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Gross Brain and Spinal Cord

Brad Cole, MD

The primary objective of these first several lectures and labs is to learn the basic “plumbing” of neuroanatomy. The
neuro-anatomical structures that are discussed in lecture should be identified in the upcoming gross brain laboratory
sessions. Only a simplistic explanation as to the function (and dysfunction) of the neuroanatomy will be given at this
time. Later in the course, much more emphasis will be given to the physiology, function, and clinical applications. It
will be helpful to read this handout with the PowerPoint slides and an atlas.

I. Major Subdivisions of the Central Nervous System

The nervous system is divided into the central nervous system (CNS) and a peripheral nervous system (PNS). The CNS
consists of the brain, brain stem, cerebellum and spinal cord, while the PNS is represented by the cranial and
peripheral nerves (including nerve roots, plexus, and peripheral nerves). This lecture will concentrate on the CNS. The
following table illustrates the major subdivisions of the CNS:

Major Components Embryologic Subdivisions Adult Derivatives Cavities

Telencephalon *Cortex Lateral

(Cerebral *White Matter Ventricles
Hemispheres) *Basal Ganglia
*Limbic System
Cerebrum Prosencephalon *Olfactory System
Brain Diencephalon *Thalamus Third Ventricle
*Subthalamus
*Hypothalamus
*Epithalamus
Mesencephalon *Midbrain Cerebral
Aqueduct
Metencephalon *Pons and Fourth Ventricle
Brain Stem *Cerebellum

Rhombencephalon
Myelencephalon *Medulla

Spinal Cord Neural Tube *Spinal Cord Central Canal

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The organization of this lecture will go through the CNS structures as follows:

• Telencephalon (cerebral hemispheres)

• Diencephalon – includes anything with the name “thalamus” in it
• Brain stem – the midbrain, pons, and medulla
• Cerebellum
• Spinal cord

II. Telencephalon (Cerebral Hemispheres)

A. Cortex

The surface of the cerebral hemispheres is made up of folds or convolutions

(called gyri) with intervening grooves (called sulci). This extensive and
intricate folding significantly increases the surface area such that 2/3 of the
brain surface is hidden in the walls of these sulci. The surface of the brain
consists of a 3-5 mm thick layer of gray substance, the cerebral cortex. The
cell bodies of the neurons lie in the cortex. Clinically, the term
“cortical” refers to certain diseases or lesions that involve the cerebral
cortex while areas of the brain that lie under the cortex are referred to as “subcortical”. The white matter
(myelinated axons) and basal ganglia (deeply located neuronal masses) are both subcortical structures.

• Alzheimer’s dementia is a condition that results in degeneration of the cortex.

• Multiple sclerosis is an example of a subcortical condition which results in demyelination of subcortical white
matter pathways.

A fissure is different than a sulcus in that it divides large components of the brain. The interhemispheric fissure, for
example, divides the brain into a left and right hemisphere.

The sulci and fissures mentioned below provide landmarks that are helpful in dividing the brain into four different
lobes: frontal, parietal, temporal, and occipital. The boundaries of the four lobes are somewhat arbitrary and are
named in accordance with the bone of the skull under which they are located. Some texts refer to an insular and a
limbic lobe. These are not true lobes, however, as they are made up of parts of the other four lobes.

Frontal Lobe

Lateral surface – bound inferiorly by the lateral or sylvian fissure. The central sulcus forms the posterior boundary.
The central sulcus is an important landmark for the sensorimotor cortex. The primary motor cortex, responsible for
the execution of voluntary movement, is located anterior to the central sulcus in the precentral gyrus. The remainder
of the surface of the frontal lobe is divided into superior, middle, and inferior frontal gyri by the superior and inferior
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frontal sulci.

The middle frontal gyrus contains the saccadic gaze center (or frontal eye fields) which initiates fast (saccadic)
horizontal eye movements. The inferior frontal gyrus of the dominant hemisphere (usually the left hemisphere in
right-handed people) contains the expressive language area (Broca’s area), of the brain (labeled “B” below).

