Dr.

Mohammad Al-Salem Parrt Summary

Done by : Amal Saeed Odeh

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 Organization of nervous system

CNS PNS

BRAIN 31 SPINAL NERVE

SPINAL CORD 12 CRANIAL NERVE

Somatic Autonomic Sensory Motor

Sensory Sensory
Muscles Receptors in visceral
organs
Joints

Skin Motor
Special sensations Involuntary ( smooth
except taste and cardiac muscles )
and glands
Motor
Voulantary ( skeletal
muscles )

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 Meninges
Outermost layer; continuous with Dense irregular connective tissue from the level of the foramen
Dura mater epineurium of the spinal nerves magnum to S2 , Closed caudal
end is anchored to the coccyx by
the filum terminale externum
Adheres to the inner surface of Thin web arrangement of delicate ------------------
Arachnoid mater the dura mater collagen and some elastic fibers.
Bound tightly to surface OF Thin transparent connective Forms the filum terminale ,
Pia mater SPINAL CORD tissue layer that adheres to the anchors spinal cord to coccyx
surface of the spinal cord and Forms the denticulate ligaments
brain that attach the spinal cord to the
arachnoid mater and inner
surface of the dura mater

Spaces
space between the dura mater Fat-fill Anesthestics injected here
Epidural and the wall of the vertebral
canal

Between dura and arachnoid serous fluid ------------------

Subdural space

between pia and arachnoid Filled with CSF Lumbar puncture at supracristal
Subarachnoid line at level of L3-L4

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 Receptors

Mechanoreceptors Thermoreceptors Nociceptors

Free nerve endings Free nerve endings

Meissner’s Merkel’s End organ Pacinian Detect change in Detect damage (pain
corpuscle disc (Tactile of Ruffini corpuscles temperature receptors)
Disc)
TRP channels Multimodal
Respond to Discriminative sensitive to skin Vibrations (high
touch, pressure touch stretch frequency)
and low
frequency Slowly Slowly rapidly
vibration (low adapting adapting adapting
frequency)

rapidly
adapting

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 Ascending sensory tracts

Medial Lateral Anterior Spinotectal Posterior Anterior

lemniscal spinothalamic spinothalamic tract spinocerebellar spinocerebellar
pathway tract tract tract tract
This is a sensory tract
Discriminative Touch Modality: transmits Modality: crude touch that relays information Modality: muscle and Modality: muscle and
Sensation , Conscious pain and temperature. and pressure from the spinal cord joint sensation joint sensation
proprioception (spino) to the tectum (unconscious (unconscious
(Conscious muscle Receptors: Free nerve Receptors: free nerve (tectal) , for proprioception) proprioception)
joint sense) endings (the opposite endings spinovisual reflexes
of the posterior Receptors: same as 1 st order neuron axons
Receptor: Most types column) 1 st Neuron: Dorsal dorsal column system terminate at the base of
the 1st order neurons
of receptors (like root ganglia (Most receptors except post gray column
start at the organs
free nerve endings) (nucleus dorsalis)
spindles and GTO) 1st Neuron: The cell involved in the
2 nd Neuron: the
except free nerve bodies lie in the Dorsal collection of • Two pathways for the
posterior horn of gray
endings root ganglia doesn’t go information for the 1 st order neuron axons: 1- the majority of
column specifically in axons of 2nd order
to the posterior white spinovisual reflexes, axons terminate at the
1st order Neuron: cell nucleus proprius which neurons cross to
column, it synapses the cell bodies for base of post gray
bodies lie in the Dorsal represents laminae 3 opposite side and ascend
with the 2nd neurons’ them is, again, in the column (nucleus
Root Ganglion and 4 of the gray as anterior
cell bodies directly in dorsal root ganglia. dorsalis or Clarks
ipsilaterally till they matter , cross spinocerebellar tract in
the dorsal horn in The 2nd order neurons nucleus in lamina 7) •
obliquely to the the contralateral white
reach the lower part of substantia gelatinosa synapses with the 1st the axons of 2 nd order
opposite side in the column. 2- the minority
medulla oblongata then cross obliquely to order neurons early in neurons enter of axons ascend as
anterior gray and
the opposite side the spinal cord, and posterolateral part of anterior spinocerebellar
2nd Neuron:lower part white commissures,
passing through the then the axons of the the lateral white tract in the lateral white
of medulla oblongata ascending in the
anterior gray and 2nd order neurons matter column on the column of the same side.
(decussation ) contralateral white
white commissures cross the midline and same side. • ascend • Ascend as anterior
column as the Anterior spinocerebellar tract to
3rd Neuron: Thalamus ascend contra-laterally ipsilaterally as the
3rd neuron pathway: spinothalamic tract. medulla oblongata and
(VPL) to area 312 in the anterolateral posterior
Thalamus to either pons. • Terminates in
3 rd Neuron: Thalamus white column of the spinocerebellar tract
area 312 (3b) , The cerebellar cortex,
(VPL) Internal Capsule , spinal cord, lying close to medulla oblongata.
Reticular formation (through superior
Corona Radiata. 5 to the lateral • Terminates in
(slow pain) , Cingulate cerebellar peduncle). the
AMAL SAEED
Termination: Primary ODEH cerebellar cortex
gyrus (emotional aspect spinothalamic tract. fibers that crossed over
Somesthetic Area (SI) This tract terminates in (through inferior in spinal cord cross back
of pain) , Insular gyrus
the superior colliculus cerebellar peduncle) within cerebellum
(autonomic response)
 Lateral & Anterior spinothalamic Spinotectal tract
Medial limniscal pathway
tract
The main
Bodies of 3 the thalamus. The difference
fibers pass through the internal is that the
capsule. Then they radiate lateral
through the space until they reach have 1st
the cortex (postcentral gyrus). neuron Terminate in
synapse superior
with the colliculus
2nd neurons’ bodies
second
lie in the nucleus
neuron in
cuneatus and
substantia
nucleus gracilis.
gelatinosa
Their fibers (internal
, while for
arcuate fibers) form Ascends Synapsing of 1st
Bodies of 1st the
the medial conralaterally order neuron with
neurons lie in anterior
lemniscus and in anterolateral 2nd order neuron in
the dorsal root will be in
ascend white column spinal cord then
ganglia. They nucleus
contralaterally cross the midline
ascend proprius
towards the
ipsilaterally thalamus.

