Brain Structure and Reflexes: Background

Why Understanding Brain Structure and Reflexes is Important in Nursing

People can develop a variety of central nervous system problems. It is important, therefore, that you
understand the basic structure and function of the different parts of the brain.

All living things must detect changes in the environment and react appropriately. This involves receptors, which
detect the change; sensory neurons, which send the information to the central nervous system where it is
processed; and motor neurons, which send the information to effectors (e.g. skeletal muscle) that produce a
response appropriate to the situation. If a motor response is initiated, it usually involves a series of action
potentials that cause muscle contraction and a movement of one or more parts of the body. Reflexes are
examples of this simple type of stimulus-response reaction. For example, something flying at your eye makes
you blink, while a tap on the tendon under the kneecap produces the knee-jerk (or 'myotatic') reflex.

Assessment of reflexes is an important part of the physical examination of a patient where neurological
disease is suspected, and you will see many patients with disturbed reflex activity.

A little history

Thomas Willis (1621 –1675), an English doctor who contributed to our understanding of anatomy, neurology
and psychiatry. Willis provided a detailed description of the blood supply to the brain and the ‘Circle of Willis’ is
named after him. He was also a founding member of the Royal Society.
Johann Jakob Wepfer (1620-1695), a Swiss pathologist and pharmacologist, was the first to recognize
that strokes resulted from a cerebral hemorrhage (“Observationes anatomicae, ex cadaveribus eorum, quos
sustulit apoplexia”, Schaffhausen, 1675). He also observed that strokes could be caused by blockage of a
major artery supplying the brain.

Brain Structure

The vertebrate brain has six main regions: the telencephalon (cerebral hemispheres), diencephalon (thalamus
and hypothalamus), mesencephalon (midbrain), cerebellum, pons, and medulla oblongata. The telencephalon
and diencephalon constitute the forebrain, and the cerebellum, pons, and medulla oblongata make up the
hindbrain. The midbrain, pons and medulla oblongata together are referred to as the brainstem. In mammals,
the hindbrain and midbrain are generally similar to those of other vertebrates; however, the forebrain is greatly
enlarged.

The brainstem

The medulla oblongata is continuous with the spinal cord. Fiber tracts connecting the forebrain and spinal
cord run through it. It also contains motor and sensory nuclei for the mouth, throat and neck, as well as nuclei
concerned with cardiorespiratory control and movement and posture.

The pons is continuous with the medulla. It contains sensory and motor nuclei for the face, as well as nuclei
involved in the control of respiration.

The midbrain contains fibers linking the cerebrum to the cerebellum. It also contains neurons concerned with
the processing of visual and auditory information, as well as nuclei that affect the state of wakefulness of the
individual.

All the cranial nerves except one (the olfactory nerves) have their nuclei in the brainstem.

The cerebellum
This sits above the pons and midbrain. It modulates outputs of other motor systems and so controls the rate,
range and direction of movement. One region of the cerebellum is concerned with processing of vestibular and
visual information and regulates balance and eye movements. Motor skills, like riding a bike or hitting a ball or
playing the piano, are ‘learnt’ by the cerebellum.

Damage to the cerebellum does not prevent a person moving, but it makes actions hesitant and clumsy and
affects balance and gait. In the neurological examination, cerebellar function is assessed by examining gait,
balance (with eyes open and shut) and finger-pointing. People with cerebellar lesions will have difficulty with
balance, even with the eyes open. They also have difficulty when asked to perform accurate rapid movements
such as touching repeatedly the examiner’s finger and then their own nose. This difficulty is termed dysmetria.
They also have difficulty with rapid alternating movements (dysdiadochokinesia). This can be demonstrated by
asking the person to show how a light bulb can be screwed into a socket.

The diencephalon

In mammals, this is covered by the cerebrum and is only visible when the brain is dissected or in brain scans.
The thalamic nuclei are involved in relaying sensory and motor signals to the cerebral cortex. One group is
involved in sleep and wakefulness.

The hypothalamic nuclei regulate autonomic functions such as body temperature, heart rate and blood
pressure. They regulate hormone release by the pituitary gland and are involved in controlling food and water
intake and in the expression of emotions.