Precentral gyrus Central sulcus

Superior
frontal gyrus

Middle FEF
frontal gyrus

Inferior B
frontal gyrus

The Lateral Prefrontal Cortex (PFC) contains both dorsolateral and ventrolateral components (DLPFC and
VLPFC). These areas are involved in:
• task setting such as developing and implementing a plan (like study plan or vacations)
• monitoring which involves checking that you are keeping on track for your plan to accomplish a task
and then making adjustments as necessary
• working memory which describes actively retaining and manipulating information in the short term

Dominant (usually left) hemisphere lesions result in impaired task setting

whereas non-dominant (usually right) hemisphere lesions result in impaired
monitoring. As an example of this, this patient with injury to the non-
dominant hemisphere lateral prefrontal cortex is asked to draw alternating
squares and triangles. Since the ability to monitor the task is impaired, the
patient cannot keep up the pattern.
VLPFC
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Medial surface - lies on top of the corpus callosum as the cingulate gyrus. The corpus callosum is the massive white
matter pathway that interconnects large portions of the two sides of the brain and consists of millions of myelinated
nerve fibers. Cortex around the medial aspect of the central sulcus is called the paracentral lobule which is the
medial portion of the pre-central and post-central gyrus.
Cingulate gyrus

Corpus callosum

The superior medial PFC including the anterior cingulate cortex are involved in energizing which describes
getting ones “mental clutch” out of neutral position – such as getting into the study “zone” before an exam.
Thus, lesions of this area (especially if bilateral) can result in:
• Akinetic mutism is most severe form. Patients are unable to initiate any activity such as to talk or
move and typically do not follow commands.
• Abulia (“lacking joy”) and apathy are common as
Anterior
well. Patients speak in a monotone voice and are often cingulate cortex

confused with depression.

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Inferior surface – lies on the orbital part of the frontal bone. The olfactory bulb and tract (the pathway for the sense
of smell) lie in the olfactory sulcus near the medial margin of the hemisphere. The gyrus rectus lies medial to the
olfactory sulcus.
Olfactory bulb and tract

Gyrus rectus

This area of the brain is known as the orbitofrontal cortex (OFC) which has a medial and a lateral area and is
involved in behavioral and emotional regulation and social cognition.

Lesions of the OFC result in:

• Hyperphagia, especially for sweets
• Disinhibition which often includes sexually
inappropriate comments, joking, argumentative
behavior and impulsivity
• Environmental dependency which results in a
need to touch and feel things in the environment

The frontal poles of the frontal lobe are involved in

meta-cognitive processing which describes self-
awareness and the ability to perceive the emotions of
others (the ability to “put yourself in someone else’s
shoes). Lesions result in impaired empathy and difficulty
interpreting the facial expressions of others.

Parietal Lobe

Lateral surface – The parietal lobe is posterior to the frontal lobe and is separated from the frontal lobe by the
central sulcus. The postcentral gyrus (primary somatosensory cortex) receives most of the sensory information from
the body. The posterior border of the parietal lobe is marked by the parieto-occipital sulcus (best seen on a sagittal
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section), while the inferior border is formed by the sylvian (lateral) fissure. The posterior parietal lobe consists of a
superior and an inferior parietal lobule which contains the supramarginal gyrus (found around the most posterior
portion of the sylvian fissure) and the angular gyrus (just posterior to the supramarginal gyrus). In the dominant
hemisphere these gyri consist of cortex that includes the receptive language area (Wernicke’s area), which is
necessary for the perception and interpretation of spoken and written language.

Medial surface – The postcentral gyrus forms the posterior portion of the paracentral lobule. The precuneus lies
between the paracentral lobule and the parieto-occipital sulcus.