Posterior spinocerebellar tract Anterior spinocerebellar tract

Majority ascend as
anterior
spinocerebellar tract
Ascends lateral in the contralateral
white matter white column then
column on the same they cross again at
side level of cerebullum ,
minority , s ascend
1 st order neuron as anterior
axons terminate at spinocerebellar tract
the base of post gray in the lateral white
column (nucleus column of the same
dorsalis or Clarks side
nucleus in lamina 7 )
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Types
according to
origin
Cutaneous pain:
originates from the skin
and is felt on it
Deep somatic pain:
originates in a relatively
large area representing
the affected muscles,
bones, joints & ligaments,
dull diffuse
Intermittent claudication:
a muscle pain which
occurs during exercise
classically in the calf
muscles due to peripheral
artery disease
Visceral pain: the origin
for this type of pain is the
internal organs, it’s poorly
localized & transmitted
via C fibers (slow pain)
Occur due to : Distention ,
Ischemia , Spasm ,
Chemical damage
Pain
Referred pain Control of
pain
Referred pain is when the
pain you feel in one part
of your body is actually Gating theory: (inhibition of the
caused by pain or injury pain by another mechanical
in another part of your stimulus). At the site where the pain
body fiber enters the central nervous
system, inhibition could occur by
means of connector neurons excited
convergence theory:
by large, myelinated afferent fibers
Referred pain is
carrying information of nonpainful
presumed to occur
touch and pressure.
because the information
from multiple nociceptor
Descending control (VIP):
afferents converges into
individual spinothalamic • Spinoreticular fibers (coming from
tract neurons. spinothalamic fiber (pain fiber))
stimulates periaqueductal gray in mid
brain (PAG) • Excitatory neurons of
PAG projects to Nucleus raphe
magnus (NRM) • (NRM) neurons
produces serotonin which activates
inhibitory neurons that secretes
enkephalins and the endorphins
(morphine like actions) in substantia
gelatinosa. This leads to termination
of pain.
Note: Locus coeruleus (in Pons) is
7 thought to directly inhibit
AMAL SAEED ODEH substantia gelatinosa neurons
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 Descending motor tracts

Pyramidal tract Extra Pyramidal tract

Both anterior and lateral corticospinal Corticonuclear Tract

tracts start from the precentral gyrus of (Corticobulbar) , Fibers descend
cerebral cortex, mainly area 4 from the cortex (lower ¼) to a Rubrospinal Reticulospinal Tectospinal
Vestibulospinal
nucleus (motor nucleus)
To the brainstem (specifically;
midbrain). Fibers will pass through The Midbrain: Oculomotor (3 rd refers to the red Pontine From pons and From Tectum is the
middle 3/5th of the crus cerebr cranial) & trochlear (4 th nucleus located in reticulospinal tract , medulla beneath the posterior aspect of
cranial). the midbrain at to the anterior floor of 4th ventricle the midbrain
In pones the fibers well scatter between white column , The
▪ The Pons: trigeminal (5 th the level of It descends in the
the pontine nuclei in the anterior fibers stay receive afferent
cranial). superior colliculus anterior white
(basilar) part uncrossed , This (sensory) fibers
tract is tonically from: ➢ The inner column close to
▪ Ponto-medullary junction
medulla oblongata, and fibers will Red nucleus active, activate the ear, from the
anterior median
(between the pons and
recollect again and form the anterior receives input axial and proximal vestibule So, it’s fissure
medulla): abducent (6 th
aspect of the medulla which is the from cerebral limb extensors
cranial) & facial (7 th cranial). responsible for the
pyramid Its function: The
cortex and the sense of balance.
▪ The Medulla: 9-12th cranial reflex movement of
cerebellum Medullary
In the lower part of the medulla, fibers nerves the head & neck in
reticulospinal tract , Input from deep
will split up: A. Majority of the fibers response to visual
Very early In the lateral white cerebellar nucleus
(85% approximately) will cross-over to However, the corticonuclear stimulus.
crossing (at the column , Some (Fastigial nuclei)
the opposite side (primary motor tract input is neither ipsilateral (visuospinal reflex)
decussation). These fibers are called level of the fibers cross and
nor contralateral, it’s
lateral corticospinal tract. B. The rest nucleus some do not cross, This tract descends the majority of
BILATERAL , But we have 2
(15%) descend ipsilaterally and are NOT tonically active uncrossed through fibers of this tract
exceptions to the bilateral Its function is to
called anterior corticospinal tract , Inhibit the axial the anterior white terminate in the
corticonuclear input:Part of facilitate the and proximal limb column anterior gray
facial nerve (7 th cranial) which activity of flexors
level of the spinal cord: A. The lateral extensors column of upper
supplies the LOWER facial
corticospinal tracts descend in the (excitatory) and This tract descends cervical segments of
muscles. Part of the
lateral funiculus of the spinal cord to the inhibit the activity uncrossed through spinal cord
hypoglossal nerve (12th cranial)
lateral part of the anterior horn and which supplies the genioglossus
of extensors the anterior white
then supply the lateral muscles. B. The (inhibitory) column
muscle. These exceptions are
anterior corticospinal tracts cross-over contralateral not bilateral 9
at the level of the spinal cord and go to (same as the spinal AMAL SAEED ODEH
the medial part of the anterior horn to
supply the axial muscles
 Corticospinal tracts

