by lesions
ranta nopsia ("pie i n the s ky" field deficit) in the left upper quad i n the pathway for the p u p i l l a ry light reflex (see Figs 8-9 and
ra nt. N e u ro l o g i c exa m i n a ti o n now revealed a B a b i n s ki re 1 5- 1 4) o r by the action of drugs that affect the b a l a nce be
sponse a n d i ncreased deep tendon reflexes on the l eft side i n tween parasympathetic a n d sym pathetic i n n ervati o n of the
a d d i t i o n t o the h o m onym o u s q u a d ra nta n o p s i a . CT scan eye (Table 1 5- 1 ) .
showed a mass lesion i n the right a nterior te mporal lobe sur Argyii-Robertson p u p i l s , usually caused b y neurosyp h i l i s,
rou n ded by edema. a re small, sometimes unequal or irreg u l a r, pu pils. The lesion is
The patient underwent s u rgery and a n ol igodendrog lioma thought to be i n the p retectal reg ion, close to the E d i n g e r
was fou n d . After s u rg i c a l re m ova l , the patient's visual fi e l d Westphal nucleus.
deficit persisted. Neverthe less, he w a s able to return t o work. I n Horner's syndrome, o n e p u p i l i s s m a l l ( m i otic). a n d
Th i s case i l l u strates that patients may co m p l a i n of v i s u a l there a re other signs o f dysfu nction o f t h e sympathetic s u pply
l o s s i n t h e r i g h t or l eft eye w h e n , in fact, they have a homony- to the pupil and orbit (see Chapter 20 and Figs 20-6 a n d 20-7).
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CHAPTER 15 The Visual System 211
.
.
•
.
. .
. .
. .
.
.
E .
.·
.. · .
.
. . . . .
.
.
.
.
.··
.
..
__
. ·
FIGURE 1 5-1 6 Typical lesions of the visual pathways. Th eir effects on the visual fields a re shown on the right side of the i l l u stration.
A: B l i nd ness i n one eye. 8: Bitemporal hemianopia. C: Homonymous hemianopia. D: Quadrantanopsia. E: Homonymous hemianopia.
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212 SECTION V Functional Systems
ways (Fig 1 5-20) . Simple cells in the visual cortex have recep
tive fields that contain an "on'' or "off" center, shaped like a
rectangle with a specific orientation, flanked by complemen
tary zones. Simple cells usually respond to stimuli at one
particular location. For example, an "on'' -center simple cell
may respond best to a bar, precisely oriented at 45 °, flanked
by a larger "off" area, at a particular location. If the bar is ro
tated slightly or moved, the response of the cell will be di
minished. Thus, these cells respond to lines, at specific ori
entations, located in particular regions within the visual
world.
Complex cells in the visual cortex have receptive fields
that are usually larger than those of simple cells (see
Fig 1 5-20). These cells respond to lines or edges with a spe
cific orientation (eg, 60°) but are excited whenever these lines
are present anywhere within the visual field regardless of their
location. Some complex cells are especially sensitive to move
ment of these specifically oriented edges or lines.
D. Hubel and T. Wiesel, who received the Nobel Prize for
their analysis of the visual cortex, suggested that the receptive
fields of simple cells in the visual cortex could be built up from
the simpler fields of visual neurons in t he lateral geniculate.
The pattern of convergence of geniculate neurons onto visual
cortical cells supports this hypothesis. Similarly, by projecting
onto a complex cell in the visual cortex, a set of simple cells
FIGURE 1 5- 1 7 Occipita l hematoma ( arrow) resulting fro m a
bleeding arteriovenous malformation. This lesion p rod uced homony with appropriate receptive fields can create a higher-level re
mous hem ianopia and headache. (Reprod uced, with permission, from sponse that recognizes lines and edges at a particular orienta
Riordan-Eva P, Whitcher JP: General Ophthalmalagy, 1 7th ed. McGraw- Hill, 2008.) tion at a variety of positions.
The visual cortex contains vertical orientation columns,
each about 1 mm in diameter. Each column contains simple
visual cortex. The projection of the macular part of the retina cells whose receptive fields have almost identical retinal po
is magnified within these maps, a design feature that probably sitions and orientations. Complex cells within t hese columns
provides increased sensitivity to visual detail in the central appear to process information so as to generalize by recog
part of the visual field. nizing the appropriate orientation regardless of t he location
As visual information is relayed from cell to cell in t he of the stimulus.
primary visual cortex, it is processed in increasingly complex
A B
FIGURE 1 5-1 8 Activation of visual cortex as shown by fu nctional magnetic r esonance imaging (fMRI). A: An oblique axial a natomic
MRI. The reg ion showing increased activity i n r esponse to a fu l l -field patterned sti m u l u s has been assessed by fM R I (using a m ethod known as
echoplanar MRI) and is shown i n wh ite. B: Activation of the visual cortex on the left side i n r esponse to patterned visual sti m u lation of the right
visual hemifield (black) and activation of the rig ht-sided visual cortex i n r esponse to patterned sti m u lation of the left hemifield. The changes in
signal intensity a re the result of cha nges i n flow, vol u m e, and oxygenation of the bl ood i n r esponse to the sti m u l i . (Data from Masuoka LK, Anderson
AW, Gore JC, McCarthy G, Novotny EJ: Activation of visual cortex in occipital lobe epilepsy using functional magnetic r esonance imaging. Epilepsia 1 994;35[5upp 8]:86.)
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CHAPTER 15 The Visual System 213
Line of Gennari
Area 1 8
FIGURE 1 5-2 1 Reconstruction o f ocu l a r domina nce co l u m n s
i n a subdivision o f layer IV of a portion of t h e r i g h t v i s u a l cortex o f a
rhesus mon key. Dark stripes represent one eye; l i g ht stripes
represent the other. (Reprod uced, with permission, from LeVay S, Hubel DH,
Wiesel TN: The pattern of ocular dominance colu m n s i n macaque visual cortex r e
vea led by a reduced silver stain. J Camp Neural 1 975;1 59:559.)
About one half of the complex cells in the visual cortex inance, and they are organized into another overlapping se
receive inputs from both eyes. The inputs are similar for ries of ocular dominance columns, each 0.8 mm in diameter.
the two eyes in terms of the preferred orientation and loca The ocular dominance columns receiving input from one
tion of the stimulus, but there is usually a preference for eye alternate with columns receiving input from the other
one eye. These cells are referred to as showing ocular dom - (Fig 1 5 -2 1 ) .
FIGURE 1 5-20 Receptive fields of cel l s i n visual pathways. Left: Ganglion cel ls, latera l genicu late cel l s, and cel ls i n layer IV of cortica l a rea
1 7 have circu lar fields with a n excitatory center and a n i n h i bitory su rround or a n i n h i bitory center and a n excitatory s u rround. There is no pre
ferred o rientation of a li near sti m u l us. Center: Simple cel l s respond best to a l i nea r sti m u l u s with a particu l a r orientation i n a specific part of the
cell's r eceptive field. Right: Com plex cel ls respond to l i near sti m u l i with a particular orientation, but they a re less selective i n t erms of l ocation
i n the receptive field. They often respond maxi m a l ly when the sti m u l u s is moved lateral ly, as indicated by the arrow. (Modified from H u bel DH: The
visual field cortex of normal and deprived mon keys. Am Sci 1 979;67:532. Reproduced, with permission, from Ganong WF: Review of Medical Physiology, 1 9th ed. Appleton &
Lange, 1 999.)
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214 SECTION V Functional Systems
C A S E 21
A 50-year-old woman experienced a loss o f consciousness optic papilla was congested and edematous, and the left op
3 months before admission. Her husband described the in tic disk was abnormally pale. Visual acuity was normal in
cident as an epileptiform attack. More recently, her family the right eye but impaired in the left. The muscles of facial
thought that her memory was failing, and the patient noted expression were slightly weaker on the right side than on
that her right hand had begun to feel heavy. Two weeks the left. Deep tendon reflexes on the right side of the body
earlier, the patient began to have a constant frontal were brisker than those on the left, and there was a Babin
headache. She felt her eyeglasses needed changing, and the ski reflex on the right. The remainder of the findings were
ophthalmologist referred her to the neurologic service. within normal limits.
While giving her history, the patient appeared distractible, Where is the lesion? What is the differential diagnosis?
displayed impaired memory, and made inappropriate j okes Would imaging be useful? What is the most likely diagno
about her health. sis?
Neurologic examination showed that olfaction was to Cases are discussed further in Chapter 25.
tally lost on the left side but normal on the right. The right
REFERENCES Hubel DH: Eye, Brain, and Vision. Scientific American Library,
1 988.
Alonzo JM: Neural connections and receptive field properties in the Livingstone MS: Art, illusion, and the visual system. Sci Am
primary visual cortex. Neuroscientist 2002;8:443-456. 1 988;258:78.
Baylor DA: Photoreceptor signals and vision. Invest Ophthalmol Vis Sereno Ml, Dale AM, Reppas JB et al: Borders of multiple visual ar
Sci 1 987;28:34. eas in humans revealed by functional MRI. Science
Cohen B, Bodis-Wollner I (editors): Vision and the Brain. Raven, 1 995;268:889.
1 990. Van Essen D: Functional organization of primate visual cortex. I n:
Dowling JE: The Retina: An Approachable Part of the Brain. Bell Cerebral Cortex. Peters A, Jones EG (editors). Plenwn, 1 985.
k.nap Press, Harvard Univ Press, 1 987. Zeki S: Parallelism and functional specialization in hwnan visual
Gilbert CD, Li W, Piech V: Perceptual learning and adult cortical cortex. Cold Spring Harb Symp Quant Bio/ 1 990;55:65 1 .
plasticity. J Physiol 2009;587:2743-275 1 .
Hicks TP, Molotchnikoff S , Ono T (editors) : The Visually Responsive
Neuron: From Basic Neurophysiology to Behavior. Elsevier, 1 993.
www.Ebook777.com
C H A P T E R
T he Auditory System
The auditory system is built to allow us to hear. It is remark elicits a depolarization in peripheral branches of neurons of
able for its sensitivity. It is especially important in humans the cochlear ganglion. As a result, action potentials are pro
because it provides the sensory input necessary for speech duced that are transmitted to the brain along axons that run
recognition. within the cochlear nerve.
The cochlea, within the inner ear, is the specialized organ that The axons that carry auditory information centrally within
registers and transduces sound waves. It lies within the the cochlear nerve originate from bipolar nerve cells in the
cochlear duct, a portion of the membranous labyrinth within spiral (or cochlear) ganglion, which innervate the cochlear
the temporal bone of the skull base (Fig 1 6 - 1 ; see also Chapter organ of Corti. Central branches of these neurons course in
1 1 ) . Sound waves converge through the pinna and outer ear the cochlear portion of nerve VIII (which also carries vestibu
canal to strike the tympanic membrane (Figs 16-1 and 1 6-2). lar fibers). These auditory axons terminate in the ventral and
The vibrations of this membrane are transmitted by way of dorsal cochlear nuclei in the brain stem where they synapse.
three ossicles (malleus, incus, and stapes) in the middle ear to Neurons in these nuclei send both crossed and uncrossed ax
the oval window, where the sound waves are transmitted to the ons rostrally (Fig 1 6-5; see also Chapter 7). Thus, second-or
cochlear duct. der fibers ascend from the cochlear nuclei on both sides; the
Two small muscles can affect the strength of the auditory crossing fibers pass through the trapezoid body, and some of
signal: the tensor tympani, which attaches to the eardrum, them synapse in the superior olivary nuclei. The ascending
and the stapedius muscle, which attaches to the stapes. These fibers course in the lateral lemnisci within the brain stem,
muscles may dampen the signal; t hey also help prevent dam
age to the ear from very loud noises.
The inner ear contains the organ of Corti within the
cochlear duct (Fig 1 6 - 3 ) . As a result of movement of the Ossicles in
stapes and tympanic membrane, a traveling wave is set up in Skull base middle ear Cochlea
Pinna
the perilymph within the scala vestibuli of the cochlea. The Cochlear division
traveling waves propagate along the cochlea; high-frequency of nerve VI I I
sound stimuli elicit waves that reach their maximum near the
base of the cochlea (ie, near the oval window) . Low-frequency
sounds elicit waves that reach their peak, in contrast, near the
apex of the cochlea (ie, close to the round window) . Thus,
sounds of different frequencies tend to excite hair cells in dif
ferent parts of the cochlea, which is tonotopically organized.
The human cochlea contains more than 1 5,000 hair cells.
These specialized receptor cells transduce mechanical (audi
tory) stimuli into electrical signals.
The traveling waves within the perilymph stimulate the
auditory
organ of Corti through the vibrations of the tectorial mem
meatus
brane against the kino cilia of the hair cells (Figs 1 6-3 and
1 6-4) . The mechanical distortions of the kinocilium of each
hair cell are transformed into depolarizations, which open cal
cium channels within the hair cells. These channels are clus F I G U R E 1 6-1 T h e h u m a n ear. T h e coch lea h a s been tu rned
tered close to synaptic zones. Influx of calcium, after opening slig htly, and the middle ear m u scles have been o m itted to make the
of these channels, evokes release of neurotransmitter, which relationship clear.
215
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216 SECTION V Functional Systems
Supporting cell
Outer
ear
canal
Basal membrane
Nasopharyngeal
tube Round
window FIGURE 1 6-4 Structure of hair cell. (Reprod uced with permission
from Hudspeth AJ: The hair cells of the i n ner ear. They are exquisitely sensitive trans
FIGURE 1 6-2 Schematic view of the ear. As sound waves hit ducers that in human beings mediate the senses of hearing and balance. A tiny
the tympanic membra ne, the position of the ossicles (wh ich move as force applied to the top of the cell produces a n electrica l signal at the bottom, Sci
shown i n blue and black) changes. Am Jan;248(1 ):54-64, 1 983.)
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CHAPTER 16 The Auditory System 217
\
Dorsal coch lear nucleus
Ampulla of
superior semi
circular canal
Genicu late
Ganglion
ganglion
of Scarpa
· ·s up erior divi si
- on
__ • •
n enor division
Coch lea r nerve
Cochlear root
C L I N ICAL CORRELATIONS
Tinnitus A peri pheral lesion in the eighth nerve with loss of heari ng,
s u c h a s a cerebellopontine a n g l e tumor, u s u a l l y i nvolves
Ringi ng, buzzi ng, h i ssing, roaring, or "paper-cru s h i ng" noises i n
both the coch lear and vesti bular nerves (Fig 1 6-8). Centra l le
the ear a re freq uently a n e a r l y sign o f peripheral cochlear d is
sions can involve either system i ndependently. Beca use the au
ease (eg, hydrops or edema of the coch lea).
d itory pathway a bove the cochlear n u clei rep resents pa rts of
Deafness the sound i n put to both ea rs, a u n i l atera l lesion in the lateral
lemn iscus, medial geniculate body, or aud itory cortex does not
Deafness in o n e ear can be cau sed by an i m p a i rment in t h e
resu lt i n ma rked loss of hearing on the ipsilatera l side.
co n d u ction of sound t h ro u g h the external ea r canal a n d ossi
cles to the endolymph a n d tecto rial membra n e; this is cal led Hearing loss becomes a sign ificant handicap when there is
d ifficu lty i n com m u n icating by speech . Beginning impairment
conduction deafness. Nerve (sensorineural) deafness can
has been defined as an average hearing-level loss of 1 6 d B at
be caused by i nte rruption of coch lear n erve fi bers from the
freq uencies of 5 00, 1 000, a n d 2000 H z. S o u n d s of these fre
hair cel l s to the bra i n stem n u c l e i (Fig 1 6-7). Tests used to d i s
quencies ca n n ot be heard when their strength is 1 6 dB or less
t i n g u i s h between nerve a n d conduction d eafness a re s h own
(a l o u d w h i s per). A person i s u s u a l l y co n s i d ered to be deaf
i n Ta b l e 1 6- 1 . Nerve d eafness i s often located i n the i n ner ear
when the hearing-level loss for these three freq uencies is at or
or i n the coc h l e a r n erve in the i ntern a l a u d itory meatus; con
a bove 82 d B (the noise level of h eavy traffic). Early hearing loss
d u ction deafn ess is t h e res u l t of m i d d l e o r external ear d i s
often a ppears i n itia l ly at a high freq uency (4000 Hz) i n both
ease. Progressive ossificati on of the l i g a m ents between the
c h i l d ren with cond u ction impairment and a d u lts with presby
ossicl es, otosclerosi s , i s a co m m o n ca u se of hearing loss i n
cusis (lessening of hearing in o l d age).
a d u lts.
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218 SECTION V Functional Systems
C A S E 2 2
/
Qi Qi
.0 30 .0 30
'(3 '(3 '
(!) 40 (!) 40
'0 '0 '
r----... �
..... ""'
,,
�
. 50 .� 50
(/) (/)
(/) 60 (/) 60
0 0
....J ....J
70 70
80 80
90 90
1 00 1 00
FIGURE 1 6-7 Left: Middle ear, or cond u ction, deafness. Representative a i r conduction curve shows g reatest i m pa i rment of pure t one
thresholds i n lower frequencies. Right: Perception, or nerve, deafness. Representative bone conduction cu rve of p u re t on e thresholds shows
g reatest deficit at higher freq uencies.
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CHAPTER 16 The Auditory System 219
TABLE 1 6- 1 Common Tests with a Tu ning Fork t o Distinguish between Nerve and Cond uction Hearing Loss.
Weber Sound equal on both sides Sound louder i n diseased Sound louder i n normal ear
Base of vi brati ng tuning ear beca use masking effect
fork placed on vertex of of environ mental noise is
skull absent on diseased side
Rinne Hears vibration i n air after Does not hear vibrations i n Hears vi bration in air after
Base of vi brating tuning bone conduction is over air after b o n e conduction is bone cond uction is over
fork placed on mastoid over
process until patient no
longer hears it, then held
i n air next t o ear
REFERENCES
Allum JM, Allum-Mecklenburg DJ, Harris FP, Probst R (editors) :
Natural and Artificial Control o f Hearing and Balance. Elsevier,
1 993.
Hart RG, Gardner DP, Howieson J: Acoustic t umors: Atypical fea
tures and recent diagnostic tests. Neurology 1 983;2 1 1 :33.
Hudspeth AJ: How hearing happens. Neuron 1 997; 1 9:947.
Luxon LM: Disorders of hearing. Pages 434-450 in: Diseases of the
Nervous System: Clinical Neurobiology, 2nd ed. Asbury AK,
McKhann GM, McDonald WI (editors). WB Saunders, 1 992.
Morest DK: Structural organization of the auditory pathways. Pages
1 9-30 in: The Nervous System, vol 3. Eagles EL (editor). Raven,
1 975.
Schubert ED: Hearing: Its Function and Dysfunction. Springer
Verlag, 1 980.
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C H A P T E R
T he Vestibular System
The vestibular system participates in the maintenance of The kinetic labyrinth consists o f the three semicircular
stance and body posture; coordination of body, head, and eye canals. Each canal ends in an enlarged ampulla, which con
movements; and visual fixation. It includes the peripheral tains hair cells, within a receptor area called the crista am
vestibular receptors, vestibular component of t he VIII nerves, pullaris. A gelatinous partition ( cupula) covers each ampulla
and the vestibular nuclei and t heir central projections. and is displaced by rotation of the head, displacing hair cells
so that they generate impulses. The three semicircular canals
are oriented at 90° to each other, providing a mechanism that
ANATOMY is sensitive to rotation along any axis.
FUNCTIONS
221
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222 SECTION V Functional Systems
To cortex
(pathway uncertai n)
Utricle
I
Semicircular canal
Vestibular nerve fibers
Clockwise
rotation
of both
semicircular
canals
Cessation of
Reversal clockwise
of flow rotation
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CHAPTER 1 7 The Vestibular System 223
C L I N ICAL CORRELATIONS
Nystagmus is a n i nvol u ntary back-a nd-forth, u p-and-d own, or mus may occ u r d u ri n g treatment with ce rta i n d ru g s. For ex
rotati ng movement of the eyeba l l s, with a slow p u l l a n d a ra pid a m p le, nysta g m u s is often seen in patients treated with the
return jerk. (The name comes fro m the ra pid jerking compo a nticonvu l s a n t p h e nyto i n . Streptomyc i n and othe r d ru g s
nent, which is a compen satory adj u stment to the slow reflex m a y eve n caus e d e g e n e ration o f t h e vesti b u l a r org a n a n d
movement.) Nystagmus can be ind uced in normal individ u a l s; nuclei.
if it occurs spontaneously, it is a sign of a lesion. The lesions that Vertigo, a n i l l u so ry fee l ing o f spinni ng, fa l l i ng, or giddi ness
cause nysta g m u s affect the com plex neural mech a n i s m that with d i sorientation in space that u s u a l l y res u lts in a d i st u r
ten d s to keep the eyes constant i n relation to their environ bance of e q u i l i bri um, can be a sign of l a byrinthine d i sease orig
ment and is thus concerned with equ i l i bri u m . i nating i n the middle or i ntern a l ear. Adj u stment to peripheral
Physiologic nystagmus can be elicited b y t u r n i n g t h e eyes vestib u l a r damage is ra pid (within a few days). Even though a
fa r to o n e s i d e or by sti m u l a t i n g o n e of t h e s e m i c i rc u l a r labyrinth is not intact or fu nctioni ng, bala nce is sti l l rema rkably
ca n a l s (us u a l ly t h e lateral) with cool ( 3 0 °C} or wa rm (40 °C} good when vision is p resent: Vi sual information ca n even com
water i njected i nto one external ear ca n a l (Fig 1 7-6) . Cool wa pensate for the Joss of both labyrinths. Vertigo can a l so res ult
ter producesnysta g m u s toward the opposite side; warm water fro m t u m o rs o r other lesions of the vesti b u l a r system (eg,
prod uces nystagmus t o the same side. (A mnemonic for t h i s is Meniere's disease, o r pa roxysmal labyri nthine vertigo) or
COWS: cool, o p pos ite, warm, sa me.) Pe r ipheral vest i b u l a r from reflex phenomena (eg, seasickness).
nysta g m u s res u lts f r o m sti m u l at i o n of t h e p e r i p h e r a l Vest i b u l a r ataxia, with c l u m sy, u n coord i n ated move
vest i b u l a r a p p a ratus a n d i s u s u a l l y accom p a n ied b y vertigo. ments, may result from the same lesions that prod uce vertigo.
Fast s p i n n i n g of the body, s o m e t i m e s seen o n t h e p l ay Nysta g m u s is often present. Vest i b u l a r ataxia m u st be d isti n
ground, is a n exa m p le: I f c h i l d re n a re s u d d e n ly stopped, th e ir g u i shed fro m other types: cerebellar ataxia (see C h a pters 7
eyes s h ow nysta g m u s for a few seconds. P rofessio n a l s katers and 1 3) and sensory ataxia (ca used by lesions in the proprio
and d a n cers Jearn n ot to be bothered by nysta g m u s a n d ver ceptive pathways; see Cha pter 5).
tigo. Central nervous system nystag m u s is seldom associ I nte rruption of the pathway between the nuclei of nerves
ated with vertigo; it occ u rs with l es i o n s i n the reg ion of the V I I I , VI, and I l l (the med i a l longitu d i n a l fa scicu l us, pathway of
fo u rth ve ntricle. Optokinetic ( ra i l road or freeway) nystag the vesti bulo-ocu lar reflex) may occur. This res u lts in internu
mus occ u rs when t h e re i s conti n u o u s move m e n t of t h e clear ophtha lmoplegia, a n inability to adduct the eye ipsilat
vi s u a l fie l d past the eyes, as when trave l i n g b y tra i n . Nystag- era l to the lesion (Fig 1 7-7) .
Left FIGURE 1 7-7 I ntern uclear ophtha l moplegia i nterru pting the
ear medial longitudi n a l fascicu l u s on the left (a left i nternuclear ophthal
moplegia). Eye movement com mand from the lateral gaze center in
the paramed i a n pontine reticu l a r formation o n the right cannot
reach the left ocu lomotor n ucleus (see Fig 8-7). As a r esu lt, the left
FIGURE 1 7-6 Exa m p l e of caloric test with normal resu lts. Sti m eye can n ot vol u ntarily turn beyond the m i d l i n e t o the rig ht.
u lation of left ear for 40 s with cool (30 ° () water p rod uces nystagmus (Reproduced, with permission, from Aminoff ML, Green berg DA, Simon RP: Clinical
lasting 1 1 0 seconds. Neurology, 6th ed. McG raw-Hill, 2005.}
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224 SECTION V Functional Systems
C A S E 2 3 REFERENCES
Allum JH, Allum-Mecklenburg DJ, Harris FP, Probst R (editors) :
Natural and Artificial Control o f Hearing and Balance. Elsevier,
A 3 8-year-old male clerk saw his doctor because of sud
1 993.
den episodes of nausea and dizziness. These attacks had Baloh RW, Honrubia V: Clinical Neurophysiology of the Vestibular
started 3 weeks earlier and seemed to be getting worse. System, 3rd ed. FA Davis, 200 1 .
The abnormal episodes at first lasted only a few min Brandt T, Daroff RB: The multisensory physiological and pathologi
cal vertigo syndromes. Ann Neural 1 980;7: 1 95.
utes, during which "the room seemed to spin." Lately, Harada Y: The Vestibular Organs. Kugler & Ghedini, 1988.
they had been lasting for many hours. A severe attack Luxon LM: Diseases of the eighth cranial nerve. In: Peripheral Neu
caused the patient to vomit and to hear abnormal sounds ropathy, 2nd ed. Dyck PJ et al (editors). WB Saunders, 1984.
Pompeiano 0: Excitatory and inhibitory mechanisms in t he control
(ringing, buzzing, paper-rolling sounds) in the left ear.
of posture during vestibulospinal reflexes. In: From Neuron to
He thought that he was becoming deaf on that side. Action. Deecke L, Eccles JC, Mountcastle VB (editors). Springer
The neurologic examination was within normal lim Verlag, 1 992.
its except for a slight sensorineural hearing loss in the
left ear. Computed tomography examination of the head
was unremarkable.
What is the probable diagnosis?
Cases are further discussed in Chapter 25.
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C H A P T E R
T he Reticular Formation
225
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226 SECTION V Functional Systems
Sleep
A. Periodicity
The daily cycle of arousal, which includes periods of sleep
and of waking, is regulated by reticular formation structures
in the hypothalamus and brain stem. The sleep process of this
24-hour circadian rhythm does not merely represent a passive
"turning off" of neuronal activity; rather, it is an active physio
logic function. Nerve cells in the reticular formation of the
pons begin to discharge j ust before the onset of sleep. Lesions
of the pons j ust forward of the trigeminal nerve produce a state
of hyperalertness and much less sleep t han normal.
B. Stages
The sleep cycle consists of several stages that follow one an
other in an orderly fashion, each taking about 90 minutes (Fig
18-3). The stages can be defined by characteristic wave pat
terns on electroencephalograms (see Chapter 2 3 ) . There are
two distinct types of sleep: slow-wave sleep and rapid eye
movement (REM) sleep.
Slow-wave sleep is further divided into stages. Stage 1 of
slow-wave (spindle) sleep is characterized by easy arousal.
FIGURE 1 8-2 Lesions that cause coma or loss of consciousness.
Stages 2 to 4 are progressively deeper, and the electroen
cephalographic pattern becomes more synchronized. In stage
4, the deepest stage of slow-wave sleep, blood pressure, pulse
rate, respiratory rate, and the amount of oxygen consumed by
the brain are very low. The control mechanisms for slow-wave
sleep are not known.
