Skull foramen Traversing structures

Anterior cranial
Cribriform plate CN I olfactory bundles
fossa
Optic canal CN II, ophthalmic artery, central retinal vein
CN III, IV, V1, VI, ophthalmic vein, sympathetic
Superior orbital fissure
fibers
Middle cranial fossa
Foramen rotundum CN V2 (maxillary)
Foramen ovale CN V3 (mandibular)
Foramen spinosum Middle meningeal artery & vein
Internal acoustic
CN VII, VIII
meatus
Posterior cranial Jugular foramen CN IX, X, XI, jugular vein
fossa Hypoglossal canal CN XII
Spinal roots of CN XI, brain stem, vertebral
Foramen magnum
arteries
CN = cranial nerve.
 Major functions of hypothalamic nuclei
Ventromedial Mediates satiety; destruction leads to hyperphagia
Lateral Mediates hunger; destruction leads to anorexia
 Anterior Mediates heat dissipation; destruction leads to hyperthermia
Posterior Mediates heat conservation; destruction leads to hypothermia
Arcuate Secretion of dopamine (inhibits prolactin), GHRH
Medial preoptic Secretion of GnRH, regulates sexual behavior
Paraventricular Secretion of oxytocin, CRH, TRH & small amounts of ADH
Supraoptic Secretion of ADH & small amounts of oxytocin
Suprachiasmatic Circadian rhythm regulation & pineal gland function
ADH = antidiuretic hormone; CRH = corticotropin-releasing hormone; GHRH = growth
hormone-releasing hormone; GnRH = gonadotropin-releasing hormone; TRH = thyrotropin-
releasing hormone.

Tremor Clinical features

 Action tremor
 Bilateral hands &/or head
Essential
 Improves with alcohol

 Resting tremor (decreases with movement)

 Hands & legs
Parkinson  "Pill-rolling"
disease  Associated parkinsonian features (eg, rigidity, masked faces, short-
stepped gait)

 Action tremor (increases as hand reaches target)

Cerebellar  Associated ataxia, dysmetria, or gait disorder

 Action & rest tremor

 Low amplitude, high frequency (ie, "fine" tremor)
 Not visible under normal circumstances
Physiologic
 Enhanced with sympathetic activation (eg, anxiety, caffeine,
hyperthyroidism)
 Eye muscle(s)
Nerve Oculomotor functions Lesion findings
innervated
 Superior rectus  Adduction  Eye deviated downward
 Medial rectus  Depression & laterally
 Inferior rectus  Elevation  Diagonal diplopia
Oculomotor  Inferior oblique  External rotation  Dilation of pupil & loss
(CN III)  Levator of accommodation
palpebrae  Ptosis
superioris

 Superior oblique  Abduction  Eye deviated upward

 Internal rotation  Vertical & torsional
Trochlear
 Depression diplopia
(CN IV)
while adducted

Abducens  Lateral rectus  Abduction  Eye deviated medially

(CN VI)
  Horizontal diplopia

Occulomotor: It also contributes parasympathetic innervation to the ciliary muscle and iris
sphincter for the efferent path of the pupillary reflex.
Motor innervation of the tongue is provided by the hypoglossal nerve (cranial nerve [CN] XII)
with the exception of the palatoglossus muscle, which is innervated by the vagus nerve (CN X)..
The subthalamic nucleus plays an important role in the modulation of basal ganglia output.
Damage to this structure (eg, due to lacunar stroke) may result in contralateral hemiballism,
characterized by wild, involuntary, large-amplitude, flinging movements of the proximal limbs
(eg, arm and/or leg) on one side of the body.
 Pharmacologic control of uterine tone
Effect on uterine
Drug Mechanism
tone
Inhibits cyclooxygenases, preventing prostaglandin
Indomethacin Decreases
production
Inhibits L-type calcium channels, preventing
Nifedipine Decreases
extracellular calcium influx
Stimulates B2-adrenoreceptor (Gs-linked GPCR),
Terbutaline Decreases leading to cyclic AMP–mediated inhibition of
MLCK
Inhibits L-type calcium channels, preventing
Magnesium sulfate Decreases
extracellular calcium influx
Stimulates oxytocin
Oxytocin Increases
receptors (Gq-linked GPCRs), leading
Misoprostol (PGE1) Stimulates to release of sarcoplasmic
Dinoprost (PGE2) Increases prostaglandin receptors calcium
Carboprost (PGF2α) (eg, EP1, FP)
GPCR = G-protein–coupled receptor; MLCK = myosin light-chain kinase; PGE =
prostaglandin E;

PGF = prostaglandin F.