A : cortex , frontal lobe

B : internal capsule

C: midbrain , Fibers will pass through middle

3/5th (1/5th medial & 1/5th lateral are
preserved) of the crus cerebr
D: pones , where the fibers well scatter
E: medulla oblongata, and fibers will recollect between the pontine nuclei in the anterior
again and form the anterior aspect of the (basilar) part
medulla which is the pyramid.

F: lower part of medulla oblongata, Majority
of the fibers (85% approximately) will cross-
over to the opposite side (primary motor
decussation). These fibers are called lateral
corticospinal tract.
The rest (15%) descend ipsilaterally and are
called anterior corticospinal tract.
G: at the level of the spinal cord: A. The
lateral corticospinal tracts descend in the
lateral funiculus of the spinal cord to the
lateral part of the anterior horn and then
supply the lateral muscles.
The anterior corticospinal tracts cross-over at
the level of the spinal cord and go to the
medial part of the anterior horn to supply the
axial muscles

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Corticonuclear tracts

Midbrain
Pons
Ponto-medullary
junction
Medulla

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 Extrapyramidal tracts

Rubrospinal tract Reticulospinal tract Vestibulospinal tract Tectospinal tract

Anterior white column

Pons Anterior white column Anterior white column ,

Anterior white column next to median fissure

Medullary
Lateral white column

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 Lamina of motor tracts

Lamina 8 Lamina 9 Lamina 10

motor interneurons, Surrounds the central

Commissural nucleus canal – the grey
Ventromedia Dorsomedial Ventrolatera Dorsolateral Reterodorsolate Central commissure. Its
l l ra function is still not
: all segments T1-L2 C5-C8 (arm), C5-C8 (In the Phrenic clear and controversia
(extensors of (intercostals L2-S2 (thigh) (Forearm), enlargements) nerve (C3-
vertebral and L3-S3 (Leg) C8-T1 (Hand), C5) →
column) abdominal S1-S2 (foot) → activates
muscles) these are lower motor
responsible for neuron that
skilled supplies the
movement diaphragm

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 Skeletal muscle innervation

Activation of alpha motor neurons:

Stretch: Muscle spindle is sensitive to stretch
Directly: from supraspinal centers, through
which means that when the length of the muscle
the descending motor pathways (UMN).
increases it gets activated then it will synapse
Indirectly: through activated muscle directly with the lower motor neuron that goes
spindles to the same muscle then the muscle will contract
and that to preserve muscle tone

Nuclear bag: the nuclei converge in the center like a bag, supplied by dynamic
gamma fibers

Nuclear chain: the nuclei converge in the center like a chain, supplied by static
gamma fibers

Primary afferent fibers: take sensation from both nuclear bag and chain , They
have large diameter and high velocity (rapidly adapting) and is responsible for
dynamic stretch reflex which happens in jerks