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CHAPTER 18 The Reticular Format ion 227
TABLE 1 8- 1 Glasgow Coma Scale. A practical method of assessi ng changes in level of consciousness, based on
eye opening and verbal and motor responses. The response can be expressed by the sum of the scores assigned to
each response. The lowest score is 3, and the highest score is 1 5.
Examiner's Assigned
Variable Test Patient's Response Score
Verbal response (ta l king) Speech Carries on a conversation correctly and t e l l s examiner where and
who he or she i s and the month and year. 5
Speech Seems confused or disoriented. 4
Speech Tal ks so exa m i ner can understand words but makes no sense. 3
Speech Makes sounds exa m i ner cannot u nderstand. 2
Speech Makes no noise. 1
Slightly modified and reproduced, with permission, from Rimel RN, Jane JA, Edlich RF: Injury scale for comprehensive management of CNS trauma. JACEP 1 979;8:64.
sleepers make intermittent REMs, are hard to awaken, show a lism (sleepwalking) and nocturnal enuresis (bed-wetting) are
striking loss of muscle tone in the limbs, and have vivid visual particularly apt to occur during arousal from slow-wave sleep.
imagery and complex dreams. There is a specific need for Somnambulists walk with their eyes open and avoid obstacles,
REM sleep, which is triggered by neurons in the dorsal mid but they cannot recall the episode (which may last several
brain and pontine tegmentum. minutes) when they are awakened.
The midline raphe system of the pons may be the main
center responsible for bringing on sleep; it may act through 2. Hypersomnia and apnea-Hypersomnia (excessive day
the secretion of serotonin, which modifies many of the effects time sleepiness) and recurrent apnea during sleep may occur.
of the reticular activating system. Paradoxic REM sleep fol Affected patients are apt to be obese middle-aged men who
lows when a second secretion (norepinephrine) , produced by snore loudly. Functional obstruction of the oropharyngeal air
the locus ceruleus, supplants the raphe secretion. The effects way during sleep has been implicated as a cause, and symp
resemble normal wakefulness. toms in severe cases may be relieved by tracheostomy.
Destruction of the rostral reticular nucleus of the pons
abolishes REM sleep, usually without affecting slow-wave 3. Narcolepsy-Narcolepsy is a chronic clinical syndrome
sleep or arousal. REM sleep is suppressed by dopa or characterized by intermittent episodes of uncontrollable sleep.
monoamine oxidase inhibitors, which increase the norepi Sudden transient loss of muscle tone in the extremities or trunk
nephrine concentration in the brain. Lesions of the raphe (cataplexy) and pathologic muscle weakness during emotional
nuclei in the pons cause prolonged wakefulness. The raphe reactions may also occur. There may be sleep paralysis, t he in
nuclei contain appreciable amounts of serotonin, and it has ability to move in the interval between sleep and arousal, and
been shown that treatment with p-chlorophenylalanine hypnogogic hallucinations may occur at the onset of sleep. Sleep
(which inhibits serotonin synthesis) causes wakefulness in attacks can occur several times daily under appropriate or inap
cats. propriate circumstances with or without forewarning. The at
tacks last from minutes to hours.
Cases are discussed further in Chapter 25.
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228 SECTION V Functional Systems
REM
Central
Occip
Stage 2
..,_._....
______.,. �- --
- ------�--
Stage 1
Stage 4
"'\�..../.!v-l'yt.,v o�...:.�""'{:v ..
10
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.
vwt"I)NM::''if'A·�'I!N..·tJ..;,\J.¥Y:·.,.�-.-.-t·,
I/VIl".iNM1�·\tvv'ti''JV'-�'ft'-¥.W.,'�">\:·""....,lV
��'\��wvWl'v l .... �
,_____,
2s
FIGURE 1 8-3 Sleep stages. Notice low m u scle tone with extensive eye m ovement i n ra pid eye movement (REM) sl eep. EOG, el ectro-ocu
logram registering eye movements; EMG, electromyogra m r egistering skeletal m uscle activity. Central, Frontal, and Occip ind icate the th ree
electroencepha lographic leads. (Reprod uced, with permission, from Kales A, Bea l l GN, Berger RJ et al: Sleep and d reams: Recent r esearch on clinical aspects. Ann Intern
Med 1 968;68:1 078.)
REFERENCES Kryger MH, Roth T, Dement WC: Principles and Practice of Sleep
Medicine. WB Saunders, 1 990.
Borbely AA, Tobler I, Groos G: Sleep homeostasis and t he circadian Llinas RR, Steriade M: Bursting of thalamic neurons and states of
sleep-wake rhythm. In: Sleep Disorders: Basic and Clinical vigilance. J Neurophysiol 2006;95:3297-3308.
Research. MTP Press, 1983. Plum F, Posner JB: The Diagnosis of Stupor and Coma, 3rd ed. FA
Crick FC, Koch C: Some reflections on visual awareness. Cold Davis, 1 980.
Spring Harb Symp Quant Bioi 1 990;55:953. Steriade M, McCarley RW: Brainstem Control of Wakefulness and
Haider B, McCormick DA: Rapid neocortical dynamics: Cellular Sleep. Plenum, 1 990.
and network mechanisms. Neuron 2009;62: 1 7 1 - 189. Steriade M, McCormick DA, Sejnowski TJ: Thalamocortical
Jasper HH, Descarries L, Castelluci VF, Rossignol S (editors): Con oscillations in the sleeping and aroused brain. Science
sciousness: At the Frontiers ofNeuroscience. Lippincott-Raven, 1993;262:679.
1 998.
Koch C, Braun J: On the functional anatomy of visual awareness.
Cold Spring Harb Symp Quant Biol 1 996;61 :49.
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C H A P T E R
T he Limbic System
The limbic system subserves basic survival functions that in archicortex, has three layers. The cortex of the transitional
clude feeding behavior, "fight-or-flight" responses, aggression, limbic lobe-the mesocortex, or juxtallocortex-has as many
and the expressions of emotion and of the autonomic, behav as five layers. The remaining cortex, known as the neocortex,
ioral, and endocrine aspects of the sexual response. It includes or isocortex, is phylogenetically newest and has five or six lay
phylogenetically ancient portions of the cerebral cortex, re ers. It includes the primary motor and sensory cortex as well
lated subcortical structures, and fiber pathways that connect as the association cortex and covers most of the cerebral hemi
with the diencephalon and brain stem (Tables 19-1 and 1 9-2). spheres (see Chapter 10).
The limbic system receives input from many parts of the The concentric architecture is more obvious in lower
cortex and contains multimodal association areas where vari species. It is also present in higher species (including humans)
ous aspects of sensory experience come together to form a and underscores the tiered arrangement of a phylogenetically
single experience. The hippocampus, within the limbic sys advanced neocortex, which rests on a more primitive and
tem, plays crucial roles in spatial problem solving and in deeply buried limbic lobe and hippocampal formation. Be
memory. cause of their purported role in olfaction, the hippocampal for
mation and limbic lobe were also termed the rhinencephalon
("smell-brain'') by classical neuroanatornists. More recent work
THE LIMBIC LOBE AND LIM B I C SYSTEM has shown that limbic structures are related to the sense of
smell but are also directly involved in primitive, affective, vis
The limbic lobe was so named because this cortical complex
ceral, and autonomic functions. Such names as the visceral
forms a limbus (border) between the diencephalon and the
brain, emotional brain, and limbic brain were once used but
more lateral neocortex of the telencephalic hemispheres (Fig
were discontinued in favor of the more neutral limbic system.
1 9 - 1 ) . This limbic lobe consists of a ring of cortex outside the
corpus callosum, largely made up of the subcallosal and cin
gulate gyri as well as the parahippocampal gyrus (Fig 1 9-2).
OLFACTORY SYSTEM
More recent authorities revised the concept of the limbic
lobe and refer to the limbic system, which includes the func Olfaction (the sense of smell) is one of the oldest senses from
tionally interrelated limbic lobe (parahippocampal, cingulate, a phylogenetic point of view. The olfactory system constitutes
and subcallosal gyri) , the amygdala, and the hippocampal for an important input to the limbic system, which is also phylo
mation and associated structures (see Table 1 9- 1 ) . The hip genetically old.
pocampal formation (a more primitive cortical complex) is
situated even closer to the diencephalon and is folded and rolled
inward so that it is submerged below the parahippocampal Olfactory Receptors
gyrus. The hippocampal formation consists of the hippocam The olfactory receptors are specialized neurons located in the
pus (Ammon's horn); the dentate gyrus; the supracallosal olfactory mucous membrane, a portion of the nasal mucosa.
gyrus (also termed the indusium griseum), which is the gray The olfactory mucous membrane is blanketed by a thin layer
matter on top of the corpus callosum; the fornix; and a primi of mucus, produced by Bowman's glands. The olfactory recep
tive precomrnissural area known as the septal area (Fig 1 9-3). tors are highly sensitive and respond with depolarizations
when confronted with odor-producing molecules that dis
solve in the mucous layer. The olfactory receptors contain, in
H i stology their membranes, specialized odorant receptors that are cou
The cortical mantle of the brain can be thought of as consist pled to G-protein molecules, which link these receptors to
ing of three concentric cortical regions (hippocampal forma adenylate cyclase. There are nearly 1 000 odorant receptor
tion, limbic lobe, and neocortex) with different cytoarchitec genes; each olfactory receptor expresses only one or a few (and
tonic features (Fig 1 9-4) . The innermost of these three regions, thus responds to only one or a few odoriferous molecules).
the hippocampal formation, is the most primitive, and the out When a specific odoriferous molecule binds to the appropri
ermost, the neocortex the most advanced. The most primitive ate olfactory receptor, it activates the G-protein molecule,
cortex, which constitutes the hippocampus, also termed the which, via adenylate cyclase, generates cyclic adenosine
229
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230 SECTION V Functional Systems
H ippoca m pal
l Phylogenetica lly
Limbic
formation
(archicortex,
th ree layers)
1
:J H i ppocampus
Dentate gyrus
Oldest
system
Amygdala
l
p
Limbic lobe :J Pa ra h ippocampal gyrus
(mesocortex, Cingu late gyrus
th ree to five layers) l Su bca l losal gyrus
Neocortex
Jp Primary motor cortex
Primary sensory cortex
(five to six layers) l Association cortex Newest
monophosphate (AMP); this, in turn, leads to opening of Na+ to a specific odorant stimulus) proj ect precisely to a small
channels, generating a depolarization in the olfactory r eceptor. number of glomeruli within the olfactory bulb. There thus ap
The axons of the olfactory receptors travel within 10 to 1 5 pears to be a spatial map within the olfactory bulb that iden
olfactory nerves to convey the sensation o f smell from the tifies the receptors that have been stimulated.
upper nasal mucosa through the cribriform plate to the olfac The mitral cells of the olfactory bulb send their axons
tory bulb (Figs 1 9-5 and 1 9-6) . The olfactory bulb and olfac posteriorly via the olfactory tracts (also termed the medial
tory tract (peduncle) lie in the olfactory sulcus on the orbital and lateral olfactory stria) to the olfactory projection area in
surface of the frontal lobe. As the tract passes posteriorly, it di the cortex. The lateral olfactory stria is the projection bundle
vides into lateral and medial olfactory striae (Fig 1 9 - 7 ) . of fibers that passes laterally along t he floor of the lateral fis
Within the olfactory bulb, the olfactory receptor axons termi sure and enters the olfactory projection area near the uncus
nate in specialized synaptic arrangements (termed glomeruli) in the temporal lobe (see Fig 1 9-7).
on the dendrites of mitral cells (see Fig 1 9-6). Olfactory neu The olfactory projection area is the part of the cortex that
rons expressing a specific odorant receptor (and thus responsive receives olfactory information. The olfactory projection area
includes the pyriform and entorhinal cortex and parts of the
amygdala. The pyriform cortex projects, in turn, via the thal
TABLE 1 9-2 Major Limbic System Con nections. amus to the frontal lobe, where conscious discrimination of
odors presumably occurs.
Structure Connections
The small medial olfactory stria passes medially and up
Dentate gyrus From entorhinal cortex (via perforant pathway toward the subcallosal gyrus near the inferior part of the cor
and a lvear pathway) pus callosum. It carries the axons of some mitral cells to the
To h ippocampus (via mossy fibers) anterior olfactory nucleus, which sends its axons back to the
H i ppoca mpus From dentate gyrus (via mossy fi bers), septum olfactory bulbs on both sides, presumably as part of a feedback
(via fornix), l i m bic lobe (via circuit that modulates the sensitivity of olfactory sensation.
cing u l um) Other olfactory fibers reach the anterior perforated sub
To mamillary bodies, anterior thalam us, septal stance, a thin layer of gray matter with many openings that
area, and tuber cinereum (via fornix); subcallosal
permit the small lenticulostriate arteries to enter the brain; it
area (via longitud inal striae)
extends from the olfactory striae to the optic tract. These
Septal a rea From olfactory b u l b, a mygdala, fornix fibers and the medial stria serve olfactory reflex reactions.
To medial forebrain bund le, hypothalamus,
habenula
Amygdala From prim itive temporal cortex and sensory H I PPOCAM PAL FORMATION
association cortex, opposite a mygdala (via
anterior commissure) The hippocampal formation is a primitive cortical structure
To hypothalamus (direct amygdalofugal that has been "folded in'' and "rolled up" so that it is submerged
pathway), septa l a rea, and hypothalamus (via
deep into the parahippocampal gyrus. It consists of the dentate
stria terminal is)
gyrus, the hippocampus, and neighboring subiculum.
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CHAPTER 19 The Limbic System 23 1
N eocortex
Cut diencephalon
FIGURE 1 9-1 Schematic i l l ustration o f the location of the l i m bic system between the diencephalon and the neocortical hemispheres.
dentate gyrus via the perforant pathways. The cells of the as a result of nasal infections, including the common cold.
Head trauma can produce anosmia as a result of inj u ry to
dentate gyrus project, in turn, to the hippocampus.
The dentate gyrus is one of the few regions of the mam the cribriform p l ate with d a m age to the olfactory n erves,
malian brain where neurogenesis (the production of new neu b u l bs, or tracts. Tu mors at the base of the fronta l lobe (ol
factory g roove menin giom as) a n d frontal lobe g l i o m a s
rons) continues through adulthood.
t h a t i nvade o r compress the olfactory b u l bs or tracts m a y
c a u s e u n i l atera l or b i l ateral a n o s m i a . Beca use d a m a g e t o
the frontal l o bes often res u lts i n c h a n g e s i n behavior, it is
i m porta nt to carefu lly examine the sense of smell on both
sides when one eva l uates any patient with abnormal be
havior.
Meso cortex Olfactory information contri butes to the sense of flavor.
(great li mbic Beca use of th is, patients with anosmia may complain of loss
lobe)
of taste o r of the a b i l ity to d iscri m i nate flavors.
Olfactory h a l l uci nations, also termed u nci nate h a l l ucina
tions, may occ u r i n patients with lesions involving the pri
mary olfactory cortex, u n cu s, o r hippoca m p us; the patient
u s u a l ly perceives the presence of a p u n g e nt, often d i s
agreea ble odor. Olfactory h a l l ucinations may be associated
Parahippocampal gyrus with co mplex partial seizures (uncinate seizu res). Their p res
ence should su ggest the possi bil ity of focal d i sease (includ
FIGURE 1 9-2 Schematic i l l u stration of the concentric main ing mass lesions) i n the tempora l lobe. An exa m p le is pro
components of the l i mbic sytem .
vided in C l i n ical I l l u stration 1 9- 1 .
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232 SECTION V Functional Systems
Fornix (crus)
Fornix (body)
Corpus
cal losum Lateral
\/
ventricle
/ /
I
----;.- Dentate
gyrus
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CHAPTER 19 The Limbic System 233
Olfactory bulb
I
Olfactory
mucosa
N asal
conchae
Archicortex
(allo- and paleocortex)
Juxtallocortex
(mesocortex)
Isocortex
(neocortex)
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234 SECTION V Functional Systems
Sommer
sector
Alveus
H ippocampus
(pyramidal cells)
Subiculum
FIGURE 1 9-8 Microgra p h of a coronal section through the medial t em pora l l obe.
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CHAPTER 19 The Limbic System 235
to reach the parahippocampal gyrus (see Fig 1 9- 1 1 ) . Thus, t he This circuit, called the Papez circuit after the neu
following circuit is formed: roanatomist who defined it, ties together the cerebral cortex
and the hypothalamus. It provides an anatomic substrate for
para h i ppoca m pa l gyrus -7 hi ppoca m p u s -7 fornix ma mil lary the convergence of cognitive (cortical) activities, emotional
bodies -7 a nterior thalamic nuclei -7 cingulate gyrus -7 para h i p experience, and expression.
poca mpal gyrus
Anterior thalamus
Frontal neocortex
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236 SECTION V Functional Systems
A number of cortical structures feed into, or are part of, be differentiated. The basolateral nuclear group receives higher
the Papez circuit. The subcallosal gyrus is the portion of gray order sensory information from association areas in the frontal,
matter that covers the inferior aspect of the rostrum of the temporal, and insular cortex. Axons run back from the amyg
corpus callosum. It continues posteriorly as the cingulate dala to the association regions of the cortex, suggesting that
gyrus and parahippocampal gyrus (see Figs 19-2 and activity in the amygdala may modulate sensory information
1 9- 1 1 ) . In the area of the genu of the corpus callosum, the processing in the association cortex. The basolateral amygdala
subcallosal gyrus also contains fibers coursing into the supra is also connected, via the stria terminalis and the amygdalofu
callosal gyrus. The supracallosal gyrus (indusium griseum) gal pathway, to the ventral striatum and the thalamus.
is a thin layer of gray matter t hat extends from the subcallosal The corticomedial nuclear group of the amygdala, located
gyrus and covers the upper surface of the corpus callosum close to the olfactory cortex, is interconnected with it as well
(see Fig 1 9- 1 1 ) . The medial and lateral longitudinal striae as the olfactory bulb. Connections also run, via the stria ter
are delicate longitudinal strands that extend along the upper minalis and amygdalofugal pathway, to and from the brain
surface of the corpus callosum to and from the hippocampal stem and hypothalamus.
formation. Because of its interconnections with the sensory associa
tion cortex and hypothalamus, it has been suggested that the
amygdala plays an important role in establishing associations
Anterior Com m issu re between sensory inputs and various affective states. Activity of
The anterior commissure is a band-like tract of white fibers neurons within the amygdala is increased during states of ap
that crosses the midline to j oin both cerebral hemispheres (see prehension, for example, in response to frightening stimuli. The
Fig 1 9- 1 1 ) . It contains two fiber systems: an interbulbar sys amygdala also appears to participate in regulating endocrine ac
tem, which j oins both anterior olfactory nuclei near the olfac tivity, sexual behavior, and food and water intake, possibly by
tory bulbs, and an intertemporal system, which connects the modulating hypothalamic activity. As described later in t his
temporal lobe areas of both cerebral hemispheres. chapter, bilateral damage to the amygdala and neighboring tem
poral cortex produces the Kluver-Bucy syndrome.
The fornix and medial forebrain bundle, coursing within
Septa l Area the hypothalamus, are also considered part of the limbic system.
The septal area, also called the septal nuclei or septal complex,
is an area of gray matter lying above the lamina terminalis and
below the rostrum of the corpus callosum, near and around FUNCTIONS AND DISORDERS
the anterior commissure (Fig 1 9- 12). The s eptal area is a focal
As might be expected from i ts pivotal placement as a multi
point within the limbic system, and is connected with t he ol
modal association region, the limbic system plays a central
factory lobe, amygdala, hippocampus, and hypothalamus. The
role in behavior. Experimental studies in b oth animals and
septal area is a "pleasure center" in the brain. Rats with elec
humans indicate that stimulating or damaging some compo
trodes implanted in the septal area will press a bar r epeatedly
nents of the limbic system causes profound changes. Stimula
to receive stimuli in this part of the brain.
tion alters somatic motor responses, leading to bizarre eating
A portion of the septal area, the septum lucidum , is a
and drinking habits, changes in sexual and grooming behav
double sheet of gray matter below the genu of the corpus cal
ior, and defensive postures of attack and rage. There can b e
losum. In humans, the septum separates the anterior portions
changes in autonomic responses, altering cardiovascular or
of the lateral ventricles.
gastrointestinal function, and in personality, with shifts from
passive to aggressive behavior. Damage to some areas of the
limbic system may also profoundly affect memory.
Amygdala a n d Hypotha l a m u s
The amygdala (amygdaloid nuclear complex) i s a gray mat
ter mass that lies in the medial temporal pole between the un Autonomic N e rvou s System
cus and the parahippocampal gyrus (Figs 1 9 - 1 2 to 1 9 - 14). It The hierarchical organization of the autonomic nervous sys
is situated j ust anterior to the tip of the anterior horn of the
tem (see Chapter 20) includes the limbic system; most of the
lateral ventricle. Its fiber connections include the semicircular limbic system output connects to the hypothalamus in part via
stria terminalis to the septal area and anterior hypothalamus the medial forebrain bundle. The specific sympathetic or
and a direct amygdalofugal pathway to the middle portion of parasympathetic aspects of autonomic control are not well lo
the hypothalamus (see Fig 1 9 - 1 2 ) . Some fibers of the stria calized in the limbic system, however.
pass across the anterior commissure to the opposite amygdala.
The stria terminalis courses along the inferior horn and body
of the lateral ventricle to the septal and preoptic areas and the
SEPTAL AREA
hypothalamus.
Two distinct groups of neurons, the large basolateral nu The septal area, or complex, is relatively large in such animals
clear group and the smaller corticomedial nuclear group , can as the cat and rat. Because i t is a pivotal region with afferent
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CHAPTER 19 The Limbic System 237
Corpus callosum
Anterior thalamus
Corpus callosum
--7"
Stria terminalis
Lateral
olfactory
1i
tract
Amygdaloid
nuclear
complex
Amygdalohypothalamic
(amygdala)
B fibers (di rect)
FIGURE 1 9-1 2 Diagram of the principal con nections of the l i m bi c system . A: H i p pocampal system and g reat l i m bic lobe. B: Olfactory
and a mygda loid con n ections.
fibers from the olfactory and limbic systems and efferent areas of pleasure have been found in the hypothalamus and
fibers to the hypothalamus, epithalamus, and midbrain, no midbrain; the stimulation of yet other areas r eportedly evokes
single function can be ascribed to the area. Experimental the opposite response. Antipsychotic drugs may act in part by
studies have shown the septal area to be a substrate mediating modifying dopaminergic inputs from the midbrain to the sep
the sensations of pleasure upon self-stimulation or self tal area. Studies suggest that an ascending pathway to the
reward. Test animals will press a bar repeatedly, to receive a septal area may be involved in the euphoric feelings described
(presumed) pleasurable stimulus in the septal area. Additional by narcotic addicts.
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238 SECTION V Functional Systems
Memory
The three types of memory are immediate recall, short-term
memory, and long-term memory. The hippocampus is in
volved in converting short-term memory (up to 60 minutes)
to long-term memory (several days or more). The anatomic
substrate for long-term memory probably includes the tempo
ral lobes. Patients with bilateral damage t o the hippocampus
can demonstrate a profound anterograde amnesia, in which
no new long-term memories can be established. This lack of
memory storage is also present in patients with bilateral inter
ruption of the fornices ( eg, by removal of a colloid cyst at the
interventricular foramen) . Memory pro cesses also involve
other structures, including the dorsomedial nuclei of the thal
FIGURE 1 9-1 3 Location of the amygdale (red) with in a coro
amus and the mamillary bodies of the hypothalamus, as dis
nal sl ice of the brain. (Reprod uced, with permission, from Koen igs M, Grafman
cussed in Chapter 2 1 .
J: Neuroscientist 2009; 1 5:54 1 .)
T h e o ccurrence of long-term potentiation , a pro
cess whereby synaptic strength i s increased when specific
efferent inputs to the hippocampus are excited in a paired
Behavior manner, provides a cellular-molecular basis for under
standing the role of the hippo campus in memory and
The hypothalamic regions associated with typical patterns
learning.
of behavior such as eating, drinking, sexual behavior, and
aggression receive input from limbic system structures, es
pecially the amygdaloid and septal complexes. Lesions in Spatial Problem Solvi ng
these areas can modify, inhibit, or unleash these behaviors.
T h e hippocampus contains "place cells" that encode spatial
For example, lesions in the lateral amygdala induce unre
memory ("Where have I been?"). Recalling of places, and of
strained eating (bulimia), whereas those in the medial
the routes required to navigate to them, requires hippocampal
amygdala induce anorexia, accompanied by hypersexuality.
activation. The hippocampus is thus involved in navigation
Electrical stimulation of t he amygdala in humans may pro -
and spatial problem solving.
N e u rogenesis a n d Depression
Neurogenesis (the production of new neurosis) continues to
occur throughout adulthood in the dentate gyrus. Recent
studies have shown a reduced rate of neurogenesis in the
dentate gyrus in association with depression. Conversely, an
tidepressant medications have been shown to increase neuro
genesis in the dentate gyrus, and this may contribute to their
mechanism of action.
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CHAPTER 19 The Limbic System 239
C A S E 2 4
B. Tem pora l Lobe Epi lepsy Banasr M, Duman RS. Cell atrophy and loss in depression: r eversal by
antidepressant treatment Curr Opin Cell Biol 20 1 1 ;23:730-738.
The temporal lobe (especially the hippocampus and amyg
Bostock E, Muller RU, Kubie JL: Experience-dependent modifica
dala) has a lower threshold for epileptic seizure activity than
tions of hippocampal place cell firing. Hippocampus 1991; 1 : 1 93.
the other cortical areas. Seizures that originate in these re Damasio AR: Toward a neurobiology of emotion and feeling.
gions, called psychomotor (complex partial) seizures, differ Neuroscientist 1 995; 1 : 19.
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240 SECTION V Functional Systems
Dityatev A, Bolshakov V: Amygdala, long -term potentiation, and fear O'Keefe J, Nadel L: The Hippocampus as a Cognitive Map. Oxford
conditioning. Neuroscientist 2005; 1 1:75-88. Univ Press, 1978.
Koenigs M, Grafman J: Posttraumatic stress disorder: Role of the Reed RR: How does the nose know? Cell 1 990;60: l.
medial prefrontal cortex and amygdala. The Neuroscientist Ressler KJ, Sullivan SL, Buck LB: Information coding in the olfacto
2009;1 5:540-548. ry system: Evidence for a stereotyped and highly organized epi
Levin GR: The amygdala, the hippocampus, and emotional modula tope map in the olfactory bulb. Cell 1 994;79: 1 245.
tion of memory. Neuroscientist 2004; 1 0:3 1 -39. Squire LR: Memory and the Brain. Oxford Univ Press, 1 988.
Macguire EA, Frackowiak SJ, Frith CD: Recalling routes around Warren-Schmidt JL, Duman RS. Hippocampal Neurogenesis:
London: Activation of the right hippocampus in taxi drivers. J Opposing effects of stress and antidepressant treatment.
Neurosci 1 997; 1 7: 7 1 03. Hippocampus 2006;1 6:239-249.
McCarthy G: Functional neuroimaging of memory. Neuroscientist Zola-Morgan S, Squire LR: Neuroanatomy of memory. Ann Rev
1 995; 1 : 155. Neurosci 1 993; 1 6:547.
Moulton DG, Beidler LM: Structure and function in the peripheral
olfactory system. Physiol Rev 1 987;47: 1.