;
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The homunculus describes the specific motor and sensory areas of the pre and post-central gyrus. Notices that the
face and arm fibers are lateral, while the leg and foot fibers are located medially in the paracentral lobule

Temporal Lobe

Lateral surface – Bordered above by the sylvian fissure and contains three gyri: the superior, middle, and inferior
temporal gyrus. The superior temporal gyrus forms the floor of the sylvian fissure. On the inner surface of the
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superior temporal gyrus lies Heschl’s gyrus, which is the primary auditory cortex (sense of hearing – see #4 below)).
The superior temporal gyrus is also the most important part of the language receptive cortex (Wernicke’s area).

Medial surface – The medial portion consists of the parahippocampal gyrus. The most medial portion of the
parahippocampal gyrus is the uncus. The uncus is a major part of the primary olfactory cortex (sense of smell). The
uncus is a common area of the brain for onset of seizure activity which results in an intense sensation of a foul-
smelling odor.
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• Uncal herniation: Notice the close relationship between the uncus and the 3rd
cranial nerve. Patients with increased intracranial pressure may have herniation of the
cerebral contents through the foramen magnum (the base of the skull). Early in the
process, the uncus may compress the 3rd nerve resulting in a third nerve palsy. The
finding of 3rd nerve palsy in a comatose (unresponsive) patient is an ominous finding.

Occipital Lobe

Most of the occipital lobe appears on the medial surface of the hemisphere,
separated from the parietal lobe by the parieto-occipital sulcus. The calcarine sulcus
lies on the medial portion of the occipital lobe and separates the cuneus (superior to the calcarine sulcus) from the
lingula (inferior to the calcarine
sulcus). The occipital lobe contains
the primary visual cortex (striate
cortex), which is the cortex around
the calcarine sulcus, and receives
visual pathways from the retina
known as optic radiations. The
inferior surface of the occipital lobe
rests cerebellar tentorium, which is
a reflection of the dura.
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Insular and Limbic “Lobes”

Both the insular and the limbic lobes are located on the medial surface of the brain and are derived from the frontal,
parietal, and temporal lobes. The insular lobe (insula) is the portion of the cortex that lies buried within the sylvian
fissure. It is exposed only after spreading apart the frontal, parietal, and temporal opercula, which cover the insula.
The opercula refer to those portions of the cortex that are around the sylvian fissure.

Frequently in neurology, discoveries are made about the function of a particular area of the brain based on what
happens when that area is destroyed. Surprisingly, patients with acute infarctions involving the insular cortex
(especially on the right side) have an increased risk of cardiac complications such as atrial fibrillation and other
arrhythmias. Thus, it appears that the insula has a role in cardiovascular regulation.1

The limbic lobe (better called the limbic system) will be discussed later in this handout.

In this dissection, the opercula has been removed to expose the insular cortex.

B. White Matter

There are three types of white matter fibers: projection, association, and
commissural. The centrum semiovale refers to areas of the white matter that
contain all three fiber types. Projection Fibers

1
In addition, ascending pain pathways that relay through thalamus transmit nociceptive signals to both the anterior cingulate gyrus and to
the insula. There is some evidence from imaging studies that the placebo effect on pain involves activation of the anterior cingulate gyrus,
the insula and amygdala.

Also, the anterior portion of the insula is known as the "insular taste cortex" although it appears that the orbitofrontal regions of the brain
are more important for the conscious motivation to eat (or not to eat) particular foods while the amygdala and hypothalamus have more
to do with affective aspects related to eating.
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Projection fibers convey impulses either from the cortex to distant loci (efferent fibers), or from distant loci to the
cortex (afferent fibers). Near the cortex, these are called the corona radiata. In the diencephalic area these fibers
funnel together as the internal capsule which consists of the anterior and posterior limbs and the genu, which lies
between the anterior and posterior limbs.

Anterior limb

Genu

Posterior limb

The posterior limb contains ascending sensory fibers traveling from the extremities to the cortex via the thalamus
(superior thalamic radiations), as well as the descending motor fibers going from the motor cortex to the spinal cord
(corticospinal tract – CST). The genu contains descending motor fibers from the motor cortex to the brain stem
(corticobulbar tract – CBT). The anterior limb contains connections between the motor cortex and the cerebellum
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(corticopontocerebellar tract – CPCT), a pathway involved in Papez circuit (the anterior thalamic radiations, see
below), and the connection between the frontal eye fields (FEF) and the brain stem to control eye movements.