Figure 1. The lobes of the Cerebrum (left), and major regions of the midbrain (right)

Figure 2. Functions of specific regions of the cerebrum which may be affected in a stroke.
The basal ganglia

Lying beneath the cerebral cortex are the basal ganglia – comprising the claustrum, putamen caudate nucleus
and globus pallidus. Also included in this group are the subthalamic nucleus, and the substantia nigra that lies
in the midbrain. These are concerned in the initiation and control of movements. Two human diseases
particularly affect the basal ganglia – Parkinson’s disease and Huntington’s chorea, which is much less
common. Parkinson’s disease involves loss of dopaminergic neurons from the basal ganglia, whereas
Huntington’s chorea involves loss of another basal ganglia neuron population. The symptoms of the two
diseases are opposite – in Parkinson’s disease there is the gradual loss of the ability to initiate movements, in
Huntington’s chorea there is the inability to prevent unintentional movements.

It is important to appreciate that in Parkinson’s disease the ability to initiate movements has a significant
motivational component. In an emergency, people with Parkinson’s disease can respond in a rapid and
coordinated way. When the emergency has passed, they return to their previous situation.

Clinically, the features of Parkinson’s disease include tremor, often described in the hands as a “pill-rolling”
action, that may also affect other parts of the body; slowness of movement with a shuffling gait and decreased
swinging of the arms; and muscle rigidity with what is described as “cogwheel rigidity” when the limb is moved
passively.

The limbic system

Included in this are structures that lie on the medial side of each hemisphere – the cingulate gyrus,
hippocampus, the amygdaloid nucleus and the anterior thalamic nucleus. Other regions, such as the
hypothalamus, are also included by some people. Structures included in this system are involved in behavior
and memory and affect endocrine and autonomic activity.
Blood Supply to the Brain

Two main pairs of arteries supply the brain. The internal carotid artery on each side is the major branch of the
common carotid artery. It divides into the anterior and middle cerebral arteries. The vertebral artery on each
side arises from the subclavian artery. After entering the skull, the two vertebral arteries unite to form the
basilar artery, which supplies the midbrain, cerebellum, and, usually, continues as the posterior cerebral artery
(Figure 3).

The two internal carotid arteries are connected via the anterior communicating artery. They are also connected
via the posterior communicating arteries with the basilar artery. This interconnected group of vessels is
referred to collectively as the Circle of Willis (Figure 4). Its importance lies in the fact that blockage of one of
these major arteries carrying blood into the skull can be compensated for, at least to some extent, by blood
arriving through the other arteries.
 Figure 3. The blood supply to the head and neck.

Figure 4. The Circle of Willis.

Cerebrovascular Accidents (CVA, also referred to as Strokes)

A CVA refers to a rapid loss of brain function (over seconds to minutes) resulting from damage to the blood
supply to the brain. Vessels may either:
• become blocked, resulting in an ischemic CVA (87% of cases), or
• may rupture, known as 'hemorrhagic CVA' (13% of cases).
Blockages result from a thrombosis (formation of a clot) or an embolism (blockage of a vessel by a detached,
intravascular mass known as an embolus arising from elsewhere in the body). The loss of blood supply for
whatever cause results in a loss of function in the affected areas of the brain.

The symptoms and signs of a CVA depend on the areas of the brain affected.

Damage to a major CNS pathway (spinothalamic tract, corticospinal tract or dorsal columns) can result in
hemiplegia, muscle weakness of the face, numbness and reduced sensations on the opposite side of the body
to the site of the lesion in the brain.

The initial symptoms tend to be similar, regardless of the site of the lesion in the brain. These include:

• Severe headache
• Loss of vision
• Dizziness or loss of balance
• Sudden paralysis or numbness in arm or side of face
• Loss of memory
• Loss of consciousness

The acronym FAST can be used to quickly identify a stroke.

F ace - smile is one sided,

A rm - weak or droopy on one side,

S peech - slurred, unable to speak,

T ime - you need to act fast because time loss leads to brain loss.

Other associated symptoms, such as loss of consciousness, headache, and vomiting, may result from
increased cranial pressure associated with intracranial hemorrhage. For symptoms that are specific to the
region of the stroke see the reference table at the bottom of this page.

Reflexes

A reflex is an involuntary movement in response to a stimulus, occurring almost immediately after the stimulus.

Stretch reflexes
 Figure 5. Cross-section of the spinal cord, showing the neuronal circuitry of the myotatic reflex.

A simple spinal reflex like the stretch (myotatic) reflex is produced via single synapses between sensory axons
and motor neurons. The essential central circuitry for this reflex is confined to the spinal cord (Figure 5),
although information also passes to the brain.