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C H A P T E R
T he Autonomic Nervous
System
The autonomic (visceral) nervous system (ANS) is concerned spinal cord or in the brain stem nuclei. It sends its axon, which
with control of target tissues: the cardiac muscle, the smooth is usually a small-diameter, myelinated B fiber (see Chapter 3),
muscle in blood vessels and viscera, and the glands. It helps out to synapse with the secondary neuron (the postsynaptic,
maintain a constant internal body environment (homeosta or postganglionic, neuron) located in one of the autonomic
sis). The ANS consists of efferent pathways, afferent pathways, ganglia. From there, the postganglionic axon passes to its ter
and groups of neurons in the brain and spinal cord t hat regu minal distribution in a target organ. Most postganglionic au
late the system's functions. Autonomic reflex activity in the tonomic axons are unmyelinated C fibers.
spinal cord accounts for some aspects of autonomic regulation The autonomic outflow system proj ects widely to most
and homeostasis. However, it is modulated by supraspinal target tissues and is not as highly focused as the somatic mo
centers such as brain stem nuclei and the hypothalamus, so tor system. Because the postganglionic fibers outnumber the
that there is a hierarchical organization within the central preganglionic neurons by a ratio of about 32: 1 , a single pre
nervous system itself. ganglionic neuron may control the autonomic functions of a
The ANS is divided into two major anatomically distinct rather extensive terminal area.
divisions that have opposing actions: the sympathetic (thora
columbar) and parasympathetic (craniosacral) divisions (Fig
20- 1 ) . The sympathetic and parasympathetic divisions of t he Sym pathetic Division
ANS are anatomically distinct from each other, and are also The sympathetic nervous system, or sympathetic ( thora
different in terms of their pharmacological properties, that is, columbar) division of the ANS arises from preganglionic cell
their response to medications. Thus, they are sometimes re bodies located in the intermediolateral cell columns of t he 12
ferred to as the sympathetic nervous system and the parasym thoracic segments and the upper two lumbar segments of the
pathetic nervous system. The critical importance of t he sympa spinal cord (Fig 20-2).
thetic and parasympathetic nervous systems is underscored by
the fact that many commonly used medications (eg, medica A. Prega nglionic Sympathetic Efferent Fiber System
tions for treating high blood pressure, for regulating gastroin Preganglionic fibers are mostly myelinated. Coursing with
testinal function, or for maintaining a regular heart beat) have the ventral roots, they form the white communicating rami
their major actions on neurons within these systems. of the thoracic and lumbar nerves, through which they reach
Some authorities consider the intrinsic neurons of the gut the ganglia of the sympathetic chains or trunks (Fig 20-3).
as forming a separate enteric nervous system . These trunk ganglia lie on the lateral sides of t he bodies of
the thoracic and lumbar vertebrae. On entering t he ganglia,
the fibers may synapse with ganglion cells, pass up or down
AUTONOM IC OUTFLOW the sympathetic trunk to synapse with ganglion cells at a
higher or lower level, or pass t hrough the trunk ganglia and
The efferent components of the autonomic system are organ
out to one of the collateral (intermediary) sympathetic gan
ized into sympathetic and parasympathetic divisions, which
glia (eg, the celiac and mesenteric ganglia ) .
arise from preganglionic cell bodies in different locations.
The splanchnic nerves arising from the lower seven tho
The autonomic outflow system is organized more dif
racic segments pass through the trunk ganglia to the celiac
fusely than the somatic motor system. In the somatic motor
and superior mesenteric ganglia . There, synaptic connec
system, lower motor neurons project directly from the spinal
tions occur with ganglion cells whose postganglionic axons
cord or brain, without an interposed synapse, to innervate a
then pass to the abdominal viscera via the celiac plexus. The
relatively small group of target cells (somatic muscle cells) .
splanchnic nerves arising from spinal cord segments in the
This permits individual muscles to be activated separately so
lowest thoracic and upper lumbar region convey fibers to
that motor action is fmely tuned. In contrast, a more slowly
synaptic stations in the inferior mesenteric ganglion and to
conducting two-neuron chain characterizes the autonomic
small ganglia associated with the hypogastric plexus, through
outflow. The cell body of the primary neuron (the presynap
which postsynaptic fibers are distributed to the lower abdom
tic, or preganglionic, neuron) within the central nervous sys
inal and pelvic viscera.
tem is located in the intermediolateral gray column of the
241
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242 SECTION V Functional Systems
Ciliary ganglion
Pupillary constrictor
Edinger-Westphal 1� and ciliary muscle
Pupillary dilator ') • • • • •
•
nucleus Sphenopalatine ganglion
• Lacrimal and
)· .
·.
Sup. salivatory nasal g lands
Lacrimal gland • • • • • ••
nucleus ---....:..---� or--,,___
'•j
and nasal glands Submaxillary ganglion
)'
'• . • . •,
Int. salivatory
:
Submaxi llary and • nucleus ---'r---::c==--=='• Submaxil lary and
subling ual glands subli ngual glands
.. . · .. .
• ' · • • •• • •
. Dorsal motor --¥----r
1
.
>--
·. . nucleus of Otic ganglion
Parotid g land vagus
. Parotid gland
··<
.
' .
Superior sympathetic
ganglion
H eart
>---+'"'"--..... T1
�....t----+•
.., T2
Heart ) . . • •, Lungs
�--···•
,
>····: :
� · · · · · · • · · · · · -e >--f"'---� T3
Lungs
T4
. Stomach
r:::;:-
:t; -...,.. rs
Stomach ) Celia c ganglion L---t,--44 T6
)- (
• • • ••
Liver • • •
Liver
Pancreas ) • (
>--�---�---4 T7
Spleen >- · · . .
:
Adrenal
medulla Small intestine
Small intestine )- • • :
Colon >··;
Colon )· · ··
Kidney > · .;.
Bladder > ·
:
Colon
)- · · · ·
Kidney
Sex organs
Bladder
Sex organs
Sympathetic trunk
FIGURE 20-1 Overview of the sym pathetic n ervous system and of its sympathetic (thoraco l u m ba r) and parasympathetic (cra niosacra l)
d ivisions. I nf., i nferior; Su p., superior.
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CHAPTER 20 The Autonomic Nervous System 243
\
prevertebral plexuses
�-
. to the head
C1 · rt '
S1
S5
,
;
Co
/1:1 .'
I
Kidney
: '
Preganglionic fibers
Postganglionic fibers ----- Sex organs
FIGURE 20-2 Sympathetic d ivision of the autonomic nervous system (left half). CG, celiac ganglion; IMG, i nferior mesenteric gang l ion;
SMG, su perior m esenteric ganglion.
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244 SECTION V Functional Systems
Cranial nerves
From spinal cord , I l l , V I I , IX, X
medulla, hypothalamus
Brain
stem
Spinal nerves
Pre T 1 -L3
Post
To blood vessels, Viscus
sweat glands
Spinal nerves
S rS 4
� G ray ramus
commun icans
Sacral outflow
FIGURE 20-3 Types of outflow i n autonomic nervous system. Pre, prega nglionic neuron; Post, postga nglionic neuron; CR, com m u n icat
ing ramus. (Reproduced, with permission, from Ganong WF: Review of Medical Physiology, 22nd ed. McGraw-Hill, 2005.)
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CHAPTER 20 The Autonomic Nervous System 245
- .: .
Pupillary dilator
Carotid plexus
I nternal carotid artery
(From superior sympathetic ganglion)
*
G reat deep petrosal nerve Maxi llary nerve Lacrimal gland
- - -
-
Zygomatic
branch
/
Nasal and
palatine
Sphenopalatine �.,..�..,.,�:l mucous
ganglion membranes
- Genicu lotympanic nerve
/ Auriculotemporal nerve
Middle meningeal artery
Parotid
gland
0 / 7IX External
maxi llary
artery
Jugular ganglion *
*
Sublingual gland
Glossopharyngeal nerve
Submax i l l a ry
-l
Superior cervical ganglion
sympathetic ganglion
-----... I ntermediolateral Parasympathetics
Vasomotor, pilomotor, --
_ .... .
_,.;' carotid and middle meningeal arteries
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246 SECTION V Functional Systems
Esophageal
plexus
(A few scattered
ganglion cells)
Postganglionic fibers
FIGURE 20-5 Parasym pathetic division of the a utonomic n ervo us system (only left half shown).
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CHAPTER 20 The Autonomic Nervous System 247
Autonomic Plexuses
C L I N ICAL CORRELATIONS
The autonomic plexuses are a large network of nerves that
serve a conduit for the distribution of the sympathetic and H o r n er's syn d ro m e co n s i sts of u n i l atera l e n o phtha l m os,
parasympathetic (and afferent) fibers that enter into their for ptosis, m i osis, and loss of sweating over the ipsilateral half
mation (see Figs 20- 1 , 20-2, and 20-5). of the face or forehead (Fig 20-6) . It is caused by ipsil ateral
The cardiac plexus, located about the bifurcation of the i nvolvement of the sympathetic pathways i n the ca roti d
trachea and roots of the great vessels at the base of the heart, plexus, the cervical sympathetic c h a i n, the upper thoracic
is formed from the cardiac sympathetic nerves and cardiac cord, or the bra i n stem (Fig 20-7).
branches of the vagus nerve, which it distributes to the my Rayn aud's d isease affects the toes, the fi n g e rs, the
ocardium and the vessels leaving the heart. edges of the ea rs, a n d the tip of the nose and spreads to in
The right and left pulmonary plexuses are joined with the volve l a rge a reas. Beg i n n i n g with local changes when the
cardiac plexus and are located about t he primary bronchi and pa rts a re pale and cold, it may progress to local asphyxia
pulmonary arteries at the roots of the lungs. They are formed cha racterized by a blue-g ray cyanosis a nd, fi n a l ly, sym met
from the vagus and the upper thoracic sympathetic nerves and ric, d ry gangrene. It is a d i sorder of the peripheral vascular
are distributed to the vessels and bronchi of the lung. innervation.
The celiac (solar) plexus is located in the epigastric re Causa lgia, a pai nfu l cond ition of the hands or feet, i s
gion over the abdominal aorta. It is formed from vagal fibers cau sed b y i rritation o f the med ian or sciatic nerve through
reaching it via the esophageal plexus, sympathetic fibers aris inju ry. It is cha racterized by severe burning pain, g l ossy skin,
ing from celiac ganglia, and sympathetic fibers coursing down swe l l i n g, red ness, sweati ng, a n d trop h i c nail c h a n ges.
from the thoracic aortic plexus. It projects to most of the ab Ca usalgia may be rel ieved by sym pathetic blocks or sympa
dominal viscera, which it reaches by way of numerous sub thectomy of the involved a reas.
plexuses, including phrenic, hepatic, splenic, superior gastric, H i rschsprung's d i sease ( megacolon) c o n s i sts of
suprarenal, renal, spermatic or ovarian, abdominal aortic, and marked d i latatio n of the colon, acco m p a n ied by c h ro n i c
superior and inferior mesenteric plexuses. consti pat i o n . I t i s associ ated w i t h congen ita l l a c k o f
The hypogastric plexus is located in front of the fifth lum parasym pathetic g a n g l i a a n d a b n o r m a l nerve fi bers i n an
bar vertebra and the promontory of the sacrum. It receives sym apparently norma l segment of l a rge bowel.
pathetic fibers from the aortic plexus and lumbar trunk ganglia
and parasympathetic fibers from the pelvic nerve. Its two lateral
portions, the pelvic plexuses, lie on either side of the rectum. It
projects to the pelvic viscera and genitals via subplexuses t hat Each ganglion receives a sympathetic, a parasympathetic, and
extend along the visceral branches of t he hypogastric artery. a sensory root (a branch of the trigeminal nerve). Only the
These subplexuses include the middle hemorrhoidal plexus, to parasympathetic fibers make synaptic connections within
the rectum; the vesical plexus, to the bladder, seminal vesicles, these ganglia, which contain the cell bodies of the postgan
and ductus deferens; the prostatic plexus, to the prostate, semi glionic parasympathetic fibers. The sympathetic and sensory
nal vesicles, and penis; the vaginal plexus, to the vagina and cli fibers pass through these ganglia without interruption.
toris; and uterine plexus, to the uterus and uterine tubes. The ciliary ganglion is located between the optic nerve
and the lateral rectus muscle in the posterior part of the orbit.
Its parasympathetic root originates from cells in or near the
AUTONOM IC INNERVATION Edinger-Westphal nucleus of the oculomotor nerve. Its sympa
OF THE HEAD thetic root is composed of postganglionic fibers from the supe
rior cervical sympathetic ganglion via t he carotid plexus of the
The autonomic supply to visceral structures in the head de internal carotid artery. The sensory root comes from the
serves special consideration (see Fig 20-4) . The skin of the nasociliary branch of the ophthalmic nerve. Distribution is
face and scalp (smooth muscle, glands, and vessels) receives through 1 0 to 12 short ciliary nerves t hat supply the ciliary
postsynaptic sympathetic innervation only, from the superior muscle of the lens and the constrictor muscle of the iris. The
cervical ganglion via the carotid plexus, which extends along dilator muscle of the iris is supplied by sympathetic nerves.
the branches of the external carotid artery. The deeper struc The sphenopalatine (pterygopalatine) ganglion , located
tures (intrinsic eye muscles, salivary glands, and mucous deep in the pterygopalatine fossa, is associated with the maxil
membranes of the nose and pharynx) , however, receive a dual lary nerve. Its parasympathetic root arises from cells of the supe
autonomic supply from the sympathetic and parasympathetic rior salivatory nucleus via the glossopalatine nerve and the great
divisions. The supply is mediated by the internal carotid petrosal nerve. The ganglion's sympathetic root comes from the
plexus (postganglionic sympathetic innervation from the su internal carotid plexus by way of the deep petrosal nerve, which
perior cervical plexus) and the visceral efferent fibers in four joins the great superficial petrosal nerve to form the vidian
pairs of cranial nerves (parasympathetic innervation) . nerve in the pterygoid (vidian) canal. Most of the sensory root
There are four pairs of autonomic ganglia-ciliary, ptery fibers originate in the maxillary nerve, but a few arise in cranial
gopalatine, otic, and submaxillary-in the head (see Fig 20-4) . nerves VII and IX via the tympanic plexus and vidian nerve.
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248 SECTION V Functional Systems
N erve to /
FIGURE 20-6 Horner's syndrome in the right eye, associated dilator muscle
with a tumor in the s u perior sulcus of the right l u ng.
/
Nerve to sweat g l and
Distribution is through the pharyngeal rami to the mucous
membranes of the roof of the pharynx; via the nasal and pala Carotid plexus
tine rami to the mucous membranes of the nasal cavity, uvula, Superior (sympathetic)
palatine tonsil, and hard and soft palates; and by way of t he or cervical ganglion
bital rami to the periosteum of the orbit and the lacrimal glands.
The otic ganglion is located medial to the mandibular FIGURE 20-7 Sym pathetic pathways to the eye and orbit.
nerve just below the foramen ovale in the infratemporal fossa. I nterru ption of these pathways inactivates the d i lator m uscle and
Its parasympathetic root fibers arise in the inferior salivatory thereby produces miosis, inactivates the tarsa l m uscle and prod uces
nucleus in the medulla and course via cranial nerve IX, the the effect of enophtha l m os, and reduces sweat secretion in the face
tympanic plexus, and the lesser superficial petrosal nerve; the (Horner's syndrome).
sympathetic root comes from the superior cervical sympa
thetic ganglion via the plexus on the middle meningeal artery. Pathways to the S p i n a l Cord
Its sensory root probably includes fibers from cranial nerve IX
Visceral afferent fibers to the spinal cord enter by way of the
and from the geniculate ganglion of cranial nerve VII via the
middle sacral, thoracic, and upper lumbar nerves . The
tympanic plexus and the lesser superficial petrosal nerve. The
sacral nerves carry sensory stimuli from the pelvic organs,
otic ganglion supplies secretory and sensory fibers to the
and the nerve fibers are involved in reflexes of the sacral
parotid gland. A few somatic motor fibers from the trigemi
parasympathetic outflow that control various sexual re
nal nerve pass through the otic ganglion and supply t he ten
sponses, micturition, and defecation. Axons carrying visceral
sor tympani and tensor veli palatini muscles.
pain impulses from the heart, upper digestive tract, kidney,
and gallbladder travel with the thoracic and upper 1 umbar
The submaxillary ganglion is located on the medial side
of the mandible between the lingual nerve and the submaxil
nerves. These visceral afferent pathways are associated with
lary duct. Its parasympathetic root fibers arise from the supe
sensations such as hunger, nausea, and poorly localized vis
rior salivatory nucleus of nerve VII via the glossopalatine,
ceral pain (see Table 20- 1 ) . Pain impulses from a viscus may
chorda tympani, and lingual nerves; its sympathetic root,
converge with pain impulses arising in a particular region of
from the plexus of the external maxillary artery; and its sen
the skin, causing referred pain. Typical examples of the phe
sory root, from the geniculate ganglion via the glossopalatine,
nomenon are the shoulder pains associated with gallstone at
chorda tympani, and lingual nerves. It is distributed to the
tacks and the pains of the left arm or t hroat associated with
submaxillary and sublingual glands.
myocardial ischemia (see Chapter 14).
Sympathetic Splanchnic (T7-L 1 ) Stomach, spleen, small viscera, colon, kidney, ureter, bladder (upper part),
uterus (fu ndus), ovaries, l u ngs
Parasympathetic Pelvic (S2-4) Rectum, trigone of the bladder, prostate, urethra, cervix of the uterus,
upper vag ina
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CHAPTER 20 The Autonomic Nervous System 249
Carotid body
Voluntary
sphincter release
Sympathetic
inhibitory fibers
I nferior
82-4
segment
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250 SECTION V Functional Systems
Lesion of
sacral
segments
Lesion
of cauda
equina
or weeks, they may be incomplete or abnormal. For example, periodic respiration if the brain stem is transected between
often the bladder cannot be completely emptied, which may the pons and the medulla.
result in cystitis, and voluntary initiation of micturition may
be absent (autonomic or neurogenic bladder). Depending on
the level of the transection, the detrusor reflex may be hyper M i d bra i n
active or diminished, and the neurogenic bladder may be Accommodation, pupillary reactions t o light, and other re
spastic or flaccid (Figs 20- 10 and 20- 1 1 ) . flexes are integrated in the midbrain, near the nuclear complex
of nerve III. Pathways from the hypothalamus to the visceral
efferent nuclei in the brain stem course through the dorsal
Med u l l a longitudinal fasciculus in the periaqueductal and periventric
Medullary connections t o and from the spinal cord are lightly ular gray matter.
myelinated fibers of the tractus proprius around the gray
matter of the cord. Visceral afferent fibers of t he glossopha
ryngeal and vagus nerves terminate in the solitary tract nu Hypot h a l a m u s
cleus and are involved in control of respiratory, cardiovascu A very important area o f autonomic coordination, the hypo
lar, and alimentary functions (see Chapters 7 and 8 ) . The thalamus integrates autonomic activities in response to
major reflex actions have connections with visceral efferent changes in the internal and external environments (ther
nuclei of the medulla and areas of the reticular formation. moregulatory mechanisms; see Chapter 9). The posterior
These areas may contribute to the regulation of blood glucose portion of the hypothalamus is involved with sympathetic
levels and to other reflex functions, including salivation, mic function, and the anterior portion is involved with parasym
turition, vomiting, sneezing, coughing, and gagging. pathetic function. The most important descending pathway
is the dorsal longitudinal fasciculus, and the connections
with the hypophysis aid in the influence of the hypothalamus
Pon s on visceral functions.
The nucleus parabrachialis consists o f a group o f neurons
that are located near the superior cerebellar peduncle and
modulate the medullary neurons responsible for rhythmic L i m bic System
respiration. This pneumotaxic center continues to control The limbic system has been called the visceral brain and has
close anatomic and functional links with the hypothalamus
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CHAPTER 20 The Autonomic Nervous System 25 1
(see Chapter 19). Various portions of the limbic system exert splanchnic nerves via primary afferent neurons whose cell
control over the visceral manifestations of emotion and drives bodies are located in the nodose ganglia .
such as sexual behavior, fear, rage, aggression, and eating be
havior. Stimulation of limbic system areas elicits such auto
nomic reactions as cardiovascular and gastrointestinal re TRANSMITTER SUBSTANCES
sponses, micturition, defecation, piloerection, and pupillary
changes. These reactions are channeled, in large part, through Types
the hypothalamus. Autonomic activity controls many essential body functions.
Pharmacology and pharmacotherapy depend, in large part, on
Cerebra l Neocortex our understanding of the neurochemistry of the autonomic
system since many medication act so as to increase, on block,
The cerebral neocortex may initiate autonomic reactions such activity in various parts of the autonomic system.
as blushing or blanching of the face in response to receiving Autonomic neurotransmitters mediate multiple visceral
bad or good news. Fainting (syncope) because of hypotension functions; the principal transmitter agents are acetylcholine
or decreased heart rate can result from a barrage of vagal ac (ACh) and norepinephrine (see Chapter 3). The two divisions
tivity evoked by an emotional stimulus. of the autonomic system (parasympathetic and sympathetic)
tend to release different transmitters (ACh and norepineph
The Enteric N e rvou s System rine) from their postganglionic neurons (although there are
several exceptions, noted later), providing a pharmacologic
It was traditionally thought that the gastrointestinal tract is in
basis for their opposing actions.
nervated by the autonomic system. However, it is now recog ACh is liberated at preganglionic endings. It is also re
nized that a collection of neurons associated with the gut,
leased by parasympathetic postganglionic neurons and by
sometimes considered to be an "intrinsic nervous system of
sympathetic postganglionic neurons that project to sweat
the gastrointestinal tract;' can function relatively independ
glands or mediate vasodilation.
ently of the central nervous system but subject to modulation
Norepinephrine (levarterenol) , a catecholamine, is the
from it. This loose meshwork of neurons, which regulates gas
transmitter at most sympathetic postganglionic endings. Nor
trointestinal motility, secretory activity, vascular activity, and epinephrine and its methyl derivative, epinephrine, are se
inflammation, has been termed the enteric nervous system. creted by the adrenal medulla. Although many viscera contain
The enteric nervous system contains nearly 100 million neu
both norepinephrine and epinephrine, the latter is not consid
rons located within numerous small ganglia. These ganglia are
ered to be a mediator at sympathetic endings. Drugs that block
interconnected, via nerve bundles, to form two networks
the effects of epinephrine but not norepinephrine have little ef
(plexuses). The first of these is the myenteric plexus (also
fect on the response of most organs to stimulation of their
called Auerbach's plexus) , which is located between the mus adrenergic nerve supply.
cular layers that make up the gastrointestinal system, from the
Substance P, somatostatin, vasoactive intestinal pep
esophagus at the rostral end to the rectum at the caudal end. tide (VIP) , adenosine, and adenosine triphosphate (ATP)
Additional projections to smaller ganglia are also associated may also function as visceral neurotransmitters.
with the pancreas and gallbladder. The submucosa plexus ,
also called Meissner's plexus, is largely confined to the submu
cosa of the gut and is most prominent within the small intes Functions
tine, where it regulates secretory activity and innervates blood The ANS can be divided into cholinergic and adrenergic di
vessels. Counterparts of the submucous plexus innervate the visions. Cholinergic neurons include preganglionic and
pancreas, gallbladder, common bile duct, and cystic duct. parasympathetic postganglionic neurons, sympathetic post
Enteric neurons innervate smooth muscle cells that are re ganglionic neurons to sweat glands, and sympathetic vasodila
sponsible for gut motility as well as secretory and endocrine tor neurons to blood vessels in skeletal muscle. There is usu
cells in the gut and its vasculature. The activity of enteric neu ally no ACh in circulating blood, and the effects of localized
rons is modulated by the parasympathetic nervous system and cholinergic discharge are generally discrete and short lived be
the sympathetic nervous system. Parasympathetic control path cause of high concentrations of cholinesterase at the choliner
ways run largely in the vagus nerves (for the upper gastroin gic nerve endings (Fig 20- 1 2 and Table 20-2).
testinal tract) and the sacral nerves (which modulate functions In the adrenal medulla, the postganglionic cells have lost
such as contractility of the lower colon and rectum). Most of the their axons and become specialized for secreting catecholamine
preganglionic parasympathetic neurons are cholinergic and act (epinephrine) directly into the blood; the cholinergic pregan
on enteric neurons via excitatory nicotinic and muscarinic re glionic neurons to these cells act as the secretomotor nerve sup
ceptors. Preganglionic sympathetic fibers projecting to the gas ply to the adrenal gland. Sympathetic postganglionic neurons
trointestinal tract, on the other hand, are adrenergic. are generally considered adrenergic except for the sympathetic
Sensory information from the gastrointestinal system is vasodilator neurons and sweat gland neurons. Norepinephrine
carried to the central nervous system in the vagus and has a more prolonged and wider action than does ACh.
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252 SECTION V Functional Systems
TABLE 20-2 Responses of Effector Organs to Autonomic Nerve Impu lses and Circulati ng Catecholami nes.
Noradrenergl c Impulses
Eye
Rad ial muscle of iris a. Contraction (myd riasis)
Sphi ncter m uscle of i ris Contraction (miosis)
Ciliary muscle Contraction for near vision Relaxation for far vision
Heart
S-A node Decrease in heart rate; vagal arrest I ncrease i n heart rate
Atria Decrease in contracti lity and I ncrease in contractility and
(usual ly) increase i n cond uction cond uction velocity
velocity
A-V node and conduction Decrease in conduction velocity; I ncrease in cond uction velocity
system A-V block
Ventricles I ncrease in contractility and
cond uction velocity
Arterioles
Coronary, skeletal muscle, Dilation Constriction
pulmonary, abdominal Dilation
viscera, renal
Skin and mucosa, cerebra l, a. Constriction
salivary g l a nds
Lung
Bronchial muscle Contraction Relaxation
Bronchial gla nds Sti m u lation I n h ibition(?)
Stomach
Motil ity and tone I ncrease a., � Decrease (usually)
Sphincters Relaxation (usual ly) a. Contraction (usual ly)
Secretion Sti m u lation Inhi bition(?)
Intestine
Motil ity and tone I ncrease Decrease
Sphi ncters Relaxation (usual ly) Contraction (usual ly)
Secretion Sti m u lation I n h ibition(?)
Urinary bladder
Detrusor Contraction Relaxation (usual ly)
Trigon and sphincter Relaxation Contraction
Ureter
Motil ity and tone I ncrease (?) a. I ncrease (usually)
"
Uterus Variable Variable '
Pancreas
Aci n i I ncrease secretion a. Decreased secretion
Islets I ncreased insulin and g l ucagon a. Decreased insulin and g l u cagon
secretion secretion
I ncreased insulin and g l u cagon
secretion
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CHAPTER 20 The Autonomic Nervous System 253
TABLE 20-2 Responses of Effector Organs to Autonomic Nerve Impulses and Circulating Catecholamines. (Cont.)
Noradrenerglc Impulses
*Depends on stage of menstrual cycle, amount of circulating estrogen and progesterone, pregnancy, and other factors.
tOn palms of hands and i n some other locations (adrenergic sweating).
Modified from Gilman AG et a l (editors): Goodman and Gilman's the Pharmacological Basis of Therapeutics, 8th edition. Macmillan, 1 990.
Effects of Drugs on
the Autonomic N ervous System
Pa rasym pathetic
Certain drugs affect the ANS by mimicking or blocking
cholinergic or adrenergic discharges (Table 20-3). Drugs can
ACh synapse
(nicotinic) also alter other activities such as synthesis, storage in nerve
endings, release near effector cells, action on effector cells, and
Sym pathetic
Adrenoreceptor
( N E receptor)
/ ACh receptor
(nicoti nic)
Preganglionic receptor
(<X:!)