Methylergonovine, an ergot alkaloid, is used to increase uterine contractions (uterotonic) through

its activity on the 5-HT2A receptor. It can be used to treat postpartum hemorrhage by stimulating
the myometrium to clamp down on uterine vessels.
Absent grasp reflex
objective:
Injury to the C5 and C6 nerve roots causes Erb-Duchenne palsy, which is characterized by
waiter's tip posture. The affected arm may have decreased or absent Moro and biceps reflexes;
grasp reflex remains intact.
The obturator nerve innervates the medial compartment of the thigh. Injury presents with
weakness of hip adduction and decreased sensation at the medial thigh; it may be injured in
pelvic (eg, bladder) surgery but is not at risk in hernia repair.
The ischial spine tip is a landmark for pudendal nerve block, which is used for anesthesia during
vaginal deliveries and for minor surgeries of the vagina and perineum.
An Frontal eye field : ischemic lesion in this area would lead to gaze deviation toward the side of
the lesion (ie, rightward deviation if the right hemisphere is impacted).
 Neurotransmitter systems of the CNS
Neurotransmitter & receptor pair Functions in the CNS
Ionotropic: Ligand-gated ion channels
Transmembrane proteins that allow ions to cross the membrane
Glutamate [E]
Long-term potentiation of learning & memory
→ NMDA receptor: Ca2+ & Na+ influx
GABA [I]
Sedation, anxiolytic & anticonvulsive
→ GABAA receptor*: Cl− & HCO3− influx
Glycine [I]
Inhibit spinal interneurons (prevents spasticity)
→ Glycine receptor: Cl− influx
Metabotropic: G protein-coupled receptors
Act through second messengers (eg, cAMP, PKA)
Dopamine
Modulate attention, movement & reward
→ D1-5 receptors
Serotonin Modulate mood, nausea & trigeminovascular
→ 5-HT receptors** nociception (migraine)
Norepinephrine
Promotes vigilance, attention & emotional memory
→ α & β adrenoceptors
Histamine
Promotes wakefulness
→ H3 receptors
*GABAB is a G-coupled metabotropic receptor that increases K+ efflux (hyperpolarization).

**Except 5-HT3 receptor, an ionotropic receptor that primarily increases Na+ influx
(depolarization).

[E] = excitatory (postsynaptic potential); [I] = inhibitory postsynaptic potential; cAMP = cyclic
adenosine monophosphate; PKA = protein kinase A.
Right phrenic nerve injury is typically recognized by elevation of the right hemidiaphragm.
The spinal root of the accessory nerve (cranial nerve XI) courses sup riorly from the upper spi
nal cord through the foramen magnum to join with the cranial root. The combined
roots then exit the cranium through the ju ular foramen to provide motor innervation to the ster
nocleidomastoid and trapezius muscles. There is risk of injury during biopsy

r ymph node dissection in the neck, but not during procedures involving the right atrium.* The sp
inal accessory nerve is vulnerable to injury in the posterior triangle of the neck. Injury
results in weakness of the trapezius muscle, which presents with drooping of the shoulder

** The serratus anterior is innervated by the long thoracic nerve and protracts and rotates the
scapula upward, assisting with elevation of the arm over the head. Although weakness of the
serratus anterior causes winging of the scapula, it usually occurs following axillary lymph node
dissection and would not be associated with shoulder droop.
The trochlear nucleus is located in the caudal midbrain, and the nerve exits the dorsal midbrain
just below the inferior colliculus (below the red nucleus). The trochlear nerve is the only cranial
nerve to decussate before innervating its target (superior oblique muscle).
 Functions of cellular organelles
 Protein modification, sorting & transport
Golgi apparatus
 Digestion of cellular debris & pathogens
Lysosomes
 TCA cycle & fatty acid oxidation
 Electron transport chain (ATP synthesis)
Mitochondria
 Apoptosis