This reflex employs only two neurons. Striking the patellar ligament just below the knee stretches the
quadriceps muscle. This stimulates sensory receptors in the muscle that trigger an impulse in a sensory axon,
whose cell body lies in the dorsal root ganglion in the lumbar region of the spinal cord. The sensory axon
synapses directly with a motor neuron that conducts the impulse to the quadriceps, triggering contraction
(Figure 6).

In everyday life, this reflex helps to maintain an upright posture. Sensory information also ascends to higher
centers, but the brain is not necessary or required for many simple reflex functions.

Figure 6. The components of the myotatic reflex.

Protective reflexes - The flexion withdrawal reflex

This reflex mediates the withdrawal of a limb from a painful stimulus, such as a pinprick or the heat of a flame.
The flexion withdrawal reflex (Figure 7) is not readily studied in human volunteers for obvious reasons.
However, a little-known reflex involving an obscure muscle in the hand (the palmaris brevis muscle) exists that
shares some features of the flexion reflex and is easily evoked. Like the other reflex pathways, local circuit
neurons in the flexion reflex pathway receive converging inputs from several different sources, including
cutaneous receptors, other spinal cord interneurons, and upper motor neuron pathways.

Figure 7. The withdrawal reflex.

Despite the speed with which we are able to withdraw from painful stimuli, this reflex involves several synaptic
links. As a result of activity in this circuitry, stimulation of pain (nociceptive) sensory neurons leads to
stimulation of flexor muscles, leading to withdrawal of the stimulated limb. At the same time, there is an
inhibition of extensor muscles in the opposite limb. Therefore, the withdrawal reflex is accompanied by an
opposite reaction in the opposite limb. This 'crossed extension reflex' serves to enhance postural support
during withdrawal of the affected limb from the painful stimulus.

The plantar reflex - Babinski Sign

In 1896, the French neurologist Joseph Jules François Félix Babinski (1857–1932) described the phenomenon
that, when the sole of the foot is stroked in patient with an upper motor neuron lesion, the big toe dorsiflexes
(extends upwards). This is now known as the Babinski sign, and is used to identify disease or damage to the
spinal cord or brain. The Babinski sign is also seen in infants younger than 12–18 months, as the corticospinal
pathways are not yet fully myelinated.
 In healthy adults and children, the Babinski sign is inhibited by the cerebral cortex. The big toe flexes (curls
downwards) and the foot everts (turns outwards) – the plantar reflex.

Figure 8. Eliciting a plantar reflex.

Diseases in which reflexes may be disturbed

Lesions in neurons in the brain affect the ability to contract muscles normally – these are upper motor neuron
lesions. Findings in the affected limbs can include:

• Increase in muscle tone (spasticity)

• Initial resistance to movement initiated by the observer, followed by relaxation (so-called clasp knife rigidity)
• Muscle weakness without wasting
• Brisk tendon jerk reflexes
• Upward movement (dorsiflexion) of big toe when sole of foot is stroked (Babinski sign). Normally, the big toe
moves downward.
Lower motor neuron lesions – in which the cell bodies of the motor neurons in the spinal cord or the nerves
running from them are damaged. Findings in the muscles supplied by the damaged neurons or nerves can
include:

• Muscle paresis or paralysis

• Spontaneous contractions of individual muscle fibers (fibrillations). These are not visible on physical
examination.
• Spontaneous contractions of groups of muscle fibers (fasciculations). These are visible on physical
examination and have characteristic EMG appearance.
• Hypotonia or atonia
• Areflexia or hyporeflexia
• No Babinski sign
What you will do in the class

In today's class you will perform five exercises and examine one case study.

1. Brain gross anatomy. You will revise some of the gross anatomy of the brain.
2. Reflex arc. You will revise the components of a monosynaptic reflex arc.
3. Knee jerk. You will elicit a knee jerk and analyze some of its properties.
4. Ankle jerk. You will elicit an ankle jerk and analyze some of its properties.
5. Plantar reflex. You will learn how to test for a Babinski sign.
Patient Case study: You will meet Mr W, a patient who has had a stroke. You will also watch video footage of
Mr W one year later, and listen to his wife and health care providers describe his care and his recovery.

Supplementary Material

The table below provides a quick reference guide to the effects of stroke in different areas of the brain.

Table 1. Effects of stroke in different regions of the brain.

References:

Lecture Notes:Human Physiology 5th Edition, edited by Petersen O.H. (Blackwell Publishing, 2007)

Rang H.P., Dale M.M., Ritter J. M. Pharmacology 6th Edition (Elsevier Science, 2007)