Secondary afferent fibers: take sensation from nuclear chain only , They have
smaller diameter and lower velocity (slowly adapting) and is responsible for static
stretch reflex which is important in muscle tone.
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Bulk of muscles
Tone of muscles
Power of muscles
Reflexes
Fasciculation , alternating contracting and relaxation in
the same muscle as the twitching of the eyelid
Babinski sign , When a doctor stimulates the sole of the Present
foot (specifically the lateral aspect) with a blunt object, the
normal response is flexion of the toes But in cases of UMN
lesions what occurs is the opposite
Clasp-knife reaction , where the patient would have a Present , Initial resistance: Exaggerated stretch
flexed muscle and when the doctor tries to extend the arm
of the patient initially there will be resistance but if he
persists and applies enough force there will be “sudden
release” and the arm will extend
Clonus , In testing for clonus the doctor would attempt to Present
dorsiflex the foot and would face resistance (remember
what we said above) and when he applies enough force
clonus happens which is rhythmic contractions and
relaxation of muscles when they are subjected to sudden
sustained stretch caused by exaggerated reflexes
Motor lesions
Upper motor neuron lesion
No wasting
Tone increases (Hypertonia) , result of an
increase in gamma motor neurons activity
Paralysis affects movements of group of
muscles Spastic/ clasp knife , muscle becomes
hypertonic and has exaggerated reflexes
Exaggerated (Hyperreflexia) , because usually,
the effect of the cortex in general on the reflexes is
inhibitory , result of an increase in gamma motor
neurons activity
Absent
reflex and Sudden release: Caused by activation of
Golgi tendon reflex also called anti-stretch reflex,
which resists excessive contraction in the muscle
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Lower motor neuron lesion
Wasting of the affected muscles (atrophy)
Tone decreases (Hypotonia) , because you
cut all innervation to the muscle
Individual muscles is paralyzed Flaccid
(flaccid paralysis) ¸due to hypotonia and
hyporeflexia , because you cut all innervation
to the muscle and muscles are relaxed
diminished or absent
(Hyporeflexia)because you cut all innervation
to the muscle
Present
Absent
Absent
Absent
 Clinical applications
Decerebrate Decorticate lamination of the Destruction of the Destruction of the Syringomyelia Brown-Séquard
ascending tracts LSTT posterior column Syndrome
if the lesion was the lesion is higher Any external Loss of pain and Loss of muscle-joint Cavitation of the Functional
lower than the level than the red nucleus pressure exerted on temperature sense, position central canal in the hemisection of the
of red nuclus it’s the spinal cord in sensation on the sense, vibration spinal cord (increase spinal cord (damage
decerebrate In decorticate there is the region of the contralateral side sense, and tactile in size of the canal) that involved half the
rigidity in the entire spinothalamic tracts (due to decussation discrimination could be due to any spinal cord), this will
in decerebrate, there body and the lower will first experience which happens at ipsilaterally (because reason cause damage to the
is also complete limbs are extended a loss of pain and the level of the the decussation corticospinal tract,
rigidity and both the while upper limbs are temperature spinal cord) below happens above at this will cause ALS, posterior
lower limbs and the flexed and rigid sensations in the the level of the the level of the bilateral loss of pain columns
upper limbs are sacral dermatome lesion medulla oblongata, and thermal
extended Decorticate posture of the body so the damage sensations Contralateral loss of
(lesion above red happened before the nociceptive and
Decerebrate posture nucleus so you Intramedullary crossing over) below In some cases this thermal sensations
(lesion below the red affected\removed the tumor: affect the the level of the cavitation extends to over the body below
nucleus) the cortex, from the cervical fibers lesion the anterior horns, the level of the
rubrospinal tract is name), remember (Medial) causing muscle lesion. Ipsilateral loss
part of the lateral what we said above weakness and even of discriminative
motor system and is about the pontine Extramedullary paralysis sometimes, tactile, vibratory,
responsible for the reticulospinal tract tumor would affect if the syrinx (cavity) and position sense
flexion of muscles in and that it is tonically lower limb fibers extends to one over the body below
upper limbs so if it is active and removing (lateral) anterior horn, this the level of the
lost, there will be an the cortex causes will cause an lesion. Ipsilateral
extension of the more activation so its Sacral sparing: ipsilateral weakness paralysis or
upper and lower effect is more Occur at if both anterior weakness
limbs prominent and it intramedullary horns are involved, (hemiparesis,
causes activation of tumor the weakness will be hemiplegia)
decerebrate is worse extensors in the leg bilateral
because the lesion is and flexors in the arm
closer to the vital (antigravity muscles)

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AMAL SAEED ODEH
 Arterial blood supply of spinal cord
centers ( CVS & RS )
so prognosis is worse
enter intervertebral foramen,
arise from: - Vertebral arteries
and deep cervical arteries (in the
neck)

- Posterior intercostal arteries (in

the thorax).

- lumbar arteries (in the

abdomen)

Posterior radicular artery (runs

with posterior "dorsal" root to
reach spinal cord). Anterior
radicular artery (runs with
anterior "ventral" root to reach
spinal cord). Segmental medullary
artery (anastomose with anterior
spinal artery

Posterior spinal arteries and usually on the left side, from the
arterial vasocorona: the left posterior intercostal artery at
posterior columns and the level of the 9th to 12th
peripheral parts of the lateral intercostal artery, which braches
and anterior funiculi from the aorta and supplies the
lower two third of the spinal cord
Anterior spinal artery: Most of
the gray matter and the This will reinforce the arterial
adjacent parts of the white supply to the lower portion of the
matter spinal cord (far from circle of
Willis)
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AMAL SAEED ODEH - Anastomose with anterior spinal
artery
Venous drainage of spinal cord Central cord syndrome

occlusion in the blood supply of the anterior spinal

artery, which often occur in the case of neck hyperextension.
This results in bilateral weakness in extremities, more in upper than
lower extremities
Also, its characterized by bilateral pain and thermal sensation loss,
bladder dysfunction
Why Bilateral weakness? Because remember that we have one
anterior spinal artery that supply both right and left side.
Why upper extremities are affected more than lower? Because the
origin of the anterior spinal artery is from the vertebral artery, so its
blood supply is coming from above so its affected more,
furthermore the lower extremities receive blood supply from other
sources (like Artery of Adamkiewicz)

Two pairs of
Compromise of blood flow in the posterior spinal
pairs on each
side artery results in: Ipsilateral reduction or loss of discriminative,
positional, and vibratory tactile sensations at and below the
segmental level of the injury
Those veins will drain into an extensive internal
vertebral plexus in the extradural (epidural) space
of the vertebral canal, then drains into
segmentally arranged vessels that connect with
major systemic veins like azygos system in the
thorax or intracranial veins.