Near the posterior limb of the internal capsule, the optic radiations convey visual information from the thalamus
(lateral geniculate nucleus – LGB) to the striate cortex; the auditory radiations convey sound from the thalamus
(medial geniculate body – MGB) to the auditory cortex.

Most of the information in the above paragraph describes pathways and nuclei that are soon to be discussed in
much more detail.
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Association Fibers

Association fibers interconnect cortical regions of the same hemisphere either

within the same lobe, or from one lobe to another. The arcuate fasciculus, for
example, connects the receptive language area (Wernicke’s area) with the
expressive language area (Broca’s area) in the dominant hemisphere.

Commissural Fibers

Commissural fibers interconnect cortical regions of the left and right

hemisphere. The major example is the massive corpus callosum. The
corpus callosum consists of the (1) rostrum, (2) genu (interconnects the
rostral portions of the frontal lobes), (3) body (connects the rest of the
frontal lobes and parietal lobes), and (4) splenium (connects the
temporal and occipital lobes). The corpus callosum forms the floor of
the interhemispheric fissure and the roof of much of the lateral
ventricles.

The anterior commissure connects the hippocampal formations.

Anterior commissure
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The posterior commissure marks the dorsal border between the midbrain and the diencephalon. This pathway is
important in the pupillary constriction to light.

Posterior commissure

C. Basal Ganglia

The basal ganglia are subcortical structures that are integrally involved with the
motor system. They allow the cortex to select wanted patterns of movement
and suppress unwanted patterns of movement. Disorders of the basal ganglia
(for example, Parkinson’s disease) are therefore classified as movement
disorders. It should be said, however, that components of the basal ganglia are
clearly involved in other important brain functions as well.

Most of the basal ganglia are derived from the telencephalon. Telencephalic
structures composing the basal ganglia are the caudate nucleus, putamen, and
globus pallidus. The putamen and the globus pallidus are together referred to
as the lentiform nucleus. The caudate nucleus and putamen
together constitute the striatum. The striatum receives information from the
cortex, while the globus pallidus is the major source of output from the basal
ganglia back to the cortex.

Caudate Nucleus

The caudate nucleus consists of a head (lies in the anterior horn of the lateral ventricle), a body and a tail (lies in the
inferior horn of the lateral ventricle). Thetail of the caudate terminates in the amygdaloid nuclear complex.

Putamen
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The putamen is the most lateral portion of the basal ganglia. It lies between the globus pallidus (medially) and the
external capsule (laterally). The putamen is connected rostrally to the caudate nucleus (the striatum).

Globus Pallidus

The globus pallidus is the medial portion of the lenticular nucleus. The
putamen forms the lateral border, while the internal capsule forms the
medial border.

The substantia nigra and subthalamic nuclei are also important functional parts of the basal ganglia. The substantia
nigra is in the midbrain (mesencephalic origin); the subthalamic nucleus, which is just superior and lateral to the
substantia nigra, is of diencephalic origin.

• Degeneration of the substantia nigra results in Parkinson’s disease.

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Caudate

Putamen

Subthalamic nucleus
Globus pallidus

Substantia nigra

D. Limbic System

The limbic system consists of cortical and subcortical prosencephalic structures on the medial aspect of the
hemispheres.
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The limbic system functions to control four main categories (HOME):

• Homeostatic function (autonomic and neuroendocrine)

• Olfaction
• Memory, especially incorporating new memory
• Emotional responsiveness and affective behavior, resulting in an individualized interpretive response to
external and internal stimuli.