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254 SECTION V Functional Systems
TABLE 20-3 Some Chemical Agents that Affect Sym pathetic Activity, Listi ng only the Principal Actions
of the Agents.
termination of transmitter activity. Sometimes a drug may af present at neuromuscular j unctions and at the synapses be
fect two transmitter systems rather t han one. tween preganglionic and postganglionic neurons.
Despite apparent similarities in the transmitter chem Curariform agents, hexamethonium, and mecamylamine
istry of preganglionic and postganglionic cholinergic neu act principally by blocking transmission at the cholinergic
rons, agents can act differently at t hese sites. Muscarine has motor neuron endings on skeletal muscle fibers. They were
little effect on autonomic ganglia, for example, but acts on used in the past in the treatment of hypertension.
smooth muscle and glands, where it mimics the effects of Drugs that block the effects of norepinephrine on visceral
ACh. The ACh receptors on these cells are termed mus effectors are often called adrenergic-neuron- blocking agents,
carinic. Drugs with muscarinic action include ACh, ACh-re adrenolytic agents, or sympatholytic agents.
lated substances, and inhibitors of cholinesterase (eg, certain
nerve gases ) . Atropine, belladonna, and other natural and
synthetic belladonna-like drugs block the muscarine effects Sen sitization
of ACh by preventing the mediator from acting on visceral Autonomic effectors (smooth muscle, cardiac muscle, and
effector organs. glands) that are partially or completely separated from t heir
Some actions of ACh, including the transmission of im normal nerve connections become more sensitive to the ac
pulses from preganglionic to postganglionic neurons, are not tion of the neurotransmitters that normally impinge on them;
affected by atropine. Because nicotine produces the same ac this has been termed denervation hypersensitivity. Known
tions, the actions of ACh in the presence of atropine are called as Cannon's law of denervation, the effect is more pronounced
its nicotine effects, and the receptors are called nicotinic after postganglionic interruption than after preganglionic in
acetylcholine receptors. Nicotinic acetylcholine receptors are terruption.
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CHAPTER 20 The Autonomic Nervous System 255
C A S E 2 5
A 55-year-old male clerk consulted his physician about ing; his speech was difficult to understand. His drop in
drooling, difficulty in swallowing, and a "funny-sounding" blood pressure with postural changes was still present.
voice. Indirect laryngoscopy showed decreased motility of Neurologic examination showed a normal mental status;
the right vocal cord. Other examinations and tests were flat optic disks; visual fields full , with pupils normal and
within normal limits . Drugs were given to control the pa reactive to light; normal extraocular movements; bilateral
tient's hypersalivation. neural hearing deficits; dysarthria; midline palate location
Eight months later, the patient returned with a 1 0-day with normal gag reflex; and a weak tongue that deviated to
history of lightheadedness and fainting. The only addi the right when protruded. The patient's gait was wide
tional abnormal findings were fasciculations in the right based and unsteady. The heel-to-shin test showed ataxia on
side of the tongue and changes in blood pressure with pos the right, and other cerebellar test results were normal. The
tural changes (lying down, 140/90; sitting up, 1 00170; and deep tendon reflexes were also normal. A computed to
standing up, too low to read) . Lumbar puncture analysis mography scan showed moderate ventricular enlargement.
showed a protein level of 95 mg/dL. While in the hospital, Magnetic resonance imaging scanning demonstrated a
the patient had one episode of rotatory vertigo. After 4 lesion.
days, he went back to work. Where is the lesion? What is the nature of the lesion?
Three months later, the patient returned with complaints What is the explanation for the autonomic dysfunctions?
of dizziness, fainting, and increased problems in swallow- Cases are discussed further in Chapter 25.
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C H A P T E R
Hi gh er Cortical
Functions
The human cerebral cortex represents, in some ways, the pin within the inferior frontal gyrus, located j ust anterior to the
nacle of evolution. In addition to containing networks of neu motor cortex controlling the lips and tongue.
rons related to the initiation of movement and to sensation The ability to comprehend language, including speech, is
from the body and the special sensory organs, the cortex is the dependent on Wernicke's area. This area is located in the pos
substrate for functions that include comprehension, cogni terior part of the superior temporal gyrus within the auditory
tion, communication, reasoning, problem-solving, abstrac association cortex (area 22).
tion, imagining, and planning. The arcuate fasciculus provides a crucial are-shaped path
way within the hemisphere white matter, connecting Wernicke's
and Broca's areas (Fig 2 1 - 1 ) . Because the arcuate fasciculus con
FRONTAL LOBE FUNCTIONS nects the speech comprehension area (Wernicke's area) with the
area responsible for production of speech (Broca's area), damage
The frontal lobes contain phylogenetically "new" parts of the to this white matter tract produces impairment of repetition.
cortex, and serve as an "executive" part of the cortex. They
participate in higher order functions that include reasoning
and abstraction; planning and initiating of activity; monitor Dysa rth ria
ing and shaping of behavior to ensure adaptive actions; in Dysarthria is a speech disorder in which t he mechanism for
hibiting maladaptive behavior; prioritizing and sequencing speech is damaged by lesions in the corticobulbar pathways; in
actions; problem solving; and coordinating elementary motor one or more cranial nerve nuclei or nerves V, VII, IX, X, and XII;
and sensory functions into a coherent and goal-directed in the cerebellum; or in the muscles that produce speech sounds.
stream of behavior. Dysarthria is characterized by dysfunction of t he phonation,
Damage to the frontal lobes (as can occur, eg, with brain articulation, resonance, or respiration aspects of speech.
tumors or head trauma) can produce profound behavioral
changes. Several syndromes are especially common: Following
damage to the dorsolateral part of the frontal lobes (the con Aphasia
vexity), patients tend to become indifferent, abulic, or apa Aphasia refers to loss or impairment of language function as
thetic (mute and motionless in some cases). Following damage a result of brain damage. There are a number of distinct types
to the orbitofrontal area of the cortex, there is a syndrome of of aphasia and most of these result from lesions in specific re
disinhibition, in which the patient appears labile and irritable. gions of the cerebral hemispheres (Table 2 1 - 1 ) . In testing for
These patients are inattentive and distractible, with impaired aphasia, the clinician first listens to the patient's spontaneous
judgment and loss of the usual inhibitions and social graces. speech output and then explores the patient's speech during
Damage to the medial part of the frontal lobes can produce a conversation. Speech may be categorized as fluent (more than
syndrome of akinesia (lack of spontaneous movements) and 50 words per minute, effortless, absence of dysarthria, normal
apathy: Injury to the basal part of the frontal lobes can also re phrase length, and normal intonation). In contrast, nonfluent
sult in impairment of memory: These frontal lobe syndromes aphasia is effortful, with decreased verbal output (less t han 50
are more frequently seen in patients with bilateral lesions. words per minute), poor articulation, degradation of inflec
tion and melodic aspects of speech, and agrammatism (ie, the
tendency to omit small, grammatical words, verb tenses, and
LANGUAGE AND SPEECH plurals and to use only nouns and verbs) . Naming (which is
Language is the comprehension and communication of abstract usually examined by asking patients to name obj ects pre
sented to them), repetition of phrases such as "dog;' "automo
ideas. This cortical function is separate from the neural mecha
bile;' "President Kennedy;' "no ifs, ands, or buts;' and compre
nisms related to primary visual, auditory, and motor function.
The ability to think of the right words, to program and hension of spoken language are also tested. Comprehsion can
coordinate the sequence of muscle contractions necessary to be assessed in patients with impaired speech output by ob
serving the response to yes-no questions of graded difficulty
produce intelligible sounds, and to assemble words into mean
ingful sentences depends on Broca's area (areas 44 and 45) ("is your name John?" "Are we in a hospital room?" "Are we in
a church?" "Do helicopters eat their young?")
257
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258 SECTION V Functional Systems
B. Wernicke's Aphasia
This common form of aphasia is caused by a lesion in or near
the superior temporal gyrus, in Wernicke's area (see Figs 2 1 - 1
and 2 1 -2). Because this part o f the cortex i s not located adja
cent to the motor cortex, there is usually no hemiplegia.
Patients with Wernicke's aphasia have fluent speech, but
repetition and comprehension are impaired. The patient usu
ally has difficulty naming objects and produces both literal
Arcuate paraphasias ( eg, "well ow" instead of "yellow") and verbal
fasciculus
paraphasias (eg, "mother" instead of "wife") . Neologisms
FIGURE 2 1 -1 Central speech a reas of the d o m i n a nt cerebral (meaningless, nonsensical words, eg, "baffer") are used com
h e m i s p h e re. Notice that Broca's a n d Wer n icke's a reas a re monly and speech may be circumlocutory (ie, wordy but
i nterco n nected via fi bers that travel in the a rcuate fasc i c u l us, s u bja meaningless) . Patients with Wernicke's aphasia usually do not
cent to the cortex. appear concerned about, or even aware of, their speech disor
der. Wernicke's aphasia commonly occurs as a result of em
bolic strokes.
Aphasia With I m pa i red Repetition
In most common forms of aphasia, the ability to repeat spo C. Global Aphasia
ken language is impaired. Broca's, Wernicke's, and global Large lesions in the dominant hemisphere, which involve
aphasia are frequently seen in clinical practice. Broca's area in the frontal lobe, Wernicke's area in the tempo
ral lobe, and the interconnecting arcuate fasciculus, can pro
A. B roca's Aphasia duce global aphasia (see Fig 2 1 -2). In this nonfluent aphasia,
Broca's aphasia is common, and is usually caused by a lesion in both repetition and comprehension are severely impaired.
the inferior frontal gyrus in the dominant hemisphere (Broca's Global aphasia most commonly occurs as a result of large in
area; Fig 2 1 - 1 ) . The patient has difficulty naming even simple farctions in the dominant hemisphere, often because of occlu
objects. Repetition is impaired, but comprehension of spoken sion of the carotid or middle cerebral artery.
Auditory
Type Naming Fluency Comprehension Repetition Location of Lesion
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CHAPTER 21 Higher Cortical Functions 259
B. Anomie Aphasia
Anomia (difficulty fmding the correct word) can occur in a
variety of conditions, including toxic and metabolic en
cephalopathies. When anomia occurs as an aphasic disorder,
speech may be fluent but devoid of meaning as a result of
word-finding difficulty. The patient has difficulty naming ob
jects. Comprehension and repetition are relatively normal.
The presence of anomie aphasia is of little value in localizing
the area of dysfunction. Focal lesions throughout the domi
nant hemisphere or, in some cases, in the nondominant
hemisphere, can produce anomie aphasia, and anomia is also
commonly present in toxic and metabolic encephalopathies.
Alexia
Alexia (the inability to read) can occur as part of aphasic syn
dromes or as an isolated abnormality. Aphasic alexia refers to
impaired reading in Broca's, Wernicke's, global, and isolation
aphasias.
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260 SECTION V Functional Systems
Visual fields
..::.···.�-.
...
• • t •
. , . . . .
Y ·?' · -
: � ::
•
I • • •
•. t �•� 0
. . . .
·, 1
:
'
.
•
.
I
. left visual field
' . .
. . .
. .
.· .
. .
• Visual cortex
FIGURE 2 1 -3 Neuroanatomic basis for the synd rome of a lexia without agraph ia. Damage to two regions (the visua l cortex in the left,
speech-dominant hemisphere and the splen i u m of the corpus ca l l osum, which carries i nterhemispheric al xons con necting the t wo visual
cortices) is req u i red. These regions a re both i rrigated by the posterior cerebral artery. Thus, occl usion of the left posterior cerebral a rtery can
produce this stri king syndrome.
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CHAPTER 2 1 Higher Cortical Functions 26 1
A B
Anosog nosia
Anosognosia, the lack of awareness of disease or denial of ill
ness, may occur together with the unilateral neglect syndrome.
FIGURE 2 1 -4 Mag netic resonance image showing lesions i n For example, patients with left hemiparesis often neglect t he
t h e left occipital l o b e and splenium o f t h e corpus ca l losum i n a paralyzed limbs and may even deny that they are part of their
48-yea r-old man who suddenly developed a right s u perior visual body, attributing them to a doll or another patient. Even when
field of quadranta nopsia and a l exia without agra p h ia. Both hyperten
sion and hypercholesterolemia placed this patient at high risk f o r
stroke.
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262 SECTION V Functional Systems
the patient is aware of the deficit, he may not be appropriately left superior temporal gyrus (the planum temporale) is
concerned about it. broader in people with left-hemisphere dominance.
When neurosurgery is contemplated for a patient, it can
be useful for one to establish which cerebral hemisphere is
Apraxia dominant for speech. Typically, amobarbital or thiopental
Apraxia, the inability to carry out motor acts correctly despite sodium is injected into a carotid artery while the patient is
intact motor and sensory pathways, intact comprehension, and counting aloud and making rapidly alternating movements of
full cooperation, can occur following injury to a variety of cor the fmgers of both hands. When the carotid artery of the dom
tical and subcortical sites. Ideomotor apraxia is the inability to inant side is injected, a much greater and longer interference
perform motor responses upon verbal command, when these with speech function occurs than with injection of the other
responses were previously carried out spontaneously. For ex side.
ample, the patient may fail to show his teeth on command, al
though he can do this spontaneously. Providing patients with
objects to be used (eg, giving them a hairbrush and asking MEMORY AND LEARNING
them to demonstrate how to brush their hair) leads to im
provement of their performance. Damage to a variety of sites, The three types of memory are immediate recall, short-term
including Broca's area, the corpus callosum, and the arcuate memory, and long-term (or remote) memory.
fasciculus, can cause ideomotor apraxia. Ideational apraxia Immediate recall is the phenomenon that allows people
is characterized by an abnormality in the conception of to remember and repeat a small amount of information
movements, so the patient may have difficulty doing anything shortly after reading or hearing it. In tests, most people can re
at all, or may have problems sequencing the different compo peat, parrot-like, a short s eries of words or numbers for up to
nents of a complex act although each separate component can 10 minutes. The anatomic substrate is thought to be the audi
be performed correctly. In ideational apraxia, introduction of tory association cortex.
objects to be used does not improve performance. Ideational Short-term memory can last up to an hour. Tests usually
apraxia may be seen after lesions of the left temporal-parietal involve short lists of more complicated numbers ( eg, tele
occipital area. phone numbers) or sentences for a period of an hour or less.
This type of memory is associated with intactness of the deep
temporal lobe. If a patient's temporal lobe is stimulated during
Gerstm a n n's Synd rome surgery or irritated by the presence of a lesion, he or she may
This tetrad of clinical findings includes right-left disorienta experience deja vu, characterized by sudden flashes of former
tion, finger agnosia (difficulty identifying or recognizing the events or by the feeling that new sensations are old and famil
fingers), impaired calculation, and impaired writing. The iar ones. (Occasionally, the feeling of deja vu occurs sponta
presence of this tetrad suggests dysfunction in the angular neously in normal, healthy persons.)
gyrus of the left hemisphere. As previously mentioned, Gerst Long-term memory allows people to remember words,
mann's syndrome may occur together with anomie aphasia numbers, other persons, events, and so forth for many years.
and alexia. The formation of memories appears to involve the strengthen
ing of certain synapses. Long-term potentiation (LTP) , a
process triggered by the accumulation of calcium in postsy
CEREBRAL DOMINANCE naptic neurons following high-frequency activity, appears to
play an important role in the processes underlying memory.
Although the projection systems of motor and sensory path Experimental and clinical observations suggest that the en
ways are relatively similar on the left and right, each hemi coding of long-term memory involves the hippocampus and
sphere is specialized and dominates the other in some specific adjacent cortex in the medial temporal lobes. The medial thal
functions. The left hemisphere controls language and speech amus and its target areas in the frontal lobes are also involved,
in most people; the right hemisphere leads in interpreting together with the basal forebrain nucleus of Meynert
three-dimensional images and spaces. Other distinctions have (Fig 2 1 -7) .
been postulated, such as music understanding in the left
hemisphere, arithmetic and design in the right.
Cerebral dominance is related to handedness. Most EPILEPSY
right-handed people are left-hemisphere dominant; so are
70% of left-handed people, while the remaining 30% are Dysfunction of the cerebral cortex, alone or together with
right-hemisphere dominant. This dominance is reflected in dysfunction of deeper structures, can lead to some forms of
anatomic differences between the hemispheres. The slope of epilepsy. Epilepsy is characterized by sudden, transient al
the left lateral fissure is less steep, and the upper aspect of the terations of brain function, usually with motor, sensory, au
tonomic, or psychic symptoms; it is often accompanied by
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CHAPTER 2 1 Higher Cortical Functions 263
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264 SECTION V Functional Systems
nom ena
tJ!otor ph e
Senso
opp osite side Foot IJr IJ
n1<. to Toes h
�o \N 1 co ntralateral l i mbs Leg Leg E>11011,
e '3-0 (('ents 0 Thigh
� �0 Thigh E>l)c$)
,._ 1('0 1 Thorax Chest
e e ra
l t
la.
f!:r�' nt a Shoulder Shoulder
CP ,o cO ,oe Arm Arm
<v..;,e"' s Forearm
Forea rm
Hand
Hand
Digit 5 Dl. glt 5
Digit 3 �����
.
Thumb Face
Face Mouth
Tongue Tongue
Jaw Larynx
Larynx ons
�1\)Cina.
. \i
��c "a .
ll osite s 1
s de
�cO� \<.to Oil I
\l�n ent 0
8� 8s . (('0� e((' (('i\ies
e
y..e'3-�9' i" la.\ e"I-\IB
e
0 �1�a
cO
FIGURE 2 1 -8 Results of electrical sti m u
lation o f the cerebral cortex.
Th i s 44-year- o l d wo m a n h a d a general i zed ton i c- c l o n i c i m a g i n g sca n n i n g showed severe atrophy of the h i p poca m p u s
seizu re associated with fever at t h e age o f 3 but w a s otherwise on the r i g h t ( F i g 2 1 -9) .
wel l until the age of 1 2, when co mplex partia l seizure activity The con cord a n ce of the EEG fi n d i n g s, together with M R I
beg a n . Her seizures were cha racterized by an a u ra consi sti ng demonstration o f right h i ppoca mpal atrop hy, ind icated right
of a rising sensation i n her g ut, fol l owed by loss of conscious med ial tem poral lobe epilepsy. Beca use the patient's seizu res
ness, ton i c activity of the l eft hand, a n d turning of the head t o h a d not been control led by a nticonv u l sant med ications, she
the left. Sometimes she wou l d fa l l if sta n d i ng. Her seizu res av underwent neurosurgical resection of the right medial tempo
eraged 5 to 1 0 per month despite treatment with anticonvu l ra l lobe (Fig 2 1 - 1 0). S u bseq uent to surgery, the patient has had
sant drugs. On exa m i n ation, no neurologic a b norma l ities were no seizu res with the exception of one that occu rred when her
obse rved. Beca use of the fa i l u re of traditional medical therapy a nticonvu lsant drug leve l s were very l ow.
to control her seizu res, the patient was hospital ized. E l ec Th is case i l l u strates a cl assica l h i story a n d fi n d i n g s for the
troence p h a l ogram mon ito r i n g revea l ed s l owi n g and a b n o r most c o m m o n form of e p i l e psy treated by s u rg ery, m e d i a l
mal spike activity in the right a nte rior te m poral lobe. D u ring tem poral l o b e epile psy. T h e response t o n e u rosurgical resec
her seizu res there was abnormal d i scharge of the right tem po tion of these a reas can be d ra matic, with nearly 90% of pa
ra l lobe. An i ntraca roti d a m o b a rbita l test, in which an a nes tients being rel ieved of seizures. The correlation of a natomic
thetic was i njected i nto her carotid a rteries, d e m o n strated local ization by electrical, structural, and cogn itive stud ies pre
left-hemisphere d o m i n ance for speech and a ma rked dispa rity operatively and the su bseq uent response to resection of a cir
of memory fu nction between the left a n d rig ht hemisph eres; cumscri bed cerebral a rea provide a dramatic demonstration of
the l eft h e m i s p h e re s h owed pe rfect m e mory a n d the rig ht a n atomic-cl in ica l correlation.
sh owed s i g n ifi cantly i m p a i red memory. Magnetic reso n a n ce
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CHAPTER 2 1 Higher Cortical Functions 265
C A S E 2 6
One month before admission to the hospital, this 60-year to light and there was slight, but definite, bilateral pa
old, right-handed widow had a 5-minute episode of numb pilledema. Other findings included decreased appreciation
ness and tingling in the left arm and hand, accompanied by of pain on the left side of the face, complete paralysis of the
loss of movement in the left hand. Two days before admis left central face, and complete flaccid paralysis of the left
sion, she fell to the floor while taking a shower and lost arm and less severe weakness of the left leg; the patient
consciousness. She was found by a neighbor, unable to seemed to ignore the left side of her body and was not con
move her left arm and leg. Her speech, although slurred cerned about her hemiparesis. Reflexes were more pro
and slow, made sense. nounced on the left than on the right, and there was a left
Neurologic examination on admission showed a blood plantar extensor response. Responses to all sensory stimuli
pressure of 1 80/1 00 with a regular heart rate of 84 beats were decreased on the left side of the body. Computed to
per minute. The patient was slow to respond but roughly mography scanning produced an image similar to Figure
oriented with regard to person, place, and time. She ig 1 2-14, but in the opposite hemisphere.
nored stimuli in the left visual field. The pupils responded What is the diagnosis?
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266 SECTION V Functional Systems
C A S E 2 7
A 63-year-old clerk suddenly experienced a strange feeling urged him to see a doctor. When asked about his medical
over his body, which he characterized as an electric shock, history, the patient indicated that he had rheumatic heart
with flashes of blue light. He said the flashes looked like a disease that had been completely under control for the past
stained-glass window with very strong sun behind it on the 3 years .
right. During this episode he felt confused. When he recov General physical examination revealed cataracts in both
ered shortly afterward, he felt tired and went to bed. The eyes, which were not severe enough to compromise vision
next day when he got up he inadvertently walked into the significantly. Neurologic examination showed normal vi
right doorj amb. He did not notice his wife bringing him a sual acuity and normal optic disks , but there was right
cup of coffee as she approached from his right side. Dur hemianopsia. No other neurologic abnormality was found.
ing the next 2 weeks, he continued to bump into people and Where is the lesion? What further tests would be helpful
objects on his right side and complained of poor vision, in confirming the site? What is the most likely diagnosis?
which he attributed to a cataract in his right eye. His wife Cases are discussedfurther in Chapter 25.
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C H A P T E R
267
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268 SECTION VI Diagnostic Aids
�--==- Carotid
bifurcations
Left vertebral
artery 1 . Internal carotid artery
2. Ophthal mic artery
3. Posterior communicati ng artery
4. Anterior choroidal artery
5. Anterior cerebral artery
6. Frontopolar artery
7. Cal losomarginal artery
8. Pericallosal artery
9. Middle cerebral artery
1 0 . Ascending frontoparietal artery
Catheter in 1 1 . Posterior parietal artery
aortic arch 1 2 . Angular artery
1 3. Posterior temporal artery
and vertebral angiograms may be complemented by other development in the 1960s, the CT scan has become a primary
films ( eg, by an external carotid series in cases of meningioma tool for demonstrating the presence of abnormal calcifications,
or arteriovenous malformation). The films are often presented brain edema, hydrocephalus, many types of tumors and cysts,
as subtracted, that is, as reversal prints superimposed on a hemorrhages, large aneurysms, vascular malformations, and
plain film of the skull. other disorders.
CT scanning is noninvasive and fast. Although it has a
high degree of sensitivity, its specificity is relatively limited.
COM PUTED TOMOGRAPHY Correlation with the clinical history and physical examina
tion is an absolute requirement. In the case of a subarach
CT, also called computed axial tomography (CAT), affords noid hemorrhage, for example, although a CT scan may
the possibility of inspecting cross sections of the skull, brain, quickly localize the areas containing blood (Fig 1 2-2 1 ) ,
ventricles, cisterns, large vessels, falx, and tentorium. Since its
Contrast medium
beginning to fill �
ophthalmic �
artery
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CHAPTER 22 Imaging of the Brain 269
Shifted
anterior
cerebral
artery
Pericallosal artery
Elevated
Branches of middle main stem
cerebral artery of middle
cerebral
artery
Stretched £4!.��
branches
over mass
additional CT images (Fig 1 2-22), magnetic resonance im (picture elements) in a matrix. In most cases, absorption is
aging, or angiography is often required to determine proportional to the density of the tissue. A converter translates
whether the cause was an aneurysm or an arteriovenous the numeric value of each pixel to a gray scale. Black-and
malformation. white pictures of head slices are then displayed, with black
The CT scanning apparatus rotates a narrow x-ray beam representing low-density structures and white representing
around the head. The quantity of x-ray absorbed in small vol high-density structures. The thickness of t he slices can vary,
umes (voxels [volume elements, or units] ) of brain, measuring from 1 . 5 mm to 1 em. The gray scale can also vary; although
2
approximately 0.5 mm x 1 .5 mm or more in length, is com a setting at which brain tissue is distinguished best is com
puted. The amount of x-ray absorbed in any slice of t he head monly used, in some cases bone, fat, or air need to be defmed
can be thus determined and depicted in various ways as pixels in great detail.
Posterior
cerebral
arteries
--:����I:;:::P.����'/" Superior
"' cerebellar
arteries
Basilar
artery
FIGURE 22-6 Schematic d rawing of a normal angiogra m of FIGURE 22-8 Vertebral ang iogram, a rterial phase, right lateral
the i nterna l carotid a rtery, a rterial phase, frontal projection. (For view. Normal i mage. Arrows indicate posterior choroidal a rteries.
sign ificance of n u m bers, see Fig 22-4.) (Redrawn and reproduced, with
permission, from List C, B u rge M, Hodges L: I ntracranial angiography. Radiology
1 945;45 : 1 .)
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270 SECTION VI Diagnostic Aids
A series of 1 0 to 20 scans, each reconstructing a slice of quency signal; gradient coils are used to localize the signal
brain, is usually required for a complete study. The plane of (Fig 22- 1 7). The signal of every voxel is shown as a pixel in a
these sections is the orbitomeatal plane, which is parallel to matrix, similar to the CT technique. The resolution of the im
both Reid's base plane and t he intercommissural line used in ages is comparable to, or exceeds, that of CT scans, and with
stereotactic neurosurgery (Fig 22- 1 3 ) . Usually, a " scout view" MRI an image of the brain or spinal cord in any plane can be
similar to a lateral skull roentgenogram is taken with a CT obtained directly; no reformation is required. Bone is poorly
scanner to align the planes of sections (Fig 22- 14). With the imaged and does not interfere with visualization of nervous tis
modern technology now available, each scan t akes only a few sue; thus, MRI is especially useful for imaging the spinal cord
seconds. Examples of normal and abnormal CT scans are and structures within the posterior fossa.
shown in Figures 22- 1 5 and 22- 16. MRI can also be used to directly and noninvasively evaluate
CT scanning of the posterior fossa may provide only lim the flow of blood within medium and larger arteries and veins,
ited information because of the many artifacts caused by with no need for intravenous injection of a contrast agent. This
dense bone. Images reformed by a computer from a series of makes MRI particularly useful in cerebrovascular studies.
Superior
anastomotic vein
· ·=--�
Sphenoparietal
sinus
FIGURE 22-1 0 Left internal carotid angiogram, venous phase, latera l vi ew. Normal i mage. ( Co m pare with Figs 1 2-9 and 22� 1 1 )
.