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AMAL SAEED ODEH

Lateral leminiscus
cant be seen at this
level , its route is
toward inferior
colliculus
Tectum Superior colliculus
Cerebral aqueduct
Tegmentum
Mesencephalic nucleus of trigeminal
Nucleus of oculomotor nerve
Curs cerebri Medial longitudinal fasciculus
Red nuleus
Decussation of rubrospinal tract

Medial , spinal , Mesencephalic nucleus of trigeminal

Trochlear nerve
trigeminal & lateral Trochlear nucleus
decussate in
leminisci Reticular formation
superior medullary
velum Substansia Deccusation of superior cerebellar peduncle
nigra
Medial longitudinal fasciculus

Superior cerebellar peduncle

Lateral leminiscus is Motor nucleus of trigiminal

lateral extremity of Main sensory nucleus of trigiminal
medial one Medial leminiscus Spinal leminiscus

Trapezoid body

Tegmentum Medial vistubular nucleus

Nucleus of Medial longitudinal fasciculus
abducent nerve Motor nucleus of facial nerve
Medial lemniscus
Spinal nucleus of
Basal part
trigiminal
Pontine nuclie

Posterior cochlear nucleus

lateral vistebular nuclus (8th)
Anterior cochlear nuclus

Medial & inferior vistebular nucleus (8th)

Inferior cerebellar
peduncle Nucleus of tractus solitarius
Tectospinal tract Dorsal vagual nucleus (10th)
Hypoglossal nucleus (12th)
Nuclus ambiguus
Medial longitudinal fasciculus
Medial leminiscal
Inferior olivay nuclus
pyramids
Fasciculus gracilis
Nuclus gracilis
Fasciculus cuneatus
Spinal nuclus of Nuclus cuneatus
spinal lemniscus lateral to the Internal arcuate fibers
trigeminal
decussation of the lemnisci , The Leminiscal decussation
Central canal
spinocerebellar vestibulospinal, and
the rubrospinal tracts (anterolateral)
Pyramids
Fasciculus gracilis
Fasciculus cuneatus
Spinal nuclus of trigeminal
Lateral and anterior white
Central canal
Columns of spinal cord is unchanged Decussation of pyramids

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AMAL SAEED ODEH
 Brain Stem

GENERAL INFORMATION
The brainstem also has vital centers in reticular formation in the core.

Pons is a bridge connect the cerebrum and cerebellum (it is not a bridge a between medulla oblongata and
midbrain).

MEDULLA OBLONGATA
The medulla oblongata is divided into 2 halves: Lower half is called closed medulla because it has a small cavity called
central canal (the same as the central canal of the spinal cord) and upper half is called opened medulla because it has
a large cavity called 4th ventricle

PONS
In the 4 th ventricle floor (rhomboid fossa), the midline is made by a sulcus known as the median sulcus. Lateral to
the midline, another sulcus can be seen, which is called the sulcus limitans. Between the median sulcus and the
sulcus limitans is the median eminence, which forms the facial colliculus inferiorly.

• Vestibular area (lateral to sulcus limitans and superior to the facial colliculus) is related to underlying structure
which is vestibular nuclei.

• Facial colliculus (inferior end of medial eminence) is related to facial nerves (not nuclei)

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AMAL SAEED ODEH
MIDBRAIN
It lies between the diencephalon and the pons. There are 2 peduncles called cerebral peduncles (NOT cerebellar).
Between the two cerebral peduncles there is the interpeduncular fossa

The cavity of the midbrain is known as the cerebral aqueduct , Posterior to the cerebral aqueduct is the tectum. The
tectum consists of 4 colliculi, 2 superior colliculi and 2 inferior colliculi (seen at posterior view)

Anterior to the cerebral aqueduct is collectively known as the cerebral peduncle, The cerebral peduncle is divided by
the substantia nigra to crus cerebri (anterior) and tegmentum (between cerebral aqueduct and substantia nigra)

Superior brachium (connects the superior colliculus with the lateral geniculate body. (connecting the visual with
visual) , Inferior brachium connects the inferior colliculus with the medial geniculate body.

Substania Nigra
Posterior to the crus cerebri is the susbtantia nigra, which separates it from the tegmentum. It is darkly stained due
to the presence of dopaminergic neurons & the high levels of melanin. Anatomically, it is part of the midbrain.
However, it is part of the basal nuclei functionally

The function of the substantia nigra is to initiate the movement (muscle tone). Degeneration of the substantia nigra
will cause difficulty in initiating movements and is known as Parkinson’s disease. Symptoms of Parkinson’s disease
include tremor and bradykinesia (difficulty in initiating movement) or even akinesia (inability to initiate movement)

Red Nuleus
It is the biggest nucleus in the reticular formation and round mass of gray matter.

The red nucleus named so because of its high vascularity and iron containing pigment)

When you focus on the GOOD

Then the GOOD become BETTER
And you will see it developed to

THE BEST

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 Acoustic Pathway
These fibers will
reach the inferior
colliculus (In
posterior aspect of
midbrain/part of
tectum), then they
will go to the
medial geniculate
body within the
thalamus, and
finally they will
project to the
auditory part of
cortex (temporal
lobe)

From the
trapezoid body,
these fibers
ascend in what is
known as the
lateral lemniscus

The acoustic
pathway starts
from the cochlea
goes to the brainstem (it pass through
in inner ear, from
pontomedullary junction) to reach the
which the
anterior and posterior cochlear nucle Where
cochlear nerve
synapse with 2nd order neuron occurs , Most
(part of
of the 2nd order neurons decussates at the
vestibulocochlear
midline (contralateral) (some stay ipsilateral)
nerve) which has
These fibers that cross the midline are known
its cell body in
as the trapezoid body
the spiral
ganglion of
cochlea
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AMAL SAEED ODEH
 Cranial Nerves

Origins of Cranial nerves (except CN1 & CN2):