 Oxidation of very long & branched-chain fatty acids

Peroxisomes  Hydrogen peroxide degradation

 Degradation of ubiquitinated proteins

Proteasomes
Rough endoplasmic reticulum
Smooth endoplasmic reticulum
 Synthesis of integral membrane & secretory proteins
 Drug detoxification
 Lipid, phospholipid & steroid synthesis
Dense perivascular aggregates of atypical lymphoid cells are a histologic feature of primary CNS
lymphoma, which is typically a diffuse large B-cell lymphoma. Although clinical symptoms
may include seizures, it usually presents in older adults or immunocompromised patients. MRI
would likely reveal an enhancing mass.
laden lipid laden macrophages with phagocytized myelin debris are seen in the demyelinating
plaques of multiple sclerosis. Symptoms are variable but commonly include unilateral visual
disturbance (eg, optic neuritis) and focal sensory and motor deficits. MRI typically reveals
periventricular white matter lesions.
An interscalene nerve block is used to provide anesthesia for the shoulder and upper arm by
anesthetizing the upper brachial plexus (C5-C7) as it passes between the anterior and middle
scalene muscles. Anesthetic also transverses along the interscalene sheath, frequently resulting
in transient ipsilateral diaphragmatic paralysis due to involvement of the phrenic nerve roots
(C3-C5).
* General sensation in the anterior tongue is carried by the lingual nerve. It is also a branch of
CN V3, but it arises proximal to the inferior alveolar nerve branch. It passes between the medial
pterygoid muscle and the ramus of the mandible (not into it), then through the floor of mouth
where it crosses (and can be injured in procedures involving) the submandibular gland duct.

* Taste sensation in the anterior tongue is mediated by the chorda tympani nerve, a branch of the
facial nerve (CN VII) that travels with the lingual nerve.

The hypoglossal nerves (CN XII) innervate the genioglossus muscles, which are responsible for
tongue protrusion. Injury to the right hypoglossal nerve (most commonly during carotid
endarterectomy) would cause ipsilateral genioglossus weakness with deviation of the tongue to
the right during protrusion.
 Intracranial hemorrhage
Epidural hematoma Subdural hematoma Subarachnoid hemorrhage
Aneurysm or arteriovenous
Vessel typically malformation of anterior or
Middle meningeal artery Bridging cortical veins
involved posterior communicating
arteries or MCA
Between skull & dura Between dura mater & Between arachnoid mater &
Location
mater arachnoid mater pia mater
Acute: coma at onset
Severe headache ("worst
Clinical Lucid interval, followed
Chronic: gradual onset headache of my life"), nuchal
manifestation by loss of consciousness
of headache and rigidity
confusion
Presentation on Crescent-shaped
Biconvex hematoma Blood in the basal cisterns
CT scan hematoma
MCA= middle cerebral artery.
typically appear as symmetric, bilateral wedge-shaped strips of necrosis over the cerebral
convexity, parallel and adjacent to the interhemispheric fissure.
The inferior division of the middle cerebral artery (MCA) supplies the lateral portions parietal
and temporal cortices. Occlusion typically causes sensory deficits of the arm and face, with
sparing of motor function. In addition, visual field defects, Wernicke aphasia (dominant
hemisphere), and profound hemineglect

** The superior division of the MCA impacts the frontal lateral cortex, resulting in motor and,
sometimes, sensory deficits that impact the face and arm. Broca aphasia (dominant hemisphere)
is common. Hemineglect (nondominant hemisphere) is variable.

** Occlusion of the proximal MCA (ie, MCA stem infarct) results in profound defects due to the
large area impacted. Deficits include hemiparesis, hemianesthesia, global aphasia (dominant
hemisphere), hemineglect (nondominant hemisphere), gaze preference, and visual deficits
(homonymous hemianopia).
 Neuroleptic malignant syndrome
 Fever (>40 C common)
 Confusion
Signs/symptoms  Muscle rigidity (generalized)
 Autonomic instability (abnormal vital signs, sweating)

 Stop antipsychotics or restart dopamine agents

 Supportive care (hydration, cooling), intensive care unit
Treatment
 Dantrolene or bromocriptine if refractory
Hematomas over the mastoid process (Battle sign), along with periorbital ecchymosis and clear
otorrhea, are signs of basilar skull fractures