The “limbic lobe” refers mainly to the hippocampal formation, parahippocampal gyrus, and the cingulate gyrus. The
limbic system includes these structures together with the amygdala, nucleus accumbens, hypothalamus, and the
anterior thalamic nucleus.
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A cut through the tip of the temporal lobe will first reveal the amygdala as a homogeneous nucleus that is about the
side of an almond:

Amygdala
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Posterior to the tip of the temporal lobe, the longer hippocampus is identified:

Hippocampus

The cingulate gyrus and hypothalamus are important parts of the limbic system and are found in the midline of the
brain:

Cingulate gyrus

Hypothalamus

Hippocampal formation and the Parahippocampal gyrus

The hippocampal formation makes an “S” shape in the brain and includes the dentate gyrus at the tip, the
hippocampus, and the subiculum. Frequently the “hippocampus” is used to refer to all three areas. The entorhinal
cortex is part of the parahippocampal gyrus that lies immediately adjacent to the subiculum and includes pathways in
and out of hippocampal formation. The most important function of these areas is to change short term into long
term memory. Damage or degeneration is
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primarily associated with impaired declarative memory2 (memories that can be consciously recalled such as facts),
an inability to store short term memory, and spatial disorientation. In 2014, the Nobel Prize in physiology was
awarded for the discovery that the hippocampus functions like an inner- GPS system.
Papez circuit includes many of the areas that are necessary for incorporating new memory and includes the following:

Cingulate
Fornix
Ant. Thalamic
nucleus
MB

Hippocampus

1) Hippocampal formations →

2) Fornix→

3) Mammillary bodies (MB) →

4) Anterior nucleus of the thalamus →

5) Cingulate cortex3 →
hippocampal formations

2 Non-declarative memories refer to unconscious memory such as skills (riding a bike, etc.) and habits and are relatively preserved with
lesions of this area
3 Anterior thalamus to cingulate gyrus connections occur via the anterior thalamic radiations (see drawing of internal capsule)
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Amygdala

The amygdala (almond in Greek) is externally focused and responds to environmental triggers. A destructive lesion
(especially if bilateral) is associated with impaired threat assessment and less fear and aggression in response to
threatening stimulation. This is part of Kluver-Bucy syndrome.

A major output of the amygdala is to the hypothalamus (via the stria terminalis) which controls the autonomic
nervous system and neuroendocrine secretions. Recall the mechanism of action of sympathetic activation as it
relates to the amygdala:

• Fear (or memory of a fear such as occurs in PTSD) is due to

activation of the amygdala which simulates the
hypothalamus. Notice the close anatomical relationship
between the stria terminalis and the caudate nucleus (we
will appreciate this in the brain dissection lab). The
hypothalamus activates the sympathetic nervous system
(norepinephrine) nervous system (norepinephrine).
• In addition, the hypothalamic-pituitary axis is involved in
activation of the adrenal gland which results in the release
of epinephrine/cortisol.
• The result of amygdala activation of the sympathetic
nervous system and the adrenal gland due to anxiety or
fear leads to elevated pulse and blood pressure, autonomic activation, and diverts blood flow to the muscles.
Under normal situations, the hippocampus and prefrontal cortex can “shut down” the activation of this
cascade once there is no longer a need for sympathetic activation. In PTSD this is impaired and there is
persistent abnormal activation of the sympathetic nervous system.
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Nucleus Accumbens

Both the amygdala and hippocampal formations project to the nucleus

accumbens, which is part of the caudate nucleus. The nucleus accumbens
also has dopaminergic projections from the ventral tegmental area (VTA) in
the midbrain and is associated with reward and motivation systems. The
emotions experienced while listening to music are also related to limbic
stimulation of this area.

• Abnormal activation of the nucleus accumbens plays an important

role in addiction behavior. One example is the dopaminergic treatment of Parkinson’s disease which can lead
to impulse control disorder (gambling behavior, etc.)
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Cingulate Gyrus

In addition to its probable role in learning and memory formation as part of Papez circuit, the cingulate gyrus is
involved in processing emotional information. Studies have also suggested that this area of the brain is active during
situations that involve emotional conflict.