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CHAPTER 22 Imaging of the Brain 271
FIGURE 22-1 1 Schematic d rawing of normal venogram i n latera l projection, obta ined by carotid i njection. Su perficial veins a re shaded
more darkly than the sinuses a n d deep veins. (Redrawn and reproduced, with permission, from List C, Burge M, Hodges L: I ntracranial angiography. Radiology
1 945;45 : 1 .)
Zero
point
Vertebral
arteries
'-----"--=- Common
carotid
arteries
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272 SECTION VI Diagnostic Aids
Hydrocephalus. Dilated ventricles in Bra i n tumor. Cerebral metastasis Brain tumor. Cerebellar medullo
a 7-year-old boy who had under from carcinoma of lung in a 65- blastoma in a 1 6-year-old male.
gone a shunting operation at age year-old man.
1 year.
Cerebral hemiatrophy. H istory of Cerebellar hemorrhage. 81 -year Tra u matic i ntracerebral hemor
subarachnoid hemorrhage 5 years old hypertensive man with acute rhage. H istory of a fall by an intox
previously in a 48-year-old woman. onset of coma and quadriparesis. icated 78-year-old man followed by
confusion and hemiplegia.
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CHAPTER 22 Imaging of the Brain 273
X
Patient bed
FIGURE 22-1 7 Schematic representatio n of MR i mager and its components. (Reprod uced with permission from deGroot J: Correlative neuroanatomy
of computed tomography and magnetic resonance imaging, 2 1 st edition. Appleton & Lange, 1 99 1 .)
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274 SECTION VI Diagnostic Aids
lobe
callosum
I nternal capsule
Thalamus
A B
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CHAPTER 22 Imaging of the Brain 275
of the fingers), sensory activity (ie, stimulation of a sensory POSITRON EMISSION TOMOGRAPHY
organ or part of the body surface), cognitive activity (eg, cal
culation, reading, or recalling) , and affective activity (eg, Positron emission tomography (PET) scanning has become a
responding mentally to a fearful stimulus) . Examples are major clinical research tool for the imaging of cerebral blood
shown in Figures 1 5 - 1 7 and 22-2 1 . flow, brain metabolism, and other chemical processes
(Fig 22-22). Radioisotopes are prepared in a cyclotron and are
inhaled or injected. Emissions are measured with a gamma-ray
FIGURE 22-2 1 Exa m p l e of fu nctional M R I showing i ncreased perfusion of the m otor cortex i n the right hemisphere associated with
ra pid fi nger tapping of the left hand. U pper left: Relative blood flow map i n the tra nsverse (horizontal) plane d u ring r est. Upper right: Relative
blood flow m a p d u ring ra pid ta pping of fi ngers of the l eft hand (the arrows point to the reg ion in the right hemisphe re where the increased
blood flow response is seen). Lower rig ht: Su btracting one image from the other provides a "difference image;' which shows a hot spot corre
sponding to the active region of the cortex. Center: Difference image s u perim posed on structu ra l MRI, showi ng that increased perfusion maps
precisely to the m otor cortex i n the a nterior bank of the central s u lcus of the right hemisphere. (Courtesy o f Dr. 5. Warach.)
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276 SECTION VI Diagnostic Aids
Enlarged
ventricles
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C H A P T E R
277
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278 SECTION VI Diagnostic Aids
_.
X
Nasion
abnormality.
Absence seizures of childhood (petit mal), which are
/
/
Fp1 Fp2 characterized by brief (up to 30 seconds) loss of consciousness
without loss of postural tone, are associated with a character
F7 FB istic three-per-second spike-and-wave abnormality on EEG.
F3 Fz F4
Complex partial seizures (which usually have a temporal
A2 lobe origin), in contrast, can also be associated with impaired
I
C3 Cz C4 T4 awareness, but the EEG usually shows focal temporal lobe
spikes or appears normal because the aberrant and relatively
Right
I
:/
deep temporal lobe discharges cannot be detected with scalp
T5 P3 Pz P4 T6 electrodes.
Infectious, toxic, and metabolic disorders affecting the
01 nervous system can be accompanied by characteristic EEG ab
normalities. For example, in herpes simplex encephalitis, the
I n ion EEG displays periodic high-voltage sharp waves over t he tem
poral lobes at regular three-per-second intervals. In
FIGURE 23-1 A single-plane projection of the head, showi ng Creutzfeldt-Jakob disease (also termed subacute spongiform
a l l sta ndard positions of e lectrode p lacement and the locations of encephalopathy), the EEG usually shows a pattern of burst
the centra l su lcus (fissure of Rolando) and the lateral cerebra l fissure
suppression characterized by stereotyped, high-voltage slow
(fissure of Sylvi us). The outer circle is d rawn at the l evel of the nasion
and sharp wave complexes superimposed on a relatively flat
and i nion; the i n ner c i rcle represents the temporal line of e lectrodes.
This diag ra m provides a usefu l g u i d e for el ectrode placement in rou
background. In hepatic encephalopathy, bilaterally synchro
tine record i ng. A, ea r; C, central; Cz, centra l at zero, or m i d l i ne; F,
nous triphasic waves are often present.
frontal; Fp, frontal pole; Fz, frontal at zero, or m i d l i ne; 0, occi pital; P,
parieta l; Pg, nasopharyngeal; Pz, parietal at zero, or m i d l in e; T,
temporal. (Courtesy of Grass Technologies, An Astro Med, I nc. Produce Group, EVOKED POTENTIALS
West Warwick, Rl.)
Whereas the EEG displays ongoing or spontaneous electrical
activity, evoked potential recordings permit the measurement
When the eyes are opened, the alpha rhythm is replaced
of activity in cortical sensory areas and subcortical relay nu
by an alpha block, a fast, irregular, low-voltage activity. Other
clei in response to stimulation of various sensory pathways.
forms of sensory stimulation or mental concentration can also
Because the electrical signals are small, computerized averag
break up the alpha pattern. Desynchronization is sometimes
ing methods are used to extract the time-locked neural signals
termed the arousal, or alerting, response , because this
evoked by a large number of identical stimuli. The latency,
breakup of the alpha pattern may be produced by sensory
amplitude, and waveform of the evoked potential provide in
stimulation and is correlated with an aroused or alert state. formation about impulse conduction along the pathway, or
The beta rhythm is characterized by low amplitude (5-20 �-tV)
group of neurons, under study, and thus about the functional
waves with a rhythm faster than 12 Hz, most prominent in the
integrity of the pathway.
frontal regions.
Theta rhythms (4-7 Hz) are normally seen over the tem
poral lobes bilaterally, particularly in older patients, but can Visual Evo ked Potentia ls
also occur as a result of focal or generalized cerebral dysfunc
Visual evoked potentials (VEPs) are usually elicited by having
tion. Delta activity ( 1-3 Hz) is never seen in the normal EEG
the patient fixate on a target and flashing a reversing checker
and indicates significant dysfunction of the underlying cortex. board pattern on a screen centered around the target. The
Brain tumors, cerebral abscesses, and subdural hematoma are
VEPs recorded in this manner are sometimes called pattern
often associated with focal or localized slow-wave activity. CT
shift VEPs (PSVEPs). These are recorded using scalp electrodes
and MRJ, however, can provide more information about the
placed over the left and right occipital poles. This reaction is
location and structure of the lesion and have largely replaced
clinically useful in detecting slight abnormalities in the visual
EEG for the diagnosis of these disorders.
pathways; for example, optic nerve lesions can be recognized
Epilepsy is an expression of various cortical diseases
by stimulating each eye separately, because the response to
characterized by transient disturbances of brain function
stimulation of an affected optic nerve is absent or impaired.
manifested by intermittent high-voltage waves. Electroen
With visual pathway lesions behind the optic chiasm, a differ
cephalograms from patients with various types of epilepsy
ence in response of the two cerebral hemispheres may occur,
are shown in Figure 2 3 - 2 . Spikes and sharp waves have
with a normal response in the occipital cortex of the normal
characteristic shapes and occur either as part of seizure dis cerebral hemisphere and an absent or abnormal response i n
charges or interictally in patients with epilepsy. These EEG
the affected cerebral hemisphere (see Chapter 15).
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CHAPTER 23 Electrodiagnostic Tests 279
LF-LAT LF-LAT
R F-RAT R F-RAT
LAT-LT LAT-LT
� ------
RAT- RT RAT-RT
LT-LO LT-LO
RT- RO RT- RO
Normal adult Focal motor epi lepsy : EEG of a 47-year-old man with
focal motor seizu res beginning in the left hand. He
stated his seizures began 20 years previously,
approximately 1 year after a severe head injury.
LF-LE
RAT-RT LT-LE
LT-LO RT-LE
RT- RO LAT-LE
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280 SECTION VI Diagnostic Aids
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CHAPTER 23 Electrodiagnostic Tests 28 1
Time in ms
:r :I
2 3 4 5 6 7 8 9 10
t
1 .9 3.0 4. 1 5.2 5.8 5.9 7.6 9.2
. .... ..
. .. .
: lll l
Superior ! Lateral ! .
I
II IV ! v
(pons) !
.
: (midbrain) (thalamus) (thalamo-
..
cortical)
Outer Superior
Inner ol ivary Pontomed-
complex
Acoustic nerve
Midbrain
level
lemniscus
geniculate
Ventral Dorsal Inferior body
cochlear cochlear col liculus
nucleus nucleus
FIGURE 23-3 Far-field recordi n g of bra i n stem aud itory response latencies in h u m a n s showing proposed fu nctiona l-anatomic
correlations. Diagram shows normal latencies for vertex-positive bra i n stem auditory evoked potentials (waves I-IV) evoked by clicks of 60 d B H L
(60 d B a bove n o r m a l h e a r i n g threshold) at a rate of 1 0/s. Lesions at d ifferent l evels o f the aud itory pathway t end to produce response
abnormal ities beg i n n i n g with the indicated components. I ntermediate latency (5.8 ms) between latencies of waves IV a n d V is the mean peak
latency of fused wave IVN when present. C z + • vertex positivity, represented by a n upward pen deflection; Cz-• vertex negativity, represented by
a downward pen deflection. (Reprod uced, w i t h permission, from Stockard J J , Stockard JE, Sharbrough F W : Detection and localization o f occult lesions w i t h bra i n stem
aud itory responses. Mayo Clin Proc 1 977;52:76 1 .)
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282 SECTION VI Diagnostic Aids
' C �L l;
M
I
FIGURE 23-4 Action potentia ls in electromyography. A: Nerve potential from normal m u scle; 8: fi brillation potential and C: positive
wave from denervated muscle; D: hig h-freq uency discharge in myotonia; E: bizarre hig h-freq uency d ischarge; F: fascicu lation potential, single
d ischarge; G: fasciculation potential, repetitive o r grouped d ischarge; H: synchron ized repetitive d ischarge in m uscle cramp; 1 : d i phasic, J:
triphasic, and K: polyphasic motor unit action potentia ls from norma l m uscle; L: short-d u ration motor u n it action potentials i n progressive m us
cular dystrophy; M: large motor u n it action potentia ls i n progressive m uscu lar dystrophy; N: highly polyphasic motor u n it action potential and
short-d u ration motor u n it action potential d u ring rein nervation. Ca l ib ration sca l e (vertical) i n m icrovo lts. The horizontal sca l e shows 1 000-Hz
waveforms. An u pwa rd deflection ind icates a change of potential in the negative d i rection at the need le electrode. (Reprod uced, with permission,
from Clinical Examinations in Neurology, 3rd ed. Members of the Section of Neurology and Section of Physiology, Mayo Clinic and Mayo Foundation f or Medical Education and
Research, Graduate School, Un iversity of Minnesota, Rochester, MN. WB Sau nders, 1 97 1 .)
on the skin surface are amplified and displayed. The electrical (or denervation) of the muscle fibers within a muscle. The
activity can be displayed on a computer screen. Observations MUP in any given muscle has a characteristic size and dura
are made in each area of the electrical activity evoked in the tion. If lower motor neurons, roots, or nerves are injured so
muscle by insertion and movement of the needle: the electri that motor axons are severed and muscle fibers are dener
cal activity of the resting muscle with the needle undisturbed, vated, the number of MUPs appearing during contraction is
and the electrical activity of t he motor units during voluntary decreased. Nevertheless, the configurations of the remaining
contraction (Fig 23-4). Because various muscle fibers may re MUPs are usually normal. The decreased number of MUPs
spond differently, several insertions of the needle into differ reflects denervation of some of the muscle fibers. Later, there
ent parts of a muscle may be necessary for adequate analysis. may be reinnervation of the previously denervated muscles as
a result of sprouting of new motor axon branches from un
damaged axons, whose motor units increase in size. As a re
Types of Activity sult, the MUPs increase in amplitude and duration and in
Insertional activity refers to the burst of action potentials that some cases become polyphasic. These polyphasic MUPs pro
is usually observed when the EMG needle is inserted into the vide evidence of reinnervation (and thus implies prior dener
muscle. In normal muscle, insertional activity is short lived, vation) and can have diagnostic value, providing evidence of
and there is usually electrical silence after the initial burst of disease involving motor neurons or their axons in the ventral
insertional activity. Increased insertional activity is observed roots or peripheral nerves.
in denervated muscles and in many forms of muscle disease. Two types of spontaneous or ongoing activity observed
Motor unit potentials (MUPs) are also examined by by EMG have particular significance. The term fibrillation is
EMG and provide important information about innervation
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CHAPTER 23 Electrodiagnostic Tests 283
reserved for spontaneous independent contractions of indi prising a given motor unit) can also be studied with t his tech
vidual muscle fibers so minute that they cannot be observed nique. Jitter appears to result from abnormalities of the preter
through the intact skin. Denervated muscle may show elec minal part of the axons close to the neuromuscular junction.
tromyographic evidence of fibrillations that are most pro Single-fiber electromyography may be especially useful for the
nounced for 1-3 weeks and that can persist for months after diagnosis of disorders involving motor neurons (eg, amy
losing its nerve supply. Fasciculations, or twitches, in con otrophic lateral sclerosis) and the neuromuscular j unction.
trast, can be seen and palpated, and they can be heard with the
aid of a stethoscope; they represent contractions of all (or
most) of the muscle fibers of a motor unit. Spontaneous fasci NERVE CONDUCTION STUDIES
culations can vary because of the length and number of mus
cle fibers involved; they usually result from disorders of the As noted in Chapter 3, myelination increases the conduction
lower motor neuron or its axon. Benign fasciculations, such as velocity (the speed of action potential transmission) along ax
those from exposure to cold or temporary ischemia ( eg, ons. Conversely, damage to the myelin (demyelination) results
caused by crossed legs), are unassociated with other clinical or in a decrease in conduction velocity. Damage to the axon or
electrical signs of denervation (see Fig 23-4) . axonal degeneration, on the other hand, results in loss of abil
In a complete nerve lesion, all of the motor axons are sev ity of the axon to conduct impulses. These physiological
ered, so that fibrillation potentials occur without MUPs; par changes can be measured in nerve conductions studies.
tial nerve lesions show both fibrillation and motor unit activ By stimulating peripheral nerves with electrodes placed
ity from voluntary muscle contraction. Diminution or on the skin and recording muscle and sensory nerve action
cessation of fibrillation potentials and the appearance of small, potentials, it is possible for one to examine conduction ve
disintegrated motor unit action potentials occur with nerve locities, distal latencies, and amplitudes of responses, which
regeneration. Fibrillations in a paretic muscle are increased by provide important information about the functional status
warmth, activity, and neostigmine; they are decreased by cold of the myelinated axons within a peripheral nerve. These
or immobilization. studies can be helpful in determining whether peripheral
After complete section of a nerve, denervation fibrillation nerves have been affected and, if so, help to determine the
potentials are evident (after about 18 days) in all areas of the pathologic process involved ( eg, demyelination vs. axonal
muscles supplied by a peripheral nerve. Some motor unit dis injury) .
charges persist in partial nerve injuries despite the clinical ap For these studies, surface electrodes are placed on the
pearance of complete paralysis. Mapping the areas of denerva skin for stimulation of accessible peripheral nerves, and the
tion fibrillation potentials aids in the diagnosis of single nerve resulting compound action potential is recorded elsewhere
root disorders and spinal nerve root compression. over the nerve or over a muscle that is innervated by the nerve
being studied. Two stimulation sites are usually used so t hat
conduction velocity can be ascertained (by dividing the dis
Repetitive Sti m u l ation tance between the two stimulation sites by the difference in
In the absence of pathologic conditions, axons can conduct conduction times) . These whole-nerve conduction velocities
impulses at a high frequency, and the neuromuscular junction measure the properties of the fastest conducting (and largest)
can faithfully follow these high-frequency impulses, produc axons within the nerve, that is, the myelinated axons and have
ing a surface muscle action potential t hat retains its amplitude normal values of more than 40 m/s in adults.
with rates of stimulation up to 20-30 Hz for up to 1 minute. In Nerve conduction studies, as carried out in clinical set
contrast, in myasthenia gravis, the response is decremental; tings, do not assess the function of slow-conducting, non
the MUP decreases in amplitude after several stimuli at rates myelinated axons, and thus cannot detect damage to these
as low as 3 or 4 Hz. The Lambert-Eaton myasthenic syn small axons, as occurs in the small fiber neuropathies. These
drome exhibits a different pattern; in this disorder, there is a can be diagnosed on the basis of the clinical picture of small
defect of neuromuscular transmission characterized by incre fiber dysfunction (pain and autonomic dysfunction) and by
mental responses, which increase in amplitude with repetitive confirmation of damage to small axons as seen in skin biopsy
stimulation. These distinct patterns of response to repetitive (which permits visualization of the distal tips of small nerve
stimulation are of considerable diagnostic value. fibers in the epidermis) .
Decreased conduction velocities are seen in peripheral
neuropathies characterized by demyelination (eg, Guillain
S i n g le-Fi ber EMG Barre syndrome, chronic inflammatory demyelinating
Single-fiber EMG (SFEMG) permits the recording of action polyneuropathy, and Charcot-Marie-Tooth disease) . Slowed
potentials from single muscle fibers using very fme electrodes. conduction velocities are also seen at sites of focal compres
This technique permits the measurement of muscle fiber den sion.
sity within a given motor unit and thus can be of significant Measurements of amplitude, of either the muscle action
value in the diagnosis of muscle disorders. Jitter (variability in potential elicited by motor axon stimulation or the sensory
the timing of action potentials for single muscle fibers com- nerve action potential, can also provide useful information.
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284 SECTION VI Diagnostic Aids
Reduction of amplitude is especially pronounced in disorders potentials then travel through the ventral roots and then to
characterized by loss of axons (eg, uremic and alcoholic the muscle. Absence of the H-reflex suggests pathologic con
nutritional neuropathies). The presence, absence, or reduction ditions along this pathway and is often a result of radicu
of innervation can be determined by electrical stimulation of lopathies (disorders involving peripheral nerves) or polyneu
peripheral nerves, and the location of a nerve block can be ropathies involving spinal roots or proximal parts of the
shown. Anomalies of innervation can be detected by noting peripheral nerves (eg, Guillain-Barre syndrome) .
which muscles respond to nerve stimulation, and abnormal The F-wave is a long-latency response, following the di
fatigability after repeated stimulation of the nerve can be rect muscle potential, that is evoked by supramaximal stimu
noted. lation of motor-sensory nerves. It is produced by antidromic
In the presence of paralysis, a normal response of inner (retrograde) stimulation of motor axons, which results in in
vated muscles to stimulation of the peripheral nerve shows vasion of action potentials into their cell bodies in the spinal
that the cause of paralysis is proximal to the stimulated point. cord and evokes a second (reflected) action potential that
Alternatively, an absent or weak response suggests further travels along the motor axon to muscle. As with the H-reflex,
testing to detect the site and nature of the defect, which prob absence of the F-wave implies pathologic conditions of spinal
ably includes pathology distal to the stimulation site. roots or proximal parts of peripheral nerves.
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C H A P T E R
C erebrospinal Fluid
Examination
Analysis of the cerebrospinal fluid (CSF) can provide useful puncture must be done extremely carefully or not at all.
diagnostic information. As noted in Chapter 6, CSF is usually This is because shifts in CSF dynamics, as a result of lum
obtained from the lumbar subarachnoid space via a spinal bar puncture, can precipitate herniation of the tonsils of the
tap, also called a lumbar puncture. Usually, this is carried out cerebellum through the foramen magnum, with resultant
at the 13-4 or L4-5 interspace, with the patient in the lateral compression of the medulla. Thus, in patients with suspect
decubitus position. In some cases, it is easier to perform lum ed intracranial mass lesions, or in those in whom there is
bar puncture with the patient in a sitting position. Because t he papilledema, lumbar puncture should be deferred until
spinal cord in adults ends at the L l - 2 level, lumbar puncture imaging has ruled out incipient herniation or a neurologist
can be performed below that level (and above the sacrum) or neurosurgeon has been consulted.
without injuring the cord. (2) Infection (or suspected infection) at the site of lumbar
puncture constitutes a contraindication because the needle
can introduce the organism into the underlying subarach
I NDICATIONS noid space. Suspected epidural abscess at the puncture site
is thus a contraindication.
There are several indications for lumbar puncture:
(3) Coagulation disorders in patients with thrombocytope
( 1) To verify suspected infection of the central nervous system nia, hemophilia, vitamin K deficiency, and so forth can be
(meningitis, encephalitis). followed by subdural or epidural bleeding at the site oflum
(2) To determine whether there is hemorrhage within the cen bar puncture. Lumbar puncture under these circumstances
tral nervous system, that is, for the diagnosis of subarach should be performed only if the possible benefits outweigh
noid hemorrhage if there is a high index of suspicion on the risks and then only after the coagulation disorder has
clinical grounds and when computed tomography scanning been corrected, if possible.
is negative or unavailable.
(3) To examine the chemical and immunologic profile of the
CSF to aid the diagnosis of disorders such as multiple ANALYSIS OF THE CSF
sclerosis.
The manometric pressure of the CSF is measured at the be
( 4) To obtain cells for cytologic examination when carcinoma
ginning and at the end of the procedure. With the patient in
tous meningitis (seeding of the meninges with neoplastic
the lateral decubitus position, the opening pressure of the CSF
cells) is a diagnostic possibility.
is normally 70 to 200 mm H 20. If lumbar puncture is per
The diagnosis of bacterial meningitis is a medical emer
formed with the patient in the sitting position, the CSF usually
gency. Untreated bacterial meningitis is almost always fatal,
rises in the manometer to about the level of the foramen mag
and the outcome of meningitis after treatment is much bet
num but not higher. If the patient coughs, sneezes, or strains
ter if diagnosis is made and the patient is treated early in the
during lumbar puncture, there is usually a prompt rise in CSF
clinical course. Similarly, early recognition and management
pressure because of congestion of spinal veins and resultant
of subarachnoid hemorrhage are high priorities, because
increased pressure of the contents of the subarachnoid
rebleeding and vasospasm commonly occur and can lead to
epidural spaces; the CSF pressure subsequently falls to the
worsening or death, unless appropriate therapy is instituted.
previous level.
After determination of the initial CSF pressure, four tubes
of CSF are withdrawn (usually containing 2-3 mL each) un
CONTRAINDICATIONS
der sterile conditions. Routine CSF examination usually in
Several important contraindications to lumbar puncture exist: cludes cell counts, measurement of total protein, glucose, and
gamma globulin levels. Cells are usually cultured, and, when
( 1 ) In patients in whom there is increased intracranial appropriate, spinal fluid electrophoresis is performed to deter
pressure-or when there is the possibility of an intracra mine whether there are oligoclonal bands. (These are present
nial mass, especially in the posterior fossa-spinal in a variety of infl amm atory disorders, most notably multiple
285
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286 SECTION VI Diagnostic Aids
Opening Oligo-
Pressure Protein Glucose clonal
Variable Appearance (mm H20) RBCs WBCs (mg/dl) (mg/dl) lgG i ndex Bands Smear Culture
Normal Clear, 70- 1 80 0 0-S iym- <SO 50-75 < 0.77 Neg Neg Neg
colorless phocytes
(O PMN)
Viral Normal Normal 0 Normal or t Normal or t Norma l May be t May be Neg Neg
encepha l itis or t (mono- present
nucleated)
Spinal cord Normal Normal 0 Normal S l ig htly t Norma l Normal Neg Neg Neg
tumor;
partial block
Spinal cord Yellow Normal 0 Normal or tt (200- Normal Normal Neg Neg Neg
tumor; or low slig htly t 600 mg/dL)
complete
block
Mutliple Normal Normal 0 Normal or < 80 (often Normal t Present Neg Neg
sclerosis slig htly t normal)
Guillai n-Barre Normal Norma l 0 0 t or tt (can Normal May be t May be Neg Neg
syndrome be 1 000 present
mg/d l)
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C H A P T E R
Discussion of C ases
As outlined in Chapter 4, the important question, "Where is • Peripheral nerves. Peripheral nerve lesions may be differen
the lesion?" (or "What is the precise location of the deficit?"), tiated from lesions of muscle or motor end-plate by clinical
must be followed by the equally important question, "What is criteria, electrical tests, or biopsy. In many disorders of
the lesion?" (or "What is the nature of the disease?"). The an peripheral nerves, both motor (lower motor neuron) and sen
swers should lead to the differential diagnosis and correct di sory deficits are present, although in some cases motor or sen
agnosis and should guide therapy. sory function is impaired in a relatively pure way. In most
peripheral neuropathies, functions subserved by the longest
axons are impaired first, so that there is a "stocking-and
THE LOCATION OF LESIONS glove" pattern of sensory loss, together with loss of distal
reflexes (such as the ankle jerks) and weakness of distal mus
Where is the lesion? In thinking about the location of the le culature (ie, intrinsic muscles of the feet), which is in severe
sion, it is important to systematically survey the nervous sys cases accompanied by muscle atrophy.
tem. Lesions can be located in one or more of the following
• Roots. A motor root lesion results in a precise segmental
anatomic sites:
motor deficit, which in some cases (eg, plexus lesions) is
• Muscles. In muscle diseases, one sees weakness, sometimes mediated through several nerves. A single sensory deficit may
with muscle atrophy. Deep tendon reflexes are usually be difficult to diagnose because of the adj acent overlapping
depressed. Diseases of muscle include the dystrophies, which dermatomes (see Fig 5-9). When a nerve root carrying axons
have specific genetic patterns and stages of onset and may mediating a deep tendon reflex is affected, the reflex may be
preferentially involve certain muscle groups; and inflammato depressed (see Table 5-5). Sensory root symptoms may include
ry disorders of muscle such as polymyositis. Diagnosis may pain that is worsened with the Valsalva maneuver, the forced
be aided by measuring the level of enzymes (such as creatine expiratory effort caused by laughing, sneezing, or coughing.
phosphokinase) in the serum because damage to muscle • Spinal cord. The staggered pattern of decussation of the later
fibers may lead to their release. Electromyography and muscle al corticospinal tract, dorsal column-medial lemniscal system,
biopsy may help with diagnosis. and spinothalamic tracts often permits localization of lesions
• Motor end-plates. Disorders of the motor end-plate include within the spinal cord. Injury to the spinal cord, at a given
myasthenia gravis and the Lambert-Eaton myasthenic syn level, may result in lower-motor-neuron signs and symptoms
drome. In these disorders, there is weakness, sometimes at that level, but will result in upper-motor-neuron abnormal
accompanied by abnormal fatigability resulting from abnor ities below the level of the lesion. Sensation may be impaired
mal function (eg, decreased effect of acetylcholine [ACh] on below the lesion; thus, the presence of a sensory level (ie, a der
the postjunctional muscle or decreased release of ACh) at the matomal level below which sensation is impaired) can alert the
neuromuscular junction. Weakness may involve the limbs or clinician to the possibility of injury to the spinal cord. The
trunk or muscles involved in chewing, swallowing, or eye injury may be located at the sensory level or above it.
movements. In addition to the characteristic clinical pattern, • Brain stem. Functional deficits in the long tracts that pass
electromyography may be helpful in diagnosis. from the brain to the spinal cord or vice versa, together with
287
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288 SECTION VII Discussion of Cases
cranial nerve signs and symptoms, suggest a lesion in the well as other neurologic deficits, and the diagnosis can often
brain stem. As a result of the crowding of numerous fiber be confirmed by lumbar puncture.
tracts and nuclei within the relatively compact brain stem, • Skull, vertebral column, and associated structures.
lesions at particular sites usually result in characteristic syn Associated structures include the intervertebral disks, liga
dromes. Lesions in the medulla involve the last few cranial ments, and articulations. For example, metastatic tumors
nerves, whereas lesions in the pons involve nerves V, VI, and involving the vertebral column can produce spinal cord com
VII, and lesions of the midbrain often involve nerve III and pression. Trauma often involves the skull and vertebral col
possibly nerve IV: umn as well as the brain and spinal cord.