The midbrain gives rise to CN3 & CN4

The mid-pontine area of the pons gives rise to CN5

The pontomedullary junction of the pons gives rise to CN6,

CN7, CN8

The medulla oblongata gives rise to CN9, CN10, CN11, CN12

The trochlear nerve (CN4) is the only nerve that arises from
the posterior aspect of the brainstem (midbrain)

The hypoglossal nerve is the only nerve that arises from the
groove found between the olive and the pyramid
(anterolateral groove). Whereas the glossopharyngeal (CN9),
Vagus (CN10), and Accessory (CN11) all arise from the groove
between the inferior cerebellar peduncle and the olive
(posterolateral groove)

Never let your

Fear
decide your

Fate
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AMAL SAEED ODEH
 Cranial Nerves
Nerve Course
Oculomotor The motor and parasympathetic fibers from the two
nuclei will pass through red nucleus without
nerve (CN3) synapse. From the red nucleus, they then pass via
the substantia nigra exiting through the
interpeduncular fossa. Then they enter the middle
cranial fossa in the lateral wall of the cavernous
sinus.The nerve leaves the cranial cavity and enters
the orbital cavity via the superior orbital fissure
between the greater and lesser wing of sphenoid.
Once there, it divides into two branches: superior
and inferior rami, which supply most of the
extraocular muscles ,the parasympathetic
fibers(preganglionic) pass through inferior ramus
and synapse in the ciliary ganglion. They will come
out as postganglionic fibers through short ciliary
nerve which eventually will innervate the intrinsic
muscles of the eye
Trochlear Nerve Nerve Course: Fibers go posteriorly around the
cerebral aqueduct and mesencephalic nucleus and
(CN4) then they emerge from the posterior aspect of the
midbrain. The fibers then turn around crus cerebri
and move along the lateral wall of the cavernous
sinus (along with the oculomotor nerve) entering
the orbit of the eye via the superior orbital fissure to
innervate the superior oblique muscle
Abducent nerve The abducent nerve leaves the brainstem anteriorly lateral rectus muscle of the eye
at the pontomedullary junction medial to the facial
(CN6) nerve. It then enters the cavernous sinus below and
lateral to the internal carotid artery. From there it
enters the orbit through the superior orbital fissure
and innervates the lateral rectus muscle of the eye
24
AMAL SAEED ODEH
Function Nuclei
The oculomotor nerve supplies at level of superior colliculus of midbrain
extrinsic muscles such as the main motor nucleus , posteriolateral to it
levator palpebrae superioris, accessory parasympathetic nucleus of
superior rectus, medial rectus, oculomotor nerve ( the Edinger-Westphal
inferior rectus, and inferior nucleus )
oblique (all eyeball muscles bilaterally fibers receiving
except the lateral rectus and
superior oblique). It also
supplies intrinsic muscles such
as the constrictor pupillae of
the iris and ciliary muscles
The action of the muscles
supplied by the oculomotor
nerve is lifting the upper
eyelid, turning the eye upward,
downward, and medially,
constricting the pupil, and
accommodating the eye
The superior oblique muscle : It has one nucleus (motor nucleus), it receives
depression of the eyeball and inputs from both cortex: Bilateral. - Location
lateral rotation of eyeball. of the nucleus: it is found anterior to the
cerebral aqueduct, at the level of the inferior
colliculi in the midbrain
- Has one motor nucleus found underneath
that turns the eye laterally the floor of fourth ventricle, at the level of the
facial colliculus (caudal part) of the pons. It
receives inputs from both cortex (bilateral).
Trigeminal Nerve The trigeminal nerve originates from three sensory
nuclei and one motor at the level of the pons
(CN5) anteriorly. The sensory nuclei merge to form a
sensory root. The motor nucleus continuesto form a
motorroot(motor runsinferior tosensory). In the
middle cranial fossa they expand into the trigeminal
ganglion. Trigeminal ganglion is located lateral to
the cavernous sinus, in the upper surface of the
apex of the petrous bone in a depression called
Meckel’s cave (which is a pouch in the dura mater)
The divisions of this nerve will go out through: –
Ophthalmic: through superior orbital fissure. –
Maxillary: through foramen rotundumto
pterygopalatine fossa. – Mandibular: through
foramen ovale to infratemporal fossa.
Facial nerve The nerve emerges from the pontomedullary
junction (remember sensory fibers go towards the
(CN7) brain while motor away from the brain), then enters
the internal acoustic meatus in the petrous part of
temporal bone and passes through the facial canal
first behind the medial wall of the cavity of the
middle ear (tympanic cavity) where it curves and
forms the geniculate ganglion (knee), then it
continues in the posterior wall of the tympanic
cavity to finally emerge from the stylomastoid
foramen. It gives two branches in the tympanic
cavity: 1. Chorda tympani: It leaves the middle ear
through the petrotympanic fissure and enters the
infratemporal fossa, then attaches to the lingual
nerve, it carries two types of fibers, preganglionic
parasympathetic from the salivatory lacrimatory
nucleus (submandibular ganglia), and taste fibers
from the anterior two thirds of the tongue. 2.
Greater petrosal: Emerges from the geniculate
ganglion, then passes through the middle ear to
enter the middle cranial fossa through the greater
25
AMAL SAEED ODEH
Receives sensations from all Motor nucleus: Posterior part of the pons
the face except the angle of (Medial) at level of trigeminal nuclei of pons