E. Olfactory System

The olfactory system consists of the olfactory bulb and tract, the olfactory stria, and the uncus (the primary olfactory
cortex). The olfactory system has a major input into the amygdala. Olfaction is carried from the amygdala to the stria
terminalis to the hypothalamus which results in increased or decreased appetite (depending on whether the odor is
pleasant or foul). Olfaction is the only primary sensory system that can bypass the thalamus and project directly to
the cortex.

Directional terms that are often used in neuroanatomy are illustrated below:
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III. Diencephalon

The diencephalon is a paired structure that lies on each side of the third ventricle. The posterior limb of the internal
capsule forms its lateral border. The diencephalon is just rostral to the midbrain, separated from the midbrain by the
posterior commissure. The diencephalon consists of four parts: the epithalamus, thalamus, hypothalamus, and the
subthalamus.

Epithalamus

The epithalamus forms the dorsal part of the diencephalon and consists mainly of the pineal gland, and the
habenular nuclei. This subdivision of the diencephalon has significant limbic connections. The pineal gland calcifies in
most adults and is an important radiologic midline marker on head CT scans (calcium on head CT scans has a white
appearance). It secretes melatonin, a skin-lightening pigment, which is produced at night and is important for
circadian rhythms. Tumors of the pineal gland compress the pretectum and cerebral aqueduct (terms covered in the
brain stem section), resulting in paralysis of up-gaze and obstructive hydrocephalus. This is known as Parinaud’s
syndrome.

Thalamus

Pineal gland

Hypothalamus
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Thalamus

This is the largest portion of the diencephalon and lies between the third ventricle and the posterior limb of the
internal capsule. The medial surface of the thalamus on each side of the third ventricle is fused in about 80% of
human brains, known as the inter-thalamic adhesion (this has no clinical significance). The thalamus consists of
multiple nuclear groups, each of which has unique connections with different parts of the neuro axis. Afferent
impulses to the cortex must first synapse in the thalamus (olfaction being the exception). For this reason, the
thalamus is sometimes called the “executive secretary” of the brain since it filters out irrelevant information and only
“talks” to the cortex when necessary. We will go through each of these individual nuclear groups and their function in
the “Subcortical CNS” lecture.

Thalamus

Hypothalamus

The hypothalamus lies ventral to the thalamus and forms the inferior and lateral walls of the third ventricle. It extends
from the optic chiasm to the mamillary bodies and is the major output of the limbic system by virtue of its two major
functions, autonomic, and neuroendocrine.

The hypothalamus is the head ganglion for the autonomic nervous system, influencing sympathetic and
parasympathetic output with respect to limbic inputs. Its neuroendocrine function includes controlling the release of
anterior pituitary hormones into the blood.
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The hypothalamus also contains visceral regulatory areas that control various visceral activities, such as feeding,
drinking, sleep, reproduction, and thermoregulation.

Subthalamus

The subthalamus is bound by the thalamus dorsally, the hypothalamus medially, and the internal capsule laterally
(you will identify this in the brain dissection lab). It forms an important functional part of the basal ganglia circuitry,
communicating mainly with the globus pallidus. A lesion to one of the subthalamic nuclei results in an involuntary
movement disorder in the contralateral limbs known as hemiballismus.

IV. Brain Stem

All the “traffic” going to and from the cerebrum must pass through the brain stem. This includes all ascending
sensory information from the extremities and the face, as well as all the descending motor pathways that move the
arms, legs and face. Autonomic pathways, and other fibers traveling to and from the cerebellum, must also journey
through the brain stem. Many of these pathways originate within the brain stem, but for the most part, they are still
controlled by the cerebral cortex.

The brain stem is the home of cranial nerves 3-12 (not 1 and 2). The reticular formation, which forms the core of the
entire brain stem, is responsible for maintaining consciousness (the reticular formation “wakes up” the cortex),
maintaining general muscle tone and posture, processing noxious (painful) stimuli, and regulating major visceral
functions (blood pressure, respirations, gastrointestinal function, and cardiac function).