• Cerebellum. Lesions in the cerebellum or its peduncles result
in characteristic abnormalities of motor integration. There is
usually impaired coordination and decreased muscle tone THE NATURE OF LESIONS
ipsilateral to a lesion in the cerebellar hemisphere.
• Diencephalon. Hypothalamic lesions can be complex and can What is the lesion? A variety of pathologic processes can affect
the nervous system. The following is a common neuropatho
cause endocrinologic disturbances as well as visual abnormal
ities resulting from compression of neighboring optic tracts. logic classification of disorders:
Thalamic lesions often cause sensory dysfunction and may • Vascular disorders. Usually, with a sudden onset of signs and
produce motor deficits as a result of compression of the neigh symptoms, cerebrovascular disease often occurs in the setting
boring internal capsule. Subthalamic lesions may cause abnor of hypertension. Stenosis or occlusion of the carotid artery in
mal movements such as hemiballismus. Epithalamic lesions the neck, or of any of the arteries described in Chapter 12,
are most frequently pineal region tumors, which can compress may be responsible. Embolism, from ulcerated plaques in the
the cerebral aqueduct, thereby producing hydrocephalus. carotid or from the heart ( eg, in patients with a trial fibrillation
• Subcortical white matter. The presence of abnormal myelin or with endocarditis) can occlude more distal vessels such as
(leukodystrophy, which is more common in infants and chil the middle cerebral. Subarachnoid hemorrhage and intra
dren than in adults) or the destruction of normal myelin parenchymal hemorrhage (often involving the basal ganglia,
(which can be caused by inflammatory disorders such as mul thalamus, pons, or cerebellum) occur in patients with hyper
tiple sclerosis ) results in abnormal axonal conduction and tension. Subdural and epidural hemorrhages occur as a result
deficits of function. Disease may be diffuse, focal, or multifo of trauma, which can be trivial (and in many cases is not
cal with a parallel pattern of clinical involvement. remembered) in the case of subdural hematoma.
• Subcortical gray matter (basal ganglia). A variety of move • Trauma. As previously noted, epidural and subdural
ment disorders, including Parkinson's disease and Huntington's hematomas can develop as a result of head injury. In addition,
disease, involve the basal ganglia. Tremors and other abnor penetrating injuries can directly destroy brain tissue, produce
mal movements, abnormalities of t one ( eg, cogwheel rigidity vascular lesions, or introduce infections. Injury to the spine is
in Parkinson's disease), and slowed movements (bradykinesia) a common cause of paraplegia and quadriplegia.
are often seen. These disorders often affect t he basal ganglia • Thmors. Primary tumors of the brain and spinal cord, as well
bilaterally, but if there is unilateral disease, the movement dis as metastases ( eg, from breast, lung, and prostate tumors) pro
order will affect the contralateral limbs. duce symptoms by direct invasion (and destruction) of neural
• Cerebral cortex. Focal lesions may produce well-circumscribed tissue, by compression of the brain and spinal cord, or by
deficits such as aphasia, hemi-inattention and neglect syn compression of the ventricles and cerebral aqueduct, which
dromes, or Gerstmann's syndrome (see Chapter 2 1 ) . In most can lead to hydrocephalus. Classically, tumors of the central
patients, aphasia is due to the left hemisphere involvement. nervous system produce subacutely or chronically progressive
When the primary motor cortex is involved on one side, for deterioration, which, in contrast to vascular disorders, pro
example by a stroke or a tumor, there is usually a "crossed gresses over weeks, months, or years. Signs of increased
hemiparesis;' that is, upper-motor-neuron weakness of the intracranial pressure (eg, papilledema, sixth nerve palsy) may
contralateral limbs. I rritative lesions of the cortex may result be present, and the patient may complain of increasing
in seizures, which can be focal or generalized. headache, which is sometimes worst in the morning.
• Meninges. Hemorrhages in the subarachnoid, subdural, and • Infections and inflammations. These disorders (eg, menin
epidural spaces have characteristic clinical and neuroradio gitis, abscess formation, encephalitis, and granulomas) may
logic features. Subarachnoid hemorrhage is often accompa be accompanied by fever, especially if the onset is acute. Most
nied by severe headache ("worse headache of my life") . infections and inflammations have characteristic signs, symp
Subdural hemorrhages may occur acutely o r chronically and toms, and causes.
can follow even trivial head injury, especially in elderly • Toxic, deficiency, and metabolic disorders. A variety of
patients and young children. Epidural hemorrhages are often intoxications, vitamin deficiencies (eg, B 12 deficiency), and
rapidly progressive and can produce sudden herniation of t he enzyme defects leading to abnormal lipid storage in neurons
brain. Infection of the subarachnoid space (meningitis) may are examples of this heterogeneous group of disorders.
present with signs of meningeal irritation ( eg, stiff neck) as Various substances in different amounts (too much or too
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CHAPTER 25 Discussion of Cases 289
little) can cause selective lesions involving particular nuclei or syndrome), an autoimmune disease seen in the context of
tracts. Vitamin B 12 deficiency, for example, causes degeneration systemic neoplasms (especially those affecting the lung and
of axons in the dorsal and lateral columns of the spinal cord. breast) . In the myasthenic syndrome, abnormal antibodies di
• Demyelinating diseases. Multiple sclerosis is the prototype rected against presynaptic Ca 2+ channels interfere with the re
demyelinating disease. As expected for a disorder character lease of ACh from the presynaptic ending at the neuromuscu
ized by multiple lesions in the white matter, examination often lar j unction.
provides evidence for involvement of several sites in the cen
tral nervous system. The cerebrospinal fluid ( CSF) often shows
Case 2, C h a pter 5
characteristic abnormalities. Magnetic resonance imaging
(MRI) scans are very useful in confirming the diagnosis. Shoulder pain radiating into the arm suggests involvement at
the C5 or C6 level. Recent weakness in the left extremities,
• Degenerative diseases. This heterogeneous group of diseases
for which the cause has not yet been determined includes abnormal reflexes in the legs, and decreased reflexes in the left
arm suggest a lower-motor-neuron-type lesion close to the
spinal, cerebellar, subcortical, and cortical degenerative disor
ders that are often characterized by specific functional left C6 ventral root and an upper-motor-neuron lesion in the
deficits. Onset often occurs insidiously, so that the patient corticospinal tract (probably on both sides) . The sensory
deficits indicate a level of C6, or perhaps C7, bilaterally. The
cannot determine date of the onset, and progression can con
course of the disease shows a slow progression and recent de
tinue over months or years.
terioration, a series of events typical of an expanding mass
• Congenital malformations and perinatal disorders.
that eventually compresses the spinal cord against the hard
Exogenous factors (eg, infection or radiation of the motor
wall of the vertebral canal. Imaging studies showed a left
cortex) or genetic and chromosomal factors can cause abnor
sided, intradural, extramedullary mass compressing and dis
malities of the brain or spinal cord in newborn infants.
placing the spinal cord at the C6-7 level.
Hydrocephalus, Chiari malformation, cortical lesions, cere
The differential diagnosis includes a mass associated with
bral palsy, neural tumors, vascular abnormalities, and other
spinal roots, meninges, and nerves; a tumor from the arach
syndromes may become apparent after birth.
noid (meningioma); and a nerve tumor (sometimes called a
• Neuromuscular disorders. This group includes muscular neuroma) . Abscesses may form a mass, but the patient's his
dystrophies, congenital myopathies, neuromuscular j unction tory does not suggest an infection.
disorders, transmitter deficiencies, and nerve lesions or neu The diagnosis in this case was a nerve root tumor of the
ropathies (inflammation, degeneration, and demyelination). left C6 nerve. During neurosurgery, the tumor was completely
removed, and the C6 sensory root was sacrificed. Pathologic
studies showed a schwannoma. The patient's recovery was
CASES complete and uneventful; 6 months after surgery, she danced
at the j unior prom.
Case 1 , C h a pter 3 Comment: MRI is now usually used to demonstrate such
Abnormal, gradual tiring of the muscles for eye movement root tumors (Figs 25- 1 and 25-2) . It is crucial to request the
and chewing is suggestive of fatigue at the neuromuscular most appropriate imaging tests. In this case, a careful examina
junction. The healthy neuromuscular j unction can transmit at tion permitted the patient's neurologist to predict the presence
high frequencies so that this type of fatigue does not normally
occur. The prominence of muscular fatigue suggested a diag
nosis of myasthenia gravis in this patient. The absence of sen
sory deficits tends to confirm the diagnosis. Electromyogra
phy is a useful procedure for confirmation of the diagnosis;
the muscle action potential, which provides a measure of t he
number of muscle cells that are contracting, decreases in size
with repetitive stimulation in myasthenia gravis. In addition,
antibodies to ACh receptors are often present and can provide
a measure of the degree of disease activity. Injection of anti Spinal
cholinesterase drugs, such as neostigmine or edrophonium cord
chloride, may reverse the fatigue and help to confrrm the di
agnosis. Treatment centers on the use of anticholinesterase Tumor
drugs and immunosuppressants, including corticosteroids,
which decrease the rate of anti-ACh receptor antibody pro
duction. In some patients, thymectomy is effective.
Comment: Myasthenia gravis often affects the extraocu FIGURE 25-1 Magnetic resonance image of horizontal section
lar and bulbar musculature. Myasthenia gravis should not be through the neck and lower face (a d ifferent patient). The i mage
confused with the myasthenic syndrome (Lambert-Eaton shows a d u m bbel l-shaped tumor growing out of the spinal canal.
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290 SECTION VII Discussion of Cases
Cut edge
of dura
Ventral roots
Dorsal roots
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CHAPTER 25 Discussion of Cases 291
Case 5, C h a pter 6
Trauma to the lower back, followed by pain down the sciatic
region, is suggestive of sciatica. One of the underlying causes
is herniation of the nucleus pulposus (the soft center of the in
tervertebral disk), which can cause a compressive radiculopa
thy (ie, compression of a nearby spinal root). The aggravation
of pain by coughing, sneezing, straining, and bending back
ward (movements that increase abdominal pressure) and the
stretching of dural root sleeves by leg raising are highly sugges
tive of root involvement (right 15 nerve). The location is con
firmed by the presence of paresthesia in the patient's right calf
as well as the loss of the Achilles tendon reflex (15, S 1 ) . Spasm F I G U R E 2 5 - 5 Photogra p h o f a horizontal section thro u g h
of the paravertebral muscles and tenderness along the course L4-5 i ntervertebral disk i n a patient w i t h l o w b a c k pain. N ote the lat
of the sciatic nerve are common in t his disorder. eral herniation of the nucleus p u l posus. (Reprod uced, with permission,
Plain radiographs are useful only for showing a decrease from deGroot J: Correlative Neuroanatomy of Computed Tomography and Magnetic
Resonance Imaging. Lea & Febiger, 2 1 st ed. Appleton & Lange, 1 99 1 .)
in the height of the intervertebral disk space. The precise loca
tion of the lesion can best be shown by CT scanning or MRI
(Figs 25-4 and 25-5). of intention tremor and ataxia in the right lower extremity; s ee
The diagnosis is herniation of the nucleus pulposus at Appendix A); and the vagus nerve and ambiguous nucleus
L5-S l . This patient responded well to conservative treatment (hoarseness). The combination of these findings suggests a lo
(anti-inflammatory drugs, bed rest) . Many patients show im cation in the posterior cranial fossa, probably in the brain stem.
provement as a result of conservative therapy. In some cases, The combination of miosis, ptosis, enophthalmosis, and de
there is a need for surgery with removal of the protruding disk creased sweating on one side of the face suggests Horner's syn
fragment. drome, caused by interruption of the sympathetic pathway.
This pathway can be interrupted in the lateral brain stem fibers
that descend from higher centers in the lateral column of the
Case 6, C h a pter 7
upper thoracic cord, the upper sympathetic ganglia, or the
Careful analysis of the signs and symptoms shows that the fol postsynaptic fibers of the carotid plexus (see Fig 20-7) .
lowing systems were involved: the vestibular system (dizziness Because the patient's disorder had a sudden onset and
and nystagmus); the trigeminal system, including the descend rapid course, a tumor was unlikely. The most frequent sudden
ing spinal tract of V (loss of pain sensation in the right half of neurologic deficits in the patient's age group have a vascular
the face); the spinothalamic system (contralateral pain deficit); basis: occlusion or bleeding. Of these, vascular occlusion (is
the cerebellum (the inability to execute the right finger-to-nose chemic infarct) is the more common (see Chapter 1 2 ) .
test or to make rapid alternating movements and t he presence The only anatomic region where all these systems are
contiguous is the lateral portion of the medulla; this is the site
of the lesion: lateral medullary syndrome (Wallenberg's syn
drome) . Damage to the lateral medulla results from occlusion
of small branches of either the posterior inferior cerebellar or
the vertebral artery. In 1 895, Wallenberg described six pa
tients with similar signs and symptoms and recognized the
vascular basis of the disorder (Figs 25-6 and 25-7) . Although
Wallenberg's syndrome commonly occurred as a complication
of meningovascular compromise due to syphils in the pre
antibiotic era, this is now rare. Disease of small blood vessels
Compressed
nerve due to hypertension can produce brain stem syndromes such
as Wallenberg's syndrome, and underscores the need for early
Hern iated recognition and textnet of high blood pressure.
L4-5 disk
Bulge in
L5-S 1 disk Case 7, C h a pter 7
The patient's signs and symptoms during his first examination
suggest lesions in the left optic nerve or tract, nerve III or its
FIGURE 25-4 Mag netic resonance image (su rface coil nucleus, the vestibular system, the portion of the corticobul
tech n i q ue) of a sagitta l section through the lower l u m bar spine of a bar pathway that supplies the face, and the corticospinal tract.
patient with l ow back pain. Note the herniation of the n ucleus p u l po It would be difficult for one lesion to involve all these areas.
sus at L4-5 com p ressi n g the cauda equina. Findings 4 months later showed additional deficits in the
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292 SECTION VII Discussion of Cases
Frequency of
·
Types of Tumors Occurrence
Gl iomas SOo/o
Gl ioblastoma multiforme SOo/o
Astrocytoma 20o/o
Ependymoma l Oo/o
Med u l loblastoma l Oo/o
Ol igodendroglioma So/o
Mixed So/o
Meningiomas 20o/o
cerebellum or cerebellar peduncles as well as in the lower merous lesions, consistent with multiple s clerosis. Increased la
cranial nerves (VII, X, and XII, the nerves of articulation); tency of the visual evoked response, suggestive of demyelina
once again, the lesions appeared in several systems or sites. tion along the visual pathway, was also consistent with this
Signs and symptoms of multiple lesions at different t imes diagnosis. The lumbar puncture findings were within normal
suggest a disseminated infectious disease, multiple infarcts, or limits except for a slightly increased gamma globulin level and
a multifocal demyelinating disorder. The patient's age was typ oligoclonal bands, which are suggestive of multiple sclerosis
ical for onset of multiple sclerosis. Disseminated infection was (Table 2 5 - 1 ) . The age of the patient (third decade), the
unlikely in this patient because he had no fever. A CT image repeated attacks, and the multifocal nature of the deficits are
did not show multiple infarcts, but MR scanning revealed nu- indicative of multiple sclerosis (Figs 25-8 and 25-9 ) .
Impaired pain
and temperature
sensation, left
face and right
side of body
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CHAPTER 25 Discussion of Cases 293
Comment: For reasons that are not yet understood, the basilar inflammatory lesions can injure cranial nerves. A viral
risk of multiple sclerosis in populations living close to the cause has been suggested in some patients.
equator between latitudes 40 °N and 40 °S is low. The time
course of the disease varies; some patients remain relatively
healthy after the fust episode, other patients (like t he one in Case 9, C h a pter 8
this case) continue to have exacerbations followed by remis Several causes of facial pain must be considered: pain from
sions, and yet others ex- perience a progressive course with dental causes, sinusitis, migraine, tumors of the base of the
out remissions. The disease is usually most active in people skull and brain stem, tumors of the maxilla or nasopharynx,
between 10 and 45 years of age. The imaging procedure of and other, rarer causes. Trigeminal neuralgia (severe episodic
choice is MRI, which readily demonstrates patches of in facial pain) can occur as a result of stroke, or in multiple scle
flammation or demyelination. Several treatments exist that rosis. These disorders can be ruled out by careful and com
slow the progression of multiple sclerosis. �-Interferon and plete examination, including a CT scan or MR imaging.
COP- 1 have been shown to reduce the rate of acquisition of The description of brief attacks of very severe pain, trig
new lesions. gered from a localized area in the face, in a patient who is
otherwise found healthy points to a diagnosis of trigeminal
neuralgia (tic douloureux) . Medical treatment (with carba
Case 8, C h a pter 8 mazepine or phenytoin) may be effective. In cases of persistent
All signs and symptoms are related to a lesion in the func painful attacks, neurosurgical treatment, aimed at relieving
tional components of nerve VII (see Figs 8- 1 3 and 8- 14). Be compression of the trigeminal nerve or root, is sometimes
cause there were no long-tract signs and no other cranial helpful.
nerve deficits, it is unlikely that the lesion was in the brain
stem, where the nuclei of nerve VII are located. Although the
sudden onset of the problem may point to a vascular cause, Case 1 0, C h a pter 9
this is unlikely because only one nerve was involved; the his The finding of bitemporal hemianopia is classical for an abnor
tory suggests an isolated lesion of nerve VII. mal mass impinging on the optic chiasm. This may explain the
The most probable diagnosis is peripheral facial paraly complaint of worsening eyesight. The other signs and symp
sis (Bell's palsy) (see Fig 8-14). As in this case, the paralysis is toms suggest pituitary dysfunction, probably of considerable
almost always unilateral. The syndrome always includes dys duration. Additional tests could confirm this, showing lowered
function of the brachial efferent fibers of the facial nerve, but levels of gonadotrophic and thyrotropic hormones. The combi
visceral efferent and afferent fiber functions may also be lost. nation of headache and incipient papilledema indicated in
In most cases, the patient recovers spontaneously. creased intracranial pressure, probably caused by a growing
Peripheral facial paralysis occurs commonly in patients mass.
with diabetes (presumably as a result of ischemic damage to Differential diagnosis includes pituitary adenoma with
the facial nerve) and is also seen as a complication of Lyme pressure on the optic chiasm; a craniopharyngioma, a con
disease. It can occur as a result of nerve damage from a tumor genital tumor that can compress the pituitary gland, the
or in sarcoidosis and in various forms of meningitis, in which optic chiasm, or both, and usually causes symptoms either
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294 SECTION VII Discussion of Cases
Case 1 1 , C h a pter 1 0
The mental impairment (disorientation, confusion, dis
tractibility, and partial loss of memory) of this patient suggests
a lesion in one or both frontal lobes. The right facial signs
made a left-sided lesion probable, and this was confirmed by
the electroencephalogram and imaging studies. The seizure
also suggested an irritative lesion in or near t he motor cortex.
The differential diagnosis based on the clinical presenta
tion must include a slow-growing tumor, an unusual type of
chronic infection (unlikely but not impossible with no history
of fever), and a degenerative disorder (unlikely in t he context
of unilateral facial weakness) . Headache was suggestive of a
mass lesion. The imaging studies suggested a multifocal tu
mor or cerebral abscesses, and a brain biopsy was performed.
The pathologic diagnosis was malignant glioma (Fig 25- 1 1 ) . FIGURE 25-1 2 Magnetic resonance image of a horizonta l sec
The tumor was a glioblastoma with calcifications and tion throu g h the head at the level of the lentiform n ucleus in a
regions of hemorrhage within it. The small hemorrhages patient with a g l ioma su rro u nded by edema ( arrows).
found in the brain stem at autopsy were indicative of rapid
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CHAPTER 25 Discussion of Cases 295
Tumor
M ul tip l e
abscesses
Cyst
Epidura l
Blood empyema
FIGURE 25-1 3 Computed tomography image of a h orizontal FIGURE 25-1 4 Com puted tomography image of a horizontal
section through the h ead at the level of the latera l ventricles i n a pa section through the t e m poral l obes, showing a n epidura l lesion and
tient with g l i oblastoma m u ltiforme. A sma l l amount of blood l ies i n m u lti p l e rounded co nfl uent masses i n the rig ht lobe.
t h e bottom o f a cystic portion o f t h e tumor.
TABLE 25-2 Brain Tumor Types Accord ing to Age and Site.
Age 20-40 Meningiomas, astrocytomas; Pitu ita ry adenomas; less Acoustic neuromas,
less common ly, metastatic commonly, meni ngiomas meningiomas,
tu mors hemangioblastomas; less
commonly, metastatic
tu mors
Over age 40 Gl iobastoma m u ltiforme, Pituita ry adenomas; less Metastatic tumors, acoustic
meningiomas, metastatic commonly, meni ngiomas neuromas, meni ngiomas
tu mors
Reproduced, with permission, from Dunphy JE, Way LW (editors): Cu rrent Surgical Diagnosis & Treatment 3rd ed. Appleton & Lange, 1 977.
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296 SECTION VII Discussion of Cases
the body; in the brain, the agent is often Toxoplasma gondii Case 1 4, C h a pter 1 1
(Fig 25- 1 5 ) .
The history indicates trauma on the right side of the head and
temporary loss of consciousness. Findings on early neuro
Case 1 3, C h a pter 1 1 logic examination were unremarkable. At this stage, t he dif
ferential diagnosis should include concussion, in which there
The history, temperature, and blood count suggest this to be an
infection. Fever, poor appetite, and cough suggest a respiratory
infection, and the neck stiffness points to meningeal irritation.
It is likely that the initial infection developed into septicemia
and spread to the central nervous system. The lumbar puncture
findings are consistent with meningitis (see Table 25- 1 ) . The
low level of glucose in the CSF, especially with a normal level of
glucose in the blood, is characteristic of bacterial infection and
a Gram-stained smear showed pneumococci.
The diagnosis is pneumococcal meningitis (Fig 25- 1 6) .
Treatment consists o f injecting t h e appropriate antibiotics in
travenously. In addition, intrathecal injection may be consid
ered.
Comment: Prognosis of meningitis depends in large part
on prompt diagnosis and treatment. Many authorities recom
mend immediate treatment with antibiotics, even prior to
confirmation of the diagnosis by lumbar puncture and spinal
fluid examination, which are carried out to definitively estab
lish the diagnosis of meningitis, and to identify the infectious
agent and its antibiotic sensitivity.
Pneumococcal meningitis and other forms of purulent
meningitis usually extend over the hemispheres, whereas tu
berculous meningitis is more caseous and is often located in
the basal cisterns (Fig 25- 1 7) . In both types, the circulation of
CSF may become impaired, leading to communicating hydro FIGURE 25-1 7 Basal view of the brain, showi ng tubercu lous
meni ngitis (arrows) i n a 26-yea r-old man.
cephalus.
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CHAPTER 25 Discussion of Cases 297
Case 1 6, Chapter 1 2
The history shows the patient to be an alcoholic who had pos
sibly received trauma to the head when he fell. His level of
consciousness had deteriorated, and he seemed to have had a
seizure (incontinence and a bitten lip), both findings suggest
ing cerebral involvement. Neurologic examination suggested a
lesion in or near the right motor cortex, and the lumbar punc
ture showed xanthochromia (fresh and old blood) in t he CSF
(see Table 24- 1 ) . All these findings indicated a hemorrhage;
the time course favored subdural bleeding. Subarachnoid
bleeding from a leaking aneurysm was less likely because
trauma initiated the process in this patient. An arachnoid tear
could have produced the bloody CSF, and subdural bleeding
could occur with additional (mild) trauma. The CT image
FIGURE 25-1 8 Com puted tomography image through the demonstrated this. The worsening of the patient's condition
head at the l evel of the external ears (bone window) i n a patient with
was caused by imminent herniation of the brain, triggered by
e p id u ra l hemorrhage. Note the fractu re site ( arrow) and nearby air
the blood mass, the drop in CSF pressure associated with lum
bubbles.
bar puncture, or both.
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298 SECTION VII Discussion of Cases
Case 1 8, C h a pter 1 3
The suddenness of the severe neurologic deficits in a patient
with hypertension most likely indicates a vascular event, pos
sibly an intracerebral hemorrhage. The patient's complaint of FIGURE 25-20 Cysti c degeneration involving principally the
headache tended to support the diagnosis of intracerebral left caudate and lenticular nuclei.
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CHAPTER 25 Discussion of Cases 299
Cerebellar tonsi ls
below foramen
magnum
Syrinx cavity
with in the
spinal cord
Partially fused
C5 and C6 bodies
FIGURE 25-2 1 Mag netic resonance image (su rface coi l tech
n i q ue) of a sag itta l section through the thoracic spine of a patient
with syri ngomye l ia (arrows).
Case 20, C h a pter 1 4
The patient was an alcoholic, as the history indicates. The
deficit. (The areas ofloss of touch were different from those of symmetric motor deficits (lower-motor-neuron type) in all
loss of pain sensation.) extremities and the sensory abnormalities in the distal por
The differential diagnosis includes traumatic injury of the tions of the limbs are highly suggestive of peripheral nerve in
spinal cord, which is unlikely because there was no history of volvement (Fig 25-23). The differential diagnosis includes
trauma in this case; myelitis, unlikely because there was no spinal cord disease, but the distribution of the lesions is not
history of fever; and bleeding or thrombosis, unlikely because compatible with the somatotopic organization of pathways in
of the slowly progressive course and the distribution of the the cord.
deficits. A plain film of the spine is not helpful in demonstrat The diagnosis is polyneuropathy, which in this case is
ing intrinsic cord lesions; therefore, MRI or CT imaging is caused by alcohol abuse. Hyperalgesia of the soles and calf
preferable. An MRI study was performed and showed enlarge muscles is characteristic of this type of nerve disease. (There
ment of the spinal cord by cavitation, or cyst formation, most are many other causes of polyneuropathy, and hyperalgesia is
severe in the lower cervical segments (Fig 25-2 1 ) . not always present.) Diabetes is a common cause of polyneu
The diagnosis i s syringomyelia . The cavity extended ropathy, and was ruled out in this case by measurement of
from C4 to C7 and involved the right cuneate tract as well as fasting blood glucose. The treatment in this case should in
portions of the ventral horns, causing atrophy of the hand clude injections of vitamin B1 (thiamine hydrochloride), insti
muscles (see Fig 5-27). Abnormal enlargement of the central tution of a vitamin-rich diet, and cessation of alcohol intake.
canal is called hydromyelia. Draining the cavity neurosurgi
cally can provide relief.