the mandible which is supplied Main sensory nucleus: Posterior part of the
by great auricular nerve,+ pons (lateral) at level of trigeminal nuclei of
receives sensations from the pons , Discriminative and light touch of the
oral cavity, nasal cavity, face as well as conscious proprioception.
paranasal sinuses (similar to PCML)
Forthe mandibular division Spinal nucleus: ends at midpontine area m
ONLY. It supplies: 1- Muscles of Inferiorly start from C2 segment , Crude
mastication (masseter, touch, pain, and temperature (similar to ALS)
temporalis, medial pterygoid, Mesencephalic nucleus: - Lateral part of the
and lateral pterygoid) 2- gray matter around the cerebral aqueduct. -
Tensor tympani 3- Tensor veli Inferiorly main sensory nucleus Reflex
palatini 4- Mylohyoid 5- proprioception of the periodontal ligament
Anterior belly of thedigastric and of the muscles of mastication in the jaw.
muscle.
Main motor nucleus is found in the deep reticular formation of the lower part of
the pons (level of facial colliculus) The upper part of the face receives upper
motor neurons from both hemispheres. The lower part only receives upper
motor neurons from the contralateral hemisphere
Sensory nucleus: Taste of the anterior two thirds of the tongue: The cell
bodies of the first order neurons are in the geniculate ganglia (from chorda
tympani), and they synapse with the second order neurons in the nucleus of
tractus solitarius, from there it ascends to the VPM nucleus of the thalamus
then radiates to the primary gustatory cortex (area 43) in the parietal lobe.
General sensation from the skin of the external acoustic meatus is carried with
the facial nerve (geniculate ganglion) into the spinal trigeminal nucleus
 petrosal foramen, afterwards it passes over
foramen lacerum and joins the deep petrosal nerve
(sympathetic fibers from the superior cervical
ganglia) to form the nerve to pterygoid canal, which
passes through the pterygoid canal to reach the
pterygopalatine fossa
Glossopharyngeal 1. The glossopharyngeal nerve emerges from the
groove between the olive and the inferior cerebellar
nerve (CN9) peduncle.
2. Descends from jugular foramen to leave the skull
and there it forms two ganglia (superior and
inferior)
3. At the level of the inferior ganglia, it gives a
branch called tympanic branch (preganglionic
parasympathetic fibers)
4. It enters through the tympanic canaliculus to
reach the tympanic cavity where it joins the
tympanic plexus near the tympanic membrane
(that’s a lot of tympanic I know
5. It leaves the tympanic cavity as the lesser
petrosal nerve through the lesser petrosal hiatus to
reach the middle cranial fossa.
6. From the middle cranial fossa, it descends
through foramen ovale to the infratemporal fossa
and synapses in the otic ganglia which is suspended
by the mandibular nerve, and through the
auriculotemporal it reaches the parotid gland
Vagus nerve Course not required; just remember that it can
reach the abdomen
(CN10)
26
AMAL SAEED ODEH
Motor nucleus, deep in the reticular formation of the medulla, arises from the
superior end of nucleus ambiguus, and only supplies the stylopharyngeus
muscle.
2. Parasympathetic nucleus (inferior salivatory nucleus), posterior to nucleus
ambiguus, receives from the hypothalamus (all autonomic from the
hypothalamus) and passes to the otic ganglia (supplies the parotid gland).
3. Sensory nucleus (general, taste, and visceral sensation): Taste from
posterior third of the tongue: cell bodies of the first order neurons are in the
inferior ganglia (special and visceral sensory), then it synapses with the second
order neurons in nucleus tractus solitarius, and from there it ascends to synapse
in the VPM of the thalamus to reach primary gustatory cortex. Visceral
sensation comes from the carotid sinus (baroreceptor). The glossopharyngeal
passes between the internal and external carotid in the neck, and there it
carries the visceral sensation from the carotid sinus. Cell bodies of the first order
neurons are in the inferior ganglia, then they synapse in the nucleus tractus
solitarius which is connected to the dorsal nucleus of the vagus nerve
(parasympathetic of the vagus) which induces the carotid sinus reflex that
reduces the blood pressure. General sensation from the skin of auditory
meatus, middle ear, auditory tube, pharynx except the nasopharynx (maxillary),
and posterior 1/3 of the tongue (common sensation), the cell bodies are in the
superior ganglion, and then it goes to the spinal nucleus of trigeminal (it carries
general sensation from many cranial nerves but primarily from the trigeminal).
1. Motor nucleus (lower part of nucleus ambiguous). Supplies the constrictor
muscles of the pharynx and the muscles of the larynx.
2. Dorsal nucleus of Vagus (parasympathetic), anterior to the floor of the lower
part of the fourth ventricle, it receives afferents from the hypothalamus and
glossopharyngeal nerve (carotid sinus reflex). Efferent to involuntary muscles of
the bronchi, heart, esophagus, stomach, small intestines, and large intestines as
far as the distal one-third of the transverse colon.
3. Sensory nucleus:
 Taste from the epiglottis: carried to the lower part of nucleus tractus
solitarius, cell bodies of the first order neurons in the inferior ganglia (don’t
confuse it with the inferior ganglion of the glossopharyngeal, both have superior
and inferior ganglia).
General sensation: cell bodies of the first order neurons in the superior
ganglia, then to the spinal nucleus of trigeminal. carries sensation from the
outer ear, mucosa of the larynx, and the dura of posterior cranial fossa