All these pathways, cranial nerves, and the reticular formation will be covered in detail later in the course. For now,
appreciate that all these vital structures are located in such a small space. For this reason, a relatively small lesion
(such as a hemorrhage) that involves the brain stem can result in sudden coma and death.

Midbrain

The midbrain (mesencephalon) is the smallest part of the brain stem. It lies between the pons and the diencephalon.
It consists of the following:
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Tectum

Tegmentum

Cerebral peduncles

CN III

A. The cerebral peduncles (crus cerebri or basis pedunculi) mark the

anterior surface of the midbrain. This pathway is the continuation of the
motor fibers in the posterior limb and genu of the internal capsule, on
their way to parts of the brain stem and spinal cord. The two cranial
nerves which emerge from the midbrain can be seen near the cerebral
peduncles.

• The oculomotor nerve (cranial nerve III) emerges between the cerebral
peduncles in a space called the interpeduncular fossa.
• The trochlear nerve (cranial nerve IV) is the only cranial nerve which exits
on the dorsal surface of the brain stem. It can be found lateral to the
cerebral peduncles.

B. The tegmentum is that part of the midbrain that lies between the
cerebral peduncles and the cerebral aqueduct. The red nucleus and the
substantia nigra (mentioned earlier) are located in the tegmentum.

C. The tectum is that portion of the midbrain posterior to the cerebral aqueduct. There are four “bumps” on the
dorsal surface of the tectum. These are the paired superior colliculi (part of the visual system), and the
inferior colliculi (part of the auditory system). Collectively, the superior and inferior colliculi are called the
quadrigeminal plate. Look for the pineal gland just dorsal to the tectum.
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Pons

The pons is the largest structure of the brain stem, and is

marked by broad bands of horizontal fibers, the basis pontis.
These horizontal fibers are the means of communication
between the cortex and the cerebellum known as the
corticopontocerebellar tract. They join the cerebellum as the
middle cerebellar peduncle (see below). In addition, the
descending corticospinal tract also travels in the basis pontis.
Cranial nerves found in association with the pons:

• Trigeminal nerve (V) exiting from the middle of the pons

• Abducens nerve (VI) exits on the medial aspect of the
pons at the pontomedullary junction
• Facial (VII) and vestibulocochlear nerves (VIII) emerge from the lateral surface of the pons at the
cerebellopontine angle, formed by the junction of the pons, cerebellum, and medulla.

• A distinctive tumor, the acoustic schwannoma (or vestibular schwannoma), arises at the cerebellopontine
angle and can compress the vestibulocochlear, facial, and trigeminal nerves, as well as the pons and
cerebellum. Typically, the vestibulocochlear nerve is involved first producing hearing loss and dizziness.
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Medulla

The medulla (myelencephalon) extends from the caudal border of the pons to the foramen magnum, where the
medulla becomes the spinal cord. The anterior surface of the medulla is marked by the medullary pyramids which
represents the continuation of the descending corticospinal tract fibers. The descending pyramidal tract fibers cross
in the caudal medulla, forming the pyramidal decussation. Lateral to the medullary pyramids is the large inferior
olivary nucleus. This nucleus “talks” to the cerebellum.

Cranial nerves associated with the medulla:

• Hypoglossal nerve (XII), which exits between the medullary pyramid and the inferior olivary eminence
• Glossopharyngeal (IX), vagus (X), and the accessory nerves (XI) which leave the medulla lateral to the inferior
olivary eminence.