Case 2 1 , C h a pter 1 5
Comment: MRI findings in syringomyelia must be dis
tinguished from those in the Arnold-Chiari malformation The history of an epileptiform attack in a 50-year-old woman
(Fig 25-22) . The latter is a congenital disorder characterized indicates irritation of the cerebral cortex, and the results of ex
by downward displacement of a small cerebellum, cavitation amination (chronic papilledema) suggest a slow-growing,
of the spinal cord, and other abnormalities. space-occupying lesion. The mental status is compatible with
involvement of one or both frontal lobes. The loss of olfaction
on the left side and the atrophy of the adjacent left optic nerve
(which resulted in a pale optic disk) suggest that the lesion is
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300 SECTION VII Discussion of Cases
FIGURE 25-23 Distri bution of sensory and lower-motor View in parasagittal section
neuro n deficits in a patient with peripheral polyneuro pathy. Notice
the "stocking-and-glove" pattern of sensory l oss. FIGURE 25-24 Olfactory groove meningioma. (From Scarff:
Classic Syndromes of Brain Tumor. Annual Clinical Conference of the Chicago Medical
Society, 1 9S3.)
located in the base of the left frontal lobe and is compressing
the optic nerve. The associated cerebral edema explains the
mild facial weakness and the effect on the motor pathways to lar angle, where nerves VII and VIII lie close to the brain
the extremities. stem. The long period of progressive worsening and the pres
The differential diagnosis is limited: The lesion may be an ence of papilledema made a slow-growing tumor likely.
intrinsic brain tumor in the left frontal lobe or olfactory re Differential diagnosis includes a cranial nerve t umor, a
gion, or it may be a meningeal tumor in that region. A CT tumor of the brain stem (eg, a glioma) or the adjacent arach
scan or MR image would show the exact location of the tumor. noid (eg, a meningioma), or another rare neoplasm. The le
Neurosurgical removal and pathologic studies of the ab sion occurring most frequently in this region is a nerve VIII
normal tissue resulted in the diagnosis of olfactory groove
meningioma with associated Foster Kennedy's syndrome
on the left side. This syndrome consists of contralateral pa
pilledema and ipsilateral optic atrophy caused by a mass in
the low frontal region (Fig 25-24).
Comment: Meningiomas arise from abnormal arachnoid
Meningioma
cells; therefore, this type of tumor occurs in many intracranial on the
locations as well as in the spinal region. Frequent sites are on convexity
the convexity of the hemisphere and along the falx (Fig
25-25). Although the robust vascularity of meningiomas can
make surgery difficult, they often can be removed surgically.
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CHAPTER 25 Discussion of Cases 301
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302 SECTION VII Discussion of Cases
Cerebellar contusion
(caused by biopsy
proced u re)
Tumor
Comment: The most common posterior fossa tumors in left-sided neglect was consistent with a lesion affecting the
children are astrocytomas, medulloblastomas, and ependy right cerebral hemisphere.
momas. Different types of tumors may occur in older persons The sudden nature of the disorder and the absence of a
(Table 25-2 and Figs 25-27 to 25-29). history of tumor or infections tend to eliminate neoplasm and
infectious mass from the differential diagnosis. The distribu
tion of the deficits suggests an infarct in the distribution of the
Case 26, C h a pter 2 1 right middle cerebral artery. The neuroradiologic examina
The history indicates a series of transient ischemic attacks, tion clarified the extent of the ischemia as well as its vascular
which are suggestive of cerebrovascular occlusive disease. The origin (Fig 25-30; see also Figs 1 2 - 1 4 and 1 2- 1 5). The diag
most common cause in elderly persons is arteriosclerosis. The nosis is occlusion of the right middle cerebral artery.
sudden deterioration of the patient's status was caused by
thrombotic or embolic occlusion of a major cerebral vessel on
the right side. Papilledema indicated an intracranial mass ef Case 27, Chapter 2 1
fect caused by swelling of the brain associated with an ischemic This patient's history is consistent with a s ensory seizure with
infarct. The flaccid paralysis and the sensory deficits suggested predominantly visual symptoms; this suggests involvement of
involvement of the blood supply to the sensory motor cortex or the occipital cortex. The sudden development of a right
the underlying white matter in the right hemisphere. The
Fourth
ventricle
Cyst
FIGURE 25-28 Computed tomography image, with contrast FIGURE 25-29 Mag netic resonance image of a m idsagittal
enhancement, of a h orizonta l section through the head. Notice the section through the head. The large mass that originates i n the clivus
low-density cystic astrocytoma with a h i g h-density nodule in the and displaces the bra i n stem backward is a chordoma ( arrows).
posterior fossa, representing a g l ioma of the cerebe l l u m .
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CHAPTER 2 5 Discussion of Cases 303
. Metastasis
in territory
of ante rior
cerebral
artery
Anterior
cerebral
artery Metastases
in territory
of middle
cerebral
Posterior -h-c'"'"----.-c.,----,��"""'-
• artery
cerebral
artery
;-..._�--=� Cerebral
edema
FIGURE 25-30 Left i nternal carotid angiogram, a rteria l phase,
latera l view, showi ng occlusion of the middle cerebral a rtery ( a rrow).
The posterior a rtery is wel l fil l ed (compare with Fig 22-4}.
REFERENCES
which small thrombi detach from the heart and pass into the
major cerebral vessels. There was no headache, so migraine
was unlikely. Adams JH, Corsellis JAN, Duchen LW: Greenfield's Neuropathology,
CT and MRI were helpful in confirming the diagnosis of 4th ed. Wiley, 1984.
embolic infarction of part of the left occipital lobe. Emboli Aminoff MJ, Greenberg DA, Simon RP: Clinical Neurology, 6th ed.
passing to the brain often lodge in the largest vessels, the mid Appleton & Lange, 2005.
dle cerebral arteries. In this case, the infarct occurred in the Bradley WG, Daroff RB, Fenichel GM, J ankovie J: Neurology in
territory of the posterior cerebral artery, which it may have Clinical Practice, 5th ed. Butterworth-Heinemann, 2005.
reached by passage through a large (embryonic type) poste Davis RL, Robertson DM (editors): Textbook ofNeuropathology,
rior communicating artery or by way of the vertebrobasilar 2nd ed. Williams & Wilkins, 1 990.
Love S, Louis DN, Ellison DW: Greenfield's Neuropathology, Wiley
system. Although angiography would help to determine t his,
Liss, 2008.
there is debate about whether it should be done shortly after
Poirier J, Gray F, Escourolle R: Manual of Basic Neuropathology, 3rd
an infarct has occurred. Treatment of embolic infarction con
ed. WB Saunders, 1990.
sists of controlled anticoagulation to prevent further emboli. Ropper Alt, Brown RH: Adams and Victor's Principles of Neurology,
Comment: Emboli, including blood-borne metastases to 8th ed. McGraw-Hill, 2005.
the brain, most frequently lodge in the territory of the middle Rowland LP (editor) : Merritt's Textbook of Neurology, 1 1th ed. Lea
cerebral artery (Fig 25-3 1 ) . & Febiger, 2007.
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A P P E N D I X
T he Neurolo g ic
Examination
AN D A D U LTS
Is there double vision? Note any facial drooping, slurred speech,
difficulty swallowing, problems with balance, tinnitus (a ring
ing or buzzing sound in one or both ears), or impaired hearing.
H ISTORY
305
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306 Appendix A
THE NEUROLOGIC EXAM INATION the patient who cannot speak by asking the patient to "make a
fist"; "show me two fmgers"; "point to the ceiling"; "point to
Level of Consciousness a n d Alertness the place where I entered the room''; or by asking the patient
The patient's level of consciousness and degree of alertness to nod "yes" or "no" in response to questions such as "is school
should be noted. Is the patient conscious and fully alert, meant for children?" and "Do helicopters eat t heir young?"
lethargic, stuporous, or comatose? A depressed level of con Check the patient's ability to read and write. (Make sure
sciousness can be the first clue, for example, in patients har the patient is wearing reading glasses, if necessary, or use a
boring subdural hematomas. large-print newspaper.)
Note the patient's ability to focus attention. Is the patient
fully alert or confused (ie, unable to maintain a coherent D. Orientation
stream of thought)? Confusional states occur with a variety of Check for orientation with respect to person, place, time, and
focal lesions in the brain and are commonly seen as a result of situation.
metabolic and toxic disorders.
E. Memory
Ask about details and dates of recent and remote events, in
Menta l Status
cluding such items as birth date, marriage date, names and
Some changes in mental status have important localizing ages of children, and specific details of the past few days and
value; that is, they suggest the presence of focal brain lesions from more remote times. It is best to ask about objective facts
in particular areas. Wernicke's and Broca's aphasia, for exam ("What happened in sports last week?", "Who won the World
ple, are seen with lesions involving Wernicke's and Broca's ar Series?'; "Who is the president?'; "Who was president before
eas in the dominant cerebral hemisphere (see Chapter 2 1 ) . that?").
Spatial disorientation suggests disease involving the dominant
parietal lobe. Hemispatial neglect, in which t he patient neg F. Abil ity to Acq u i re and Manipu late Knowledge
lects stimuli, usually in the left-hand side of t he world, sug 1 . General information-These questions should be adapted
gests a disorder involving the right hemisphere. With some to the patient's background and education. Examples are the
neurologic disorders (eg, brain tumor, multiple sclerosis), the
names of prominent political and world figures, the capitals of
insidious onset and the course of remissions and exacerba
countries and states, and current e vents in politics, sports, and
tions can result in the misdiagnosis of psychogenic i llness.
performing arts.
Early neurologic disease may occur without significant physi
cal, laboratory, imaging, or other special diagnostic findings, 2. Similarities and differences-Have the patient compare
and changes in mental status as a side effect of medications wood and coal; president and king; dwarf and child; human
may further complicate the clinical picture. and plant; lie and mistake.
ing the patient's behavior, mode of speech, appearance, groom 7 86; 86 - 7 79). Add, multiply, or divide single numbers
= =
ing, and degree of cooperation. Can the patient give a coherent (eg, 3 X 5, 4 X 3, 1 6 X 3) and double-digit numbers ( 1 1 X 1 7
and accurate history? Is the patient appropriately concerned = 1 87). Calculate interest at 6 % for 1 8 months. The examiner
about the illness? Does the patient interact appropriately with should make the calculations easier or more difficult depend
family members who are present in the examining room? ing on the patient's educational background.
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The Neurologic Examination 307
6. Judgment-Ask the patient for the symbolic or specific 2. Ophthalmoscopic examination- Examine each optic
meaning of simple proverbs such as the following: "A stitch in fundus. Details of the ophthalmoscopic examination should
time saves nine;' "A rolling stone gathers no moss:' "People include the color, size, and shape of the optic disk; the pres
who live in glass houses should not throw stones:' ence or absence of a physiologic cup; the distinctness of t he
optic disk edges; the size, shape, and configuration of the ves
7. Memory and comprehension-The content of a simple sels; and the presence of hemorrhage, exudate, or pigment. Pa
story from a newspaper or magazine can be read and t he pa pilledema or disk pallor, if present, should be explicitly noted.
tient's retention, comprehension, and formulation observed.
Alternatively, the examiner tells a story, which is then retold in 3. Visual field test-Test the visual fields by confrontation,
the patient's own words. The patient is also asked to explain with the patient seated about 1 m from the examiner. With the
the meaning of the story. The following stories can be used. left eye covered, the patient looks at the examiner's left eye. The
a. Cowboy story- A cowboy went to San Francisco with his examiner slowly raises both hands upward from a position
dog, which he left at a friend's house while he went to buy a new where they can barely be seen in the lower two quadrants, and
suit of clothes. Dressed in his brand-new clothing, he came back the patient signifies when the examiner's moving hands first be
to the dog, whistled to it, called it by name, and patted it. But the come visible. The upper quadrants are similarly tested, with the
dog would have nothing to do with him in his new coat and hat. examiner's hands moving downward. The left eye of the patient
Coaxing was to no avail, so the cowboy went away and put on is then tested against the right eye of the examiner.
his old suit, and the dog immediately showed its wild joy in see More accurate visual field examination can be carried out
ing its master as it thought he ought to be. using a perimeter or tangent screen.
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308 Appendix A
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The Neurologic Examination 309
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310 Appendix A
the distal portion of the foot. In abnormal responses, there attempts to determine whether it is moved upward or down
may be extension of the great toe, with fanning and flexion of ward. Test the ankles, wrists, knees, and elbows if impairment
the other toes (Babinski's reflex). The Babinski reflex (also is demonstrated in the digits.
termed the "extensor plantar" response ) suggests dysfunction
of the corticospinal system, although it does not, in itself, tell F. Stereog nosis
the examiner the rostrocaudal location (spinal cord vs. brain To test the patient's capacity to recognize the forms, sizes, and
stem vs. cerebrum) of the lesion. weights of objects, place a familiar object (eg, a coin, key, or
knife) in the patient's hand and ask him or her to identify the
C. Clonus object without looking at it.
Clonus (repeated reflex muscular movements) may be elicited
in patients with exaggerated reflexes. Wrist clonus is some G. Two-Point Discri m i nation
times elicited by forcible flexion or extension of the wrist. The shortest distance between two separate points of a com
Patellar clonus can be elicited by sudden downward move pass or calipers at which the patient perceives two stimuli is
ment of the patella, with consequent clonic contraction of the compared for homologous areas of the body. (Normal: finger
quadriceps muscle. Ankle clonus is tested by quickly flexing tips, 0.3-0.6 mm; palms of hands and soles of feet, 1 .5-2 mm;
the foot dorsally, producing clonic contractions of the calf dorsum of hands, 3 mm; shin, 4 mm.)
muscles. Clonus can be sustained or transient (usually meas
ured in number of beats; three to four beats of clonus can be H. Topognosis
elicited at the ankles in some normal individuals).
With the patient's eyes closed, the examiner touches the pa
tient's body. The patient then points to the spot touched, en
Sensory System abling the examiner to assess the patient's ability to localize
tactile sensation. Similar areas of both sides of the body are
Sensory examination depends on the patient's subjective re
compared. Extinction on double simultaneous stimulation ( eg,
sponses and thus can be difficult and tiring for both the pa
the ability to perceive tactile sensation on the right hand when
tient and the examiner. The patient should be well rested and
presented alone but not when presented simultaneously with
in a cooperative frame of mind. Abnormalities, especially of
a stimulus to the left hand) suggests a disorder involving the
minor degree, should be checked by reexamination. The fol
contralateral parietal lobe.
lowing modalities are tested and charted.
A. Pain
EXAM INING N EONATES
Test the patient's ability to perceive pinprick or deep pressure.
If there is an abnormality, note the topographic pattern (over The neonatal neurologic examination is usually performed
a specific dermatome? distal, over the hands and feet in a shortly after birth. Repeat examinations at weekly intervals
"stocking-and -glove" distribution?). may be desirable. The examination should be planned with lit
tle stimulation of the infant occurring initially so that sponta
B. Tem perature neous behavior can be observed.
To check for the ability to detect and distinguish between
warm and cold, use a test tube of warm water and one of cold
water. Alternatively, check whether the patient perceives the GENERAL STATUS
flat side of the tuning fork as cold. Observe the motor pattern and supine and prone body pos
ture and evaluate the reflexes throughout the examination.
C. Touch In normal infants, the limbs are flexed, the head may be
Test the ability to perceive light stroking of the skin with cotton. turned to the side, and there may be kicking movements oft he
lower limbs. Extension of the limbs can occur with intracra
D. Vi bration nial hemorrhage, opisthotonos with kernicterus, and asym
The patient should be able to feel the buzz of a tuning fork (at metry of the upper limbs with brachial plexus palsy. Paucity of
a frequency of 1 2 8 Hz) applied to the bony prominences. movements may occur with brachial plexus palsy and
Compare the patient's ability to sense vibration with your meningomyelocele.
own, with the fork applied to the malleoli, patellas, iliac crests,
vertebral spinous processes, and ulnar prominences.
E. Sense of Position
This is tested by having the patient determine the position of
toes and fingers when these are grasped by the examiner. A
digit is grasped on the sides, and the patient, with eyes closed,
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The Neurologic Examination 311
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A P P E N D I X
muscle tested should always be compared with t hat of its con 5: Normal motor power
tralateral muscle.
Modified from Aids to the I nvestigation of Peripheral Nerve I nqu iries. Her Majesty's
The strength of various muscles should also be graded Royal Stationary Office. London, UK, 1953.
and charted. Scales of various types are used, most commonly
grading strength from 0 (no muscle contraction) to 5 (nor
mal).
313
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3 14 Appendix B
Cord
Action to Be Tested Muscle Segment Nerves Plexus
Adduction of arm from behind t o Pectora lis major and minor C5-8; T1 Pectora l (thoracic; from Brachial
front medial and latera l cords of
plexus)
Medial rotation of arm Latissimus dorsi, teres major, C5-8 S u bscapular (from posterior
Adduction of arm from front to and subscapularis cord of plexus)
back
Ulnar flexion of hand Flexor carpi u l na ris C7, 8; T1 U l n a r (from medial cord of
Flexion of a l l fi ngers but thumb Flexor digitorum profu ndus C7, 8; T1 plexus)
(ulnar portion)
Add uction of metacarpal of thumb Adductor pollicis C8, Tl
Abduction of l ittle fi nger Abductor digiti q u i nti C8, T1
Opposition of l ittle fi nger Opponens digiti q u i nti C7, 8; T1
Flexion of l ittle fi nger Flexor digiti q u inti C7, 8; T1
Flexion of proximal phalanx, I nterossei C8,T1
extension of 2 distal phalanges,
adduction and abduction of
fi ngers
Abduction of m etacarpal of thumb Abductor poll icis brevis C7, 8; T1 Median (C7, 8 from lateral Brachial
Flexion of proximal phalanx of Flexor pol l i cis brevis C7, 8; T1 cord of plexus; C8, Tl from
thumb medial cord of plexus)
Opposition of m etacarpa l of Opponens pollicis C8, Tl
thumb
Flexion of proximal phalanx and Lumbricales (the 2 lateral) C8, Tl
extension of the 2 distal
phalanges of i ndex, m iddle, ring, Lubricales (the 2 medial) C8, Tl Ulnar
or l ittle fi nger
(continued)
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Testing Muscle Function 315
Cord
Action to Be Tested Muscle Segment Nerves Plexus
Extension of forearm Triceps brachii and anconeus (6-8 Radial (from posterior cord
Flexion of forearm Brachiorad ialis (5, 6 of plexus)
Rad ial extension of hand Extensor carpi radialis (6-8
Extension of phalanges of index, Extensor digitorum C7-8
midd le, ring, or little fi nger
Extension of hand
Extension of phalanges of little Extensor digiti quanti (6-8
fi nger propri us
Extension of hand
Ulnar extension of hand Extensor carpi u l naris (6-8
Supi nation of forearm Supi nator CS-7 Radial (from posterior cord
Abduction of m etacarpal of thumb Abductor poll icis longus C7, 8; T1 of plexus)
Rad ial extension of hand
Extension of thumb Extensor poll icis brevis C7, 8
Rad ial extension of hand Extensor poll icis longus (6-8
Extension of index fi nger Extensor indicis proprius (6-8
Extension of hand
Elevation of ribs Thoracic, abdominal, and T1 -L3 Thoracic and posterior Brachial
Depression of ribs back l u mbosacral branches
Contraction of abdomen
Anteroflexion of trunk
Lateral flexion of trunk
Abduction of thigh Gl uteus medius and minimus L4, 5; 5 1 Su perior g l uteal Sacral
Medial rotation of thigh
Flexion of thigh Tensor fasciae latae L4, 5
Lateral rotation of thigh Obtu rator i ntern us L5, 5 1 Muscular branches from
Gemelli L4, 5; 5 1 sacra l plexus
Quadratus femoris L4, 5; 5 1
Flexion of leg (assist in extension Biceps femoris L4, 5; 5 1 , 2 Sciatic (tru n k) Sacral
of thigh) Semitendinosus L4, 5; 5 1
Semimem branosus L4, 5; 5 1
(continued)
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316 Appendix B
Cord
Action to Be Tested Muscle Segment Nerves Plexus
Plantar flexion of foot in pronation Peroneus longus and brevis LS; 5 1 Su perficial peroneal
Gastrocnemius LS; 5 1 , 2 Tibial
Plantar flexion of foot in supination Tibialis posterior and triceps LS, 5 1 Tibial
surae
Plantar flexion of foot in supination Flexor digitorum longus 51; 2
Flexion of term inal phalanx of
toes 11-V
Plantar flexion of foot in supination Flexor hallucis longus LS; 5 1 , 2
Flexion of term inal phalanx of
g reat toe
Flexion of middle phalanx of Flexor digitorum brevis LS; 5 1
toes 11-V
Flexion of proximal phalanx of Flexor hallucis brevis LS; 5 1 , 2
g reat toe
Spreading and closing of toes Small m uscles of foot 51 , 2
Flexion of proximal phalanx of toes
Voluntary control of pelvic floor Peri neal and sphincters 52-4 Pudendal
FIGURE B-1 Tra pezi u s, u pper portio n (C3, 4; spinal accessory FIGURE B-2 Tra pezius, lower portion (C3, 4; spinal accessory
nerve). The shoulder is elevated against resistance. nerve) . The shoulder is th rust backward agai nst r esista nce.
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Testing Muscle Function 317
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318 Appendix B
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Testing Muscle Function 319
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320 Appendix B
FIGURE B-21 Abd uctor poll icis longus (C7, 8; T1 ; radial nerve).
The t h u m b is abducted agai nst resista n ce in a plane at a right angle
to the palmar s urface.
FIGURE B-22 Flexor carpi rad ialis ( C6, 7; median nerve). The
wrist is flexed t o the radial side agai nst resistance.
FIGURE B-1 8 Extensor poll icis longus (C7, 8; radial nerve). The
t h u m b is extended agai nst resistan ce.
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Testing Muscle Function 321
FIGURE B-24 Flexor dig itorum profundus {C7, 8; T1 ; median FIGURE B - 2 7 Flexor pollicis longus {C7, 8; T1 ; median nerve).
nerve) . The term i nal phalanges of the i ndex a n d m iddle fi ngers are The term i nal phalanx of the t h u m b is flexed agai nst r esista nce as the
flexed agai nst resista nce while the second phala n ges a re held i n ex proximal phalanx is held i n extension.
tension.
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322 Appendix B
FIGURE B-32 Abductor digiti q u inti (CS, Tl ; u l n a r nerve). The FIGURE B-35 Dorsa l inte rossei (CS, Tl ; u l n a r nerve). The i ndex
little fi nger is abd ucted against resistance as the s u p inated hand
and ring fi ngers a re a bd ucted from the m i d l i n e agai nst r esista nce as
with fi ngers extended l ies on the ta ble.
the palm of the hand l ies flat on the table.
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Testing Muscle Function 323
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324 Appendix B
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Testing Muscle Function 325
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326 Appendix B
FIGURE 8-46 Flexor digitorum longus (5 1 , 2; tibial nerve). The FIGURE 8-47 Flexor h a l l ucis longus (LS; 5 1 , 2; tibial nerve). The
toe joi nts are plantar-flexed against resistance. g reat toe is planta r-flexed against resista nce. The second and third
toes a re also flexed.
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Testing Muscle Function 327
FIGURE B-48 Extensor hall ucis longus (L4, 5; 5 1 ; deep FIGURE B-50 Ti bialis anterior (L4, 5; deep peroneal nerve) . The
peroneal n erve) . The l a rge toe is dorsiflexed against resista nce. foot is dorsiflexed and i nverted against r esista nce appl ied by
gripping the foot with the examiner's hand.
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328 Appendix B
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A P P E N D I X
329
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330 Appendix C
Hearing, equilibrium
Taste Facial muscles VI I
Pha�nx, esophagus Pha�ngeal , palatine muscles X
La�ngeal muscles X I
�
La�nx, trachea
Occipital reg ion (C1 , 2) Tongue muscles X I I
Neck reg ion (C2, 3, 4) Esophagus X
Shoulder (C4, 5) Sternocleidomastoid XI (C1 , 2, 3)
}
ilia� (CS, 6) Neck muscles (C1 , 2, 3)
E adial (C6, 7, 8) Trapezius (C3, 4)
.;c edian (C6, 7, 8) Rhomboids (C4, 5)
nar (C8, T1 ) Diaphragm (C3, 4, 5)
Supra- , infraspinatus (C4, 5, 6)
Deltoid, brachioradialis,
and biceps (CS, 6)
Serratus anterior (CS, 6, 7)
Pectoralis major (CS, 6, 7, 8) E
C"' }
<(
scapula (T3) Teres minor (C4, 5)
Pronators (C6, 7, 8; T1 )
Thorax Triceps (C6, 7, 8)
Long extensors of carpi
and digits (C6, 7, 8) E
�
nferior en Latissimus dorsi, teres (ij
Q)
}"
angle of u
major (CS, 6, 7, 8)
en Long flexors (C7, 8; T1 ) LL
Epigastri u m scapula (T7) :::l
E Thumb extensors (C7, 8)
�
en
Interossei , lum bricales,
T
£ ' thenar, hypothenar (C8, T1 ) J:
E :::l
E
E
Abdomen o
� Iliopsoas (L 1 , 2, 3)
<( .0
E Sartorius (L2, 3)
:::l Quadriceps femoris (L2, 3, 4)
...J
Umbilicus Gluteal muscles ( L4, 5; 5 1 )
(T1 0) Tensor fasciae latae ( L4, 5)
Adductors of fem u r (L2, 3, 4)
en Abductors of fem u r (L4, 5 ; 5 1 )
f' "
:::l
Gluteal region (T1 2, L1 ) X
Q)
Tibialis anterior (LS)
Ingu inal reg ion (L 1 , 2) c. Gastrocnemius, soleus (LS; S 1 , 2)
(ij Biceps, semitendinosus,
.0
E semimembranosus (L4, 5 ; 5 1 )
Femoral :::l Obtu rator, pi riform is,
reg ion Median ...J
Lateral quadratus femoris (L4, 5 ; 5 1 )
(L1 , 2 , 3) Flexors of the foot,
Posterior
extensors of toes (LS, S 1 )
f
Peronei (LS, S 1 )
Cru ral Flexors of toes (LS; 5 1 , 2)
reg ion Median Interossei (51 , 2)
(L4, 5) Lateral Perineal muscles (53, 4)
Vesicular muscles (54, 5)
en
:::l Rectal muscles (54, 5 ; Co1 )
X
Q)
c.
iii
Scrotu m , penis, u
labia, l1:l
en
perineum (51 , 2)
Bladder (53, 4)
Rectum (54, 5)
Anus (55, Co1 )
Filum
terminale
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Spinal Nerves and Plexuses 331
Meningeal
branch of X I I
G reat
Small
-
occipital
nerve
Sternomastoid
muscle
nerve
Trapezius r;"--,liill!""
muscle
Posterior
plexus
Anterior
Middle
Phrenic
Supraclavicular nerves nerve
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332 Appendix C
Nerves or
plexus roots
Tru nks
* Divisions
To phrenic nerve
Cords
Dorsal
scapular
To subclavius
nerve (5)
muscle (5 - 6)
Suprascapular
nerve
(4 - 5 - 6)
Musculocutaneous nerve
(4 - 5 - 6)
Median nerve
(5 - 6 - 7 - 8 -1 )
* Spl itting of the plexus into anterior and posterior divisions is one of the most sign ificant features
in the redistribution of nerve fibers, because it is here that fibers supplying the flexor and
extensor groups of muscles of the upper extremity are separated . Similar splitti ng is noted
in the lu mbar and sacral plexuses for the supply of muscles of the lower extremity.