V. Cerebellum

The cerebellum lies under the occipital lobe of the brain, separated from it by the cerebellar tentorium (see
“vasculature and coverings of the brain” handout). The cerebellum consists of the midline vermis, the paravermis
located laterally, and the cerebellar hemispheres. The cerebellum has an outer layer of gray substance (the cerebellar
cortex) similar to the cerebral cortex, with underlying white matter. The surface of the cerebellum is extensively
folded into numerous folia (the cerebral cortex equivalent are gyri). The cerebellar cortex is organized into groups of
folia, termed lobules (of which there are at least 10) which are separated by fissures. Two of the fissures (primary
and posterolateral fissures) are very prominent and divide the cerebellum into the three lobes, the anterior,
posterior, and flocculonodular lobes.
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The cerebellum communicates with the brain stem as follows:

Brain stem Connection with cerebellum

Midbrain Superior cerebellar peduncle (SCP, brachium conjunctivum)
Pons Middle cerebellar peduncle (MCP, brachium pontis)
Medulla Inferior cerebellar peduncle (ICP, restiform body)

The SCP contains mainly efferent fibers going from the cerebellum to the cerebral hemispheres. The MCP and ICP
contain afferent fibers coming from the cerebral hemispheres and the spinal cord, respectively. The exceptions to this
rule of thumb we will cover later.
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The cerebellum is a “comparator,” and as such coordinates and corrects motor activity by comparing the position of
body parts in space with the intended movement of those body parts. For example, when the brain “decides” to
move a limb, it sends that information not only to the spinal cord to move the limb, but also to the cerebellum (via
the MCP). The cerebellum then gets information from that limb as it moves (via mainly the ICP), and then compares
the intended movement with the actual movement. It then sends information to the brain (via the SCP) and tells the
brain if the movement was accurate.

The cerebellum also has important connections with the vestibular system and with the cranial nerves that control
eye movements (3, 4, and 6). Diseases or lesions of the cerebellum result in ataxia (irregularity of voluntary
movements) nystagmus (rhythmic, oscillatory and involuntary eye movements).
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VI. Spinal Cord

The spinal cord is in the vertebral canal, and in the adult human, extends from the foramen magnum to the L1-2
vertebral level. This is explained by the fact that during development, the bony vertebral column grows more rapidly
than the spinal cord that it encloses. Hence, vertebral levels and spinal levels do not correspond, especially in the
lumbar and sacral regions. The tapering end of the spinal cord at L1-2 is known as the conus medullaris.
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3 months 4 months 5 months 7 months

The spinal cord is divided into 31 segments as follows:

• 8 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 1 coccygeal

Cervical nerves C1-C7 exit above their corresponding vertebrae, while C8 exits above vertebrae T1. This occurs since
there are C1-C8 cervical nerves, but there are only C1-C7 cervical vertebrae. All cervical nerves below C8 exit below
their corresponding numbered vertebrae (i.e. cervical nerve C6 exits above vertebrae C6; T6 exits below vertebrae
T6).

Dorsal and ventral roots exit the spinal cord at each spinal level. The dorsal roots carry sensory information into the
spinal cord, while the ventral roots carry motor and autonomic information away from the spinal cord. Both dorsal
and ventral nerve roots are located within the bony intraspinal canal. The dorsal and ventral roots join a short
distance from the spinal cord to form a spinal nerve. Since the spinal cord ends at L1-2, lumbar and sacral nerve roots
must travel caudally a certain distance before exiting the vertebral canal. This collection of nerves is known as the
cauda equina (horse’s tail).
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The spinal cord consists of both gray matter, which contains collections of cell bodies, and white matter, which
contains myelinated ascending and descending fiber tracts. The gray matter is found centrally in the spinal cord,
arranged in a “butterfly” or H-shaped pattern. The white matter surrounds the gray matter and thus is found
peripherally in the spinal cord. Notice that this is the opposite of the cerebral cortex representation, where the gray
matter is found on the surface. The gray matter is divided into a dorsal horn that receives sensory information, and a
ventral horn that contains the cell bodies of the lower motor neurons (anterior horn cells), which send motor
information to the extremities.
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• A mass lesion that compresses the spinal cord results in a myelopathy with spastic weakness below the level
of the lesion; a mass lesion that compresses a nerve root results in a radiculopathy with sharp shooting pain
and weakness in the distribution of the nerve root.
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