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Spinal Nerves and Plexuses 333
FIGURE C-4 Segmental i n ne rvatio n of the right upper extremity, a nterior view.
C4
FIGURE C-5 Segmental innervation of the rig ht upper extremity, posterior view.
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334 Appendix C
Brachial plexus
Lateral cord
Posterior cord
Medial cord
Deltoid muscle
\
(by superior division)
t Axillary nerve
Coracobrachialis
muscle Teres minor muscle
Biceps
brachialis muscle
{
Short head
Muscu locutaneous nerve
Long head
Brachialis muscle
Lateral antebrachial
cutaneous nerve
Posterior branch
Sensory distribution
,I
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Spinal Nerves and Plexuses 335
Lateral cord
Wristd rop in radial nerve injury Posterior cord
Medial cord
Triceps
brachii
muscle
{ Lateral head
Long head
Medial head of triceps brachii
Dorsal antebrachial
Extensor carpi radialis longus -- cutaneous nerve
Sensory d i stribution
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336 Appendix C
Lateral cord
Medial cord
Sensory distribution
Median nerve
Palmaris longus
Thenar muscles
Pronator
Abductor poll icis brevis quadratus
Opponens pollicis
Unopposed
Anastomosis with thumb
ulnar nerve
Flexor pollicis brevis
(superficial head)
Thenar
atrophy
"Ape-hand" deformity
in median nerve lesion
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Spinal Nerves and Plexuses 337
Medial cord
Sensory distribution
Cutaneous branches
Interosseous
atrophy
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338 Appendix C
Plexus roots
Branches
Divisions
Term i n a l branches From anterior
primary
(Posterior shaded) divisions
I liac branch L1
Hypogastric branch
*
L2
Gen itofemoral nerve ( L 1 , 2)
*
Lumboi nguinal branch
External spermatic branch
L3
Lateral femoral
cutaneous nerve (L2, 3)
L4
L5
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Spinal Nerves and Plexuses 339
L4
I liacus muscle
Pectineus muscle
Sartorius muscle
Rectus femoris
Vastus medialis
Femoral
Vastus lateralis
Subsartorial or
cutaneous branch
of obtu rator
/ Saphenous
Saphenous
branch
of femoral �
Sensory distribution
FIGURE C-1 1 The fem o ra l (L2-4) and obtu rator (L2-4) nerves.
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340 Appendix C
Plexus root
Divisions
(From anterior
Term inal and collateral branches (Posterior [black] primary divisions)
and anterior)
L5
S1
Branch from both a nterior
and posterior divisions
Posterior femoral S2
cutaneous nerve
(S1 , 2, 3)
S3
L4 5 . 5 1
(To hamstring muscles) gemellus inferior muscles r ' '
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Spinal Nerves and Plexuses 34 1
L5 S1
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342 Appendix C
Sem itendinosus
Semimembranosus
Short head
of biceps
nerve
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Spinal Nerves and Plexuses 343
Common
peroneal
nerve
Tibialis anterior
Su perficial
peroneal
nerve
Peroneus longus
muscle
Peroneus brevis
muscle
Sural nerve
Deep
peroneal
Extensor digitorum
brevis muscle Sensory distribution
Terminal cutaneous
rami to the foot
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344 Appendix C
Common
peroneal
nerve
Tibial nerve
Calf muscles
Gastrocnemius Lateral
Medial su ral plantar
cutaneous nerve nerve
Popliteus
Lateral sural nerve
cutaneous nerve
Sensory distribution
Plantaris
Sural nerve
Soleus
, •
.
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Spinal Nerves and Plexuses 345
S2
To sacral plexus
S3
S4
S5
Anococcygeal nerves
* Visceral branches
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A P P E N D I X
347
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348 Appendix D
1 1 . The myelin sheath is- 20. The cell layer around the central canal of the spinal
1. produced within the CNS by oligodendrocytes cord-
2. produced within the peripheral nervous system by I. is called the ventricular zone
Schwann cells 2. is the same as the pia
3. interrupted periodically by the nodes of Ranvier 3. encloses cerebrospinal fluid
4. composed of spirally wrapped plasma membrane 4. is called the marginal zone
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Questions and Answers 349
3. The following fiber systems in the spinal cord are ascend 9. Fine-diameter dorsal root axons of LS on one side termi-
ing tracts except for the- nate in the-
A. cuneate tract 1. marginal layer of the ipsilateral dorsal horn
B. ventral spinocerebellar tract 2. ipsilateral substantia gelatinosa
C. spinothalamic tract 3. ipsilateral lamina V of the dorsal horn
D. spinoreticular tract 4. ipsilateral dorsal nucleus (of Clarke)
E. reticulospinal tract
1 0. Axons in the spinothalamic tract-
4. Axons in the spinothalamic tracts decussate- 1. carry information about pain and temperature (lat
A. in the medullary decussation eral spinothalamic tract) and light touch (anterior
B. in the medullary lemniscus spinothalamic tract)
C. within the spinal cord, five to six segments above 2. carry information about pain (lateral spinothalamic
the level where they enter tract) and temperature (anterior spinothalamic
D. within the spinal cord, within one to two segments tract)
of the level where they enter 3. decussate within the spinal cord, within one or two
E. in the medial lemniscus segments of their origin
4. synapse in the gracile and cuneate nuclei
5. The spinal subarachnoid space normally-
A. lies between the pachymeninx and the arachnoid 1 1 . The dorsal spinocerebellar tract-
B. lies between the pia and the arachnoid 1. arises in the dorsal nucleus of Clarke and, above
C. ends at the cauda equina C8, in the accessory cuneate nucleus
D. communicates with the peritoneal space 2. carries information arising in the muscle spindles,
E. is adjacent to the vertebrae Golgi tendon organs, touch and pressure receptors
3. ascends to terminate in the cerebellar cortex
6. The subclavian artery gives rise directly to the-
4. projects without synapses to the basal ganglia and
A. lumbar radicular artery
cerebellum
B. great ventral radicular artery
C. anterior spinal artery 12. Second-order neurons in the dorsal column system-
D. vertebral artery 1. convey information about pain and temperature
2. cross within the lemniscal decussation
7. The dorsal nucleus (of Clarke) in the spinal cord-
3. cross within the pyramidal decussation
A. receives contralateral input from dorsal root
4. convey well-localized sensations of fme touch, vi
ganglia
bration, two-point discrimination, and propriocep
B. terminates at the L2 segment
tion
C. terminates in the midbrain
D. terminates in the ipsilateral cerebellum 13. The following rules about dermatomes are correct-
E. receives fibers from the external cuneate nucleus 1 . the C4 and T2 dermatomes are contiguous over t he
anterior trunk
8. A patient complains of unsteadiness. Examination shows
2. the nipple is at the level of C8
a marked diminution of position sense, vibration sense,
3. the thumb, middle fmger, and 5th digit are within
and stereognosis of all extremities. He is unable to stand
the C6, C7, and C8 dermatomes, respectively
without wavering for more than a few seconds when his
4. the umbilicus is at the level of L2
eyes are closed. There are no other abnormal findings.
The lesion most likely involves the- 14. Signs of upper-motor-neuron lesions include-
A. lateral columns of the spinal cord, bilaterally 1. Babinski's sign
B. inferior cerebellar peduncles, bilaterally 2. hypoactive deep tendon reflexes and hyporetlexia
C. dorsal columns of the spinal cord, bilaterally 3. spastic paralysis
D. spinothalamic tracts, bilaterally 4. severe muscle atrophy
E. corticospinal tracts
15. A-delta and C peripheral afferent fibers-
In the following questions, one or more answers may be 1. terminate in laminas I and II of the dorsal horn
correct. Select- 2. convey the sensation of pain
A if 1, 2, and 3 are correct 3. terminate in lamina V of the dorsal horn
B if 1 and 3 are correct 4. convey the sensation of light touch
C if 2 and 4 are correct
D if only 4 is correct
E if all are correct
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350 Appendix D
16. The following are correct- 3. can arise from cells of the external cuneate nucleus
1. the diaphragm is innervated via the C3 and C4 4. are important elements in the conscious sensation
roots of joint position
2. the deltoid and triceps are innervated via the CS
23. The intermediolateral gray column-
root
1. contains preganglionic neurons for the autonomic
3. the biceps are innervated via the CS root
nervous system
4. the gastrocnemius is innervated via the L4 root
2. is prominent in the thoracic region
1 7. The long-term consequences of a left hemisection of 3. is prominent in upper lumbar regions
the spinal cord at midthoracic level would include- 4. is prominent in cervical regions
1. loss of voluntary movement of the left leg
24. In adults-
2. loss of pain and temperature sensation in t he right
1. there is very little myelin in the spinal cord
leg
2. the dorsal columns and lateral columns are heavily
3. diminished position and vibration sense in the left
myelinated
leg
3. the spinal cord terminates at the level of the SS ver
4. diminished deep tendon reflexes in the left leg
tebrae
18. The spinal nerve roots- 4. the spinal cord terminates at the level of the Ll or
1. exit below the corresponding vertebral bodies in 12 vertebra
the cervical spine
25. In humans, the spinothalamic tract-
2. exit above the corresponding vertebral bodies in
1. carries information from the ipsilateral side of the
the cervical spine
body
3. exit above the corresponding vertebral bodies in
2. exhibits topographic organization
the lower spine
3. arises principally from neurons of the same side of
4. exit below the corresponding vertebral bodies in
the cord
the lower spine
4. mediates information about pain and temperature
19. Gamma-efferent motor neurons-
1. are located in the intermedial lateral cell column of
the spinal cord Section IV: C h a pters 7 th ro u g h 1 2
2. cause contraction of intrafusal muscle fibers
In the following questions, select t he single best answer.
3. provide vasomotor control to blood vessels in mus
1 . Examination of a patient revealed a drooping left eyelid,
cles
together with weakness of adduction and elevation of
4. are modulated by axons in the vestibulospinal tract
the left eye, loss of the pupillary light reflex in the left
20. The dorsal column system of one side of the spinal eye, and weakness of the limbs and lower facial muscles
cord- on the right side. A single lesion most likely to produce
I. is essential for normal two-point discrimination on all these signs would be located in the-
that side A. medial region of the left pontomedullary j unction
2. arises from both dorsal root ganglion cells and dor B. basomedial region of the left cerebral peduncle
sal horn neurons C. superior region of the left mesencephalon
3. synapses on neurons of the ipsilateral gracile and D. dorsolateral region of the medulla on the left side
cuneate nuclei E. periaqueductal gray matter on the left side
4. consists primarily of large, myelinated, rapidly con
2. A neurologic syndrome is characterized by loss of pain
ducting axons
and thermosensitivity on the left side of t he face and on
2 1 . Large-diameter dorsal root axons of one side of LS ter- the right side of the body from the neck down; partial
minate in the- paralysis of the soft palate, larynx, and pharynx on the
1. marginal layer of the ipsilateral dorsal horn left side; ataxia on the left side; and hiccuping. This syn
2. ipsilateral gracile nucleus drome could be expected from infarction in the territory
3. ipsilateral cuneate nucleus of the-
4. ipsilateral dorsal nucleus (of Clarke) A. basilar artery
B. right posterior inferior cerebellar artery
22. The fibers carrying information from the spinal cord to
C. left posterior inferior cerebellar artery
the cerebellum-
D. right superior cerebellar artery
!. can arise from Clarke's column cells (dorsal nu
E. left superior cerebellar artery
cleus)
2. represent the contralateral body half in the dorsal
spinocerebellar tract
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Questions and Answers 35 1
3. Hemiplegia and sensory deficit on the right side of the 10. Within the internal capsule, descending motor fibers
body may be caused by infarction in the territory of the- for the face-
A. left middle cerebral artery A. are located in front of fibers for the arm, in the an
B. right anterior cerebral artery terior part of the anterior limb
C. left posterior cerebral artery B. are located posterior to the fibers for the leg, in the
D. left superior cerebellar artery posterior half of the posterior limb
E. anterior communicating artery C. are located in front of the fibers for the arm, in the
anterior part of the posterior limb
4. If the oculomotor nerve (III) is sectioned, each of the fol
D. travel within the corticovestibular tract
lowing may result except for-
E. synapse in the capsular nucleus
A. partial ptosis
B. abduction of the eyeball 1 1 . Brodrnann's area 4 corresponds to the-
C. dilation of the pupil A. primary motor cortex
D. impairment of lacrimal secretion B. premotor cortex
E. paralysis of the ciliary muscle C. Broca's area
D. primary sensory cortex
5. Structures in the ventromedial regions of the medulla re
E. striate cortex
ceive their blood supply from the-
A. posterior spinal and superior cerebellar arteries 12. In a stroke affecting the territory of the middle cerebral
B. vertebral and anterior spinal arteries artery-
C. posterior spinal and posterior cerebral arteries A. weakness and sensory loss are most severe in the
D. posterior spinal and posterior inferior cerebellar ar contralateral leg
teries B. weakness and sensory loss are most severe in the
E. posterior and anterior inferior cerebellar arteries contralateral face and arm
C. weakness and sensory loss are most severe in the
6. The efferent axons of the cerebellar cortex arise from-
ipsilateral leg
A. Golgi cells
D. weakness and sensory loss are most severe in the
B. vestigial nucleus cells
ipsilateral face and arm
C. granule cells
E. akinetic mutism is often seen
D. Purkinje cells
E. pyramidal cells In the following questions, one or more answers may be
correct. Select-
7. A lesion in the nucleus of cranial nerve IV would pro
A if 1, 2, and 3 are correct
duce a deficit in the-
B if 1 and 3 are correct
A. upward gaze of the ipsilateral eye
C if 2 and 4 are correct
B. upward gaze of the contralateral eye
D if only 4 is correct
C. downward gaze of the contralateral eye
E if all are correct
D. downward gaze of the ipsilateral eye
13. Cortical area 1 7-
8. Sensory input for taste is carried by-
1 . is also termed the striate cortex
A. the vestibulocochlear (VIII) nerve
2. is involved in the processing of auditory stimuli
B. the facial (VII) nerve for the entire tongue
3. receives input from the lateral geniculate body
C. the facial (VII) and glossopharyngeal (IX) nerves
4. receives input from the medial geniculate body
for the anterior two-thirds and posterior one-third
of the tongue, respectively 14. Within the cerebellum-
D. the glossopharyngeal (IX) and vagus (X) nerves for !. climbing fibers and mossy fibers carry afferent in
the anterior two-thirds and posterior one-third of formation
the tongue, respectively 2. Purkinje cells provide the primary output from the
cerebellar cortex
9. In central facial paralysis resulting from damage of the
3. Purkinje cells project to the ipsilateral deep cerebel
facial (VII) nucleus there is-
lar nuclei
A. paralysis of all ipsilateral facial muscles
4. efferents from the deep cerebellar nuclei project to
B. paralysis of all contralateral facial muscles
the contralateral red nucleus and thalamic nuclei
C. paralysis of ipsilateral facial muscles except the
buccinator 15. In a patient with a missile wound involving the left
D. paralysis of all contralateral muscles except the cerebral hemisphere, the following might be expected-
buccinator 1. dense neglect of stimuli on the left side
E. paralysis of contralateral facial muscles except the 2. hemiplegia involving the right arm and leg
frontalis and orbicularis oculi 3. hemiplegia involving the left arm and leg
4. aphasia
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352 Appendix D
16. The striatum includes- 3. mediates pain arising from the heart during my
1. the caudate nucleus ocardial ischemia
2. the globus pallidus 4. receives axons running with nerve VII
3. the putamen
23. Sensory nuclei of the thalamus include-
4. the substantia nigra
1. lateral geniculate
1 7. The ventroposterior medial nucleus of the thalamus- 2. superior geniculate
1. receives axons from neurons located in the con 3. ventral posterior, lateral
tralateral cuneate nucleus in the medulla 4. ventral anterior
2. receives axons from neurons located in area 4 on
24. Axon pathways that decussate before they terminate in
the medial surface of the ipsilateral cerebral hemi
clude the-
sphere
1. optic nerve (II) fibers from the temporal halves of
3. contains neurons that respond to olfactory stimuli
the two retinas
applied ipsilaterally
2. gracile fasciculus
4. contains neurons whose axons project to the so
3. cuneate fasciculus
matosensory cortex of the ipsilateral cerebral hemi
4. olivocerebellar fibers
sphere
25. A 55-year-old patient presented with an 8-month his
18. A healthy 25-year-old man had an episode of blurred
tory of gradually progressive incoordination in the right
vision in the left eye that lasted 2 weeks and then re
arm and leg. Examination revealed hypotonia and
solved. Six months later he developed difficulty walk
ataxia in the limbs on the right side. The most likely di
ing. Examination showed decreased visual acuity in t he
agnosis is-
left eye, nystagmus, loss of vibratory sensation and po 1. a stroke
sition sense at the toes and knees bilaterally, and hyper
2. a tumor
active deep tendon reflexes with a Babinski reflex on
3. in the left cerebellar hemisphere
the right. Three years later, the man was admitted to the
4. in the right cerebellar hemisphere
hospital with dysarthria, intention tremor of the left
arm, and urinary incontinence. The clinical features are
consistent with- Section V: Cha pters 1 3 th ro u g h 2 1
1. myasthenia gravis
In the following questions, select the single best answer.
2. a series of strokes
1 . A lesion of the right frontal cortex (area 8) produces-
3. a cerebellar tumor
A. double vision (diplopia)
4. multiple sclerosis
B. impaired gaze to the right
19. The vagus (X) nerve contains- C. impaired gaze to the left
1. visceral afferent fibers D. dilated pupils
2. visceral efferent fibers E. no disturbances of the ocular motor system
3. branchial efferent fibers
2. Axons in the optic nerve originate from-
4. somatic efferent fibers
A. rods and cones
20. Lesions of the cerebral cortex on one side can result in a B. retinal ganglion cells
deficit in muscles innervated by the- C. amacrine cells
1. contralateral spinal motor neurons D. all of the above
2. ipsilateral spinal motor neurons
3. Meyer's loop carries optic radiation fibers representing-
3. contralateral facial (VII) nerve
A. the upper part of the contralateral visual field
4. ipsilateral facial (VII) nerve
B. the lower part of the contralateral visual field
2 1 . The trigeminal nuclear complex- C. the upper part of the ipsilateral visual field
1. has somatic afferent components D. the lower part of the ipsilateral visual field
2. participates in certain reflex responses of cranial
4. Which of the following statements about the auditory
muscles
system is not true?
3. has a branchial efferent component
A. the lateral lemniscus carries information from both
4. receives projections of axons coursing with nerve X
ears
22. The solitary nucleus- B. it has a major synaptic delay in the midbrain
1. serves visceral functions, none of which are con C. it has a major synaptic delay in the thalamus
sciously perceived D. it has a major synaptic delay in the inferior olivary
2. gives rise to preganglionic parasympathetic axons nucleus
E. crossing fibers pass through the trapezoid body
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Questions and Answers 353
5. The hippocampal formation consists of the- 1 1 . Auditory stimuli normally cause impulses to pass
A. dentate gyrus through the-
B. hippocampus 1. trapezoid body
C. subiculum 2. inferior olivary nucleus
D. all of the above 3. medial geniculate nucleus
4. medial lemniscus
6. Which of the following is not part of the Papez circuit?
A. hippocampus 1 2. The principal neurotransmitter(s) released by synaptic
B. mamillary bodies terminals of sympathetic axons is/are-
C. posterior thalamic nuclei 1. epinephrine
D. cingulate gyrus 2. norepinephrine
E. parahippocampal gyrus 3. acetylcholine
4. gamma-aminobutyric acid
7. Wernicke's aphasia is usually caused by-
A. a lesion in the superior temporal gyrus 1 3. Alzheimer's disease is characterized by-
B. a lesion in the inferior temporal gyrus 1. neurofibrillary tangles
C. a lesion in the inferior frontal gyrus of the domi 2. loss of neurons in the basal forebrain (Meynert)
nant hemisphere nucleus
D. lesions in the midbrain 3. senile plaques
E. alcohol abuse 4. severe pathology in CA1
8. Which of the following statements about the globus pal 14. Destruction of the lower cervical and upper thoracic
lidus is not true? ventral roots on the left side leads to-
A. it is located adjacent to the internal capsule 1. dilated right pupil
B. it receives excitatory axons from the caudate and 2. constricted right pupil
putamen 3. dilated left pupil
C. it is the major outflow nucleus of the corpus stria 4. constricted left pupil
tum
15. After transection of the peripheral nerve, the-
D. it sends inhibitory axons to the thalamus
1. axons and Schwarm cells distal to the cut undergo
9. In a patient with hemiparkinsonism (unilateral Parkin degeneration and disappear
son's disease) affecting the right arm, a lesion is most 2. sensory axons distal to the cut survive, but motor
likely in the- axons degenerate
A. right subthalamic nucleus 3. motor neurons whose axons were cut degenerate
B. left subthalamic nucleus and disappear
C. right substantia nigra 4. surviving axons of the proximal stump will send
D. left substantia nigra out new growth cones to attempt regeneration
E. right globus pallidus
16. The Kliiver-Bucy syndrome-
F. left globus pallidus
1. is characterized by hyperorality and hypersexuality
10. Complex cells in the visual cortex have receptive fields 2. is characterized by psychic blindness and personal
that- ity changes
A. are smaller than the receptive fields of simple cells 3. is seen in patients with bilateral temporal lobe le
B. respond to lines or edges with a specific orienta sions
tion, only when presented at one location in the vi 4. is seen in patients with lesions of t he anterior thala
sual field mus
C. respond to lines or edges with a specific orienta
1 7. Pain sensation-
tion, presented anywhere within the visual field
!. is carried in large myelinated (A-alpha) axons
D. contain "on'' or "off" centers
2. is carried by small myelinated and unmyelinated
In the following questions, one or more answers may be (A-delta and C) axons
correct. Select- 3. is carried upward in the dorsal columns of the
A if 1, 2, and 3 are correct spinal cord
B if 1 and 3 are correct 4. is carried upward in the spinothalamic tract and
C if 2 and 4 are correct spinoreticulothalamic system
D if only 4 is correct 18. Parasympathetic fibers are carried in-
E if all are correct 1. cranial nerves III and VII
2. cranial nerves IX and X
3. sacral roots S2-4
4. thoracic roots TS- 12
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354 Appendix D
19. A 68-year-old teacher with hypertension complained of In the following question, select the single best answer.
a severe headache and was taken to the hospital. Exami- 25. A 54-year-old accountant, who worked until the day of
nation revealed that he could write normally but could his illness, was found on the floor, with a right hemi-
not read. His speech was normal. The lesion(s) most paresis (arm and face more severely affected than the
likely involved the- leg) and severe aphasia. The diagnosis is most likely-
1 . corpus callosum A. a tumor involving the thalamus on the left
2. Broca's area B. a large tumor of the left cerebral hemisphere
3. left visual cortex c. a stroke involving the right middle cerebral terri-
4. left angular gyrus tory
D. a stroke involving the right anterior cerebral terri-
20. In the patient described in question No. 1 9-
tory
1 . the left anterior cerebral artery was probably in-
E. a stroke involving the left middle cerebral territory
volved
F. a stroke involving the left anterior cerebral territory
2. there was probably a right homonymous hemi-
anopia
3. the left middle cerebral artery was probably in-
ANSWERS
volved
4. the left posterior cerebral artery was probably in-
Section I
volved
1. B 6. D 11. E 1 6. E 21. A
2 1 . The extrastriate cortex- 2. A 7. c 12. A 1 7. A 22. c
1 . is Brodmann's areas 1 8 and 1 9 3. B 8. B 13. A 18. D 23. D
2. receives input from area 1 7 4. c 9. A 1 4. A 19. E 24. c
3. is the visual association cortex 5. c 1 0. A 1 5. E 20. B 25. B
4. is the primary auditory cortex
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Index
Note: Page numbers followed by f and t indicate figures and tables respectively.
355
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Index 365
Neuroimaging investigations, 39 0
Neurologic disease Occipital condyles, 157
dysfunctions in, 36t Occipital hematoma, 212f
treatment of, 40-41 Occipital lobe, 135, 141
Neurologic diseases (symptoms and signs), 33 Occipital sinus, 1 60
focal pathology in nervous system, 34 Occlusive cerebrovascular disease, 1 70, 1 72
gray matter lesions, 34 Ocular dominance columns, 2 1 3
negative manifestations, 34 Ocular muscles, 1 04
neighborhood signs, 35 Oculomotor (nerve III) paralysis, 107
neural tissue compression, 35-36 Oculomotor nucleus, 89, 244
neural tissue destruction, 35-36 Olfactory bulb, 230, 233f
positive abnormalities, 34 Olfactory groove meningioma, 23 1 , 300
syndromes, 34-35 Olfactory mucous membrane, 229
white matter lesions, 34 Olfactory nerves, 230, 233f
Neurologic examination (children and adults) Olfactory projection area, 230
consciousness and alertness, 306 Olfactory receptors, 229
coordination and gait, 309 Olfactory sulcus, 135, 230
cranial nerves, 305, 307 Olfactory system, 30
examining neonates, 3 1 0 Olfactory tract, 230
general status, 3 1 0 Oligodendrocytes, 9, 13, 13f, 50
headache, 305 Oligodendroglia! cells, 17
loss of consciousness, 305 Olivocochlear bundle, 2 1 6
mental status, 306 Olivopontocerebellar atrophies, 9 6
motor function, 305 Ophthalmic artery, 164
motor system and reflexes, 3 1 1 Ophthalmoplegias, 107
motor system, 308 abducens (nerve VI) paralysis, 107
pain, 305 internuclear ophthalmoplegia, 108
physical examination, 305 oculomotor (nerve III) paralysis, 107
reflexes, 309 trochlear (nerve IV) paralysis, 107
seizures, 305 Opponens digiti quinti, 322f
sensory function, 305 Opponens pollicis, 32lf
sensory system, 3 1 0 Optic atrophy, 206, 207f
sensory system, 3 1 1 Optic canal, 1 59, 159
visual disturbances, 305 Optic chiasm, 206
Neuromuscular endings, 61 Optic dis, 202
Neuromuscular synapse, 28 Optic nerve, 205
Neurons, 5 Optic neuritis (papillitis), 207f
destruction of, 35 Optic radiation, 207
light mucrograph of, 14f Optic recess, 149
See also under Nervous system, cellular constituents of Optic tract, 206
Neuropathic pain, 198 Orbital sulci, 135
Neuropil, 1 1 Organ of corti, 2 1 5
Neurotransmitters, 24, 26t, 28, 28t. See also under Nervous system, Orientation columns, 2 1 2
signaling in Ossicles, 2 1 5
Nigrostriatal projection, 186 Otic ganglion, 248
Nigrostriatal system, 3 1 Otoliths, 22 1
Nissl substance, 16 Otosclerosis, 2 1 7
Nissl-stained motor neuron, 8 Outer ear canal, 2 1 5
NMDA receptor, 30 Outer segment, 20 1 , 202f
Nociceptors, 196
Noncommunicating hydrocephalus, 1 54 p
Nonmyelinated axons, 22 Pachyrneninx, 67, 150
Nonmyelinated nerve fiber, 22f Pain, 305
Norepinephrine, 30 Pain control, 200f
Normal nerve fiber, 16, 247 Palatine rami, 248
Normal-pressure hydrocephalus, 154 Paleocerebellum, 9 1
Nuclear bag fibers, 58 Pallidotomy, 193
Nuclear chain fibers, 58 Palmar interossei, 323f
Nuclei, 2 Papez circuit, 235, 235f
Nucleus pulposus, 7 1 Papilledema, 207f
Nystagmus, 1 93, 223 Paracentral lobule, 135
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