Accessory nerve The spinal root ascends to the cranial cavity though foramen magnum to join the Motor and has two roots: cranial and spinal.
cranial root, they then move together (fibers of the two roots don’t mix) and leave 1. Cranial root from nucleus ambiguous. 2.
(CN11) through the jugular foramen. They separate once more and the cranial root joins the Spinal root originates from the spinal cord
vagus nerve and courses along with it, while the spinal descends by itself and supplies (lamina IX from the upper 5 cervical
the trapezius and sternocleidomastoid. *The soft palate is thought to be supplied by segments)
the cranial root
Hypoglossal Emerges between the olive and the pyramid (the Supplies all the muscles of the Has one motor nucleus, Beneath the floor of
other medullary cranial nerves emerge between the tongue except palatoglossus the lower part of the fourth ventricle (at level
nerve (CN12) inferior cerebellar peduncle and the olive). (from the vagus). of olive in medulla oblongata )
Leaves the skull through the hypoglossal canal. Cells responsible for supplying the
Courses between the internal carotid artery and genioglossus muscle receive from the
the internal jugular vein to eventually reach the opposite cerebral hemisphere (not bilateral)
tongue, during its course it attaches to the C1 spinal
nerve but doesn’t mix with it.

27
AMAL SAEED ODEH
 Cranial Nerves Injuries

Nerve Lesions
Oculomotor Complete lesion of oculomotor nerve: Complete cut of the oculomotor nerve. All of the muscles are
nerve (CN3) paralyzed except lateral rectus and superior oblique. , Symptoms: External strabismus , Diplopia , Ptosis,
Mydriasis , Paralyzed accommodation
Incomplete lesions: 1) Internal ophthalmoplegia: Loss of the autonomic innervation of the sphincter
pupillae and ciliary muscle. Symptoms: the pupil will be widely dilated and nonreactive to light , 2)
Incomplete lesions: Internal ophthalmoplegia: Loss of the autonomic innervation of the sphincter pupillae
and ciliary muscle. Symptoms : the pupil will be widely dilated and nonreactive to light only
Trochlear Nerve symptoms: 1- Diplopia 2- Difficulty in turning the eye downward and laterally. So, at rest the patient eye will
go upward & medially. 3- Difficulty in descending stairs
(CN4)
Abducent nerve symptoms: 1- Diplopia. 2- Internal strabismus
(CN6)
Facial nerve Location of the lesion 1. In the pons: Abducens and facial not working. 2. Internal acoustic meatus:
Vestibulocochlear and facial 3. Chorda tympani: Loss of taste over the anterior two thirds of the tongue
(CN7) Order of the neuron affected: 1. Lower motor neuron lesion -> ipsilateral half paralysis 2. Upper motor
neuron lesion -> contralateral lower part paralysis
Bell’s palsy: Usually unilateral, lower motor neuron paralysis, the cause is still not known.
Glossopharyngeal Loss of the gag reflex (normally induces vomiting)
Loss of the carotid sinus reflex
nerve (CN9) Loss of taste from the posterior third of the tongue
Vagus nerve Uvula deviates to the healthy side. , Hoarseness of voice (paralysis in the muscles of the larynx) , Dysphagia
and nasal regurgitation (paralysis in the muscles of the pharynx) , Arrhythmia in heart and irregularity in GI
(CN10) tract because (parasympathetic dysfunction)
Hypoglossal Lower motor neuron lesion: Tongue deviates toward the paralyzed side during protrusion with muscle
atrophy (ipsilateral)
nerve (CN12) Upper motor neuron lesion: On protrusion, tongue will deviate to the side opposite the lesion (genioglossus
paralysis) with no atrophy.

28
AMAL SAEED ODEH
 Pontine arteries
Paramedian : give structures
Blood supply of the brain stem
close to midline in pons ,
The parts closer to the
midline of midbrain

, Circumferential : give
structures lateral & posterior
in pons , Anterolateral parts of
midbrain are supplied by
circumferential branch of the
quadrigeminal and posterior
choroidal arteries

medial posterior choroidal Thalamogeniculate , the

arteries will give most lateral part of upper
posteriolateral parts of levels of midbrain
midbrain
Supply superior surface of
posterior part of midbrain
from quadrigeminal cerebellum & pons ,
posterior parts of midbrain

Supply posterior Supply Inferior surface of

lateral parts of cerebellum , also contribute to
medulla lateral part of pons

Supply anterior
Supply anterior
lateral parts of
medial parts of
medulla
medulla

Posterior spinal artery

Supply posterior parts of closed medulla

29
AMAL SAEED ODEH
 Blood supply of the brain stem
Subclavian

Posterior
Posterior
Anterior
spinal artery
Vertebral inferior
spinal artery
cerebellar artery

Two vertebral through foramen

magnum unit to form

Basilar

Anterior inferior Pontine arteries Superior Posterior

cerebellar artery cerebellar artery cerebral artery

Can you complete it

with your
imagination ?

30
AMAL SAEED ODEH
 Syndromes according to Blood supply of the brain stem

Medulla
Medial medullary It is caused • Contralateral hemiparesis (pyramids (corticospinal
syndrome by a lesion in tracts)) \ no decussation
(Dejerine anterior • Contralateral loss of proprioception, fine touch and
syndrome) spinal artery vibratory sense due to damage to the medial lemniscus
which \ decussation
supplies the • Deviation of the tongue to the ipsilateral (hypoglossal
area close to root or nucleus injury)
the midline

Lateral medullary It is caused by a lesion in PICA which - contralateral loss of pain and temperature sensation
syndrome supplies the area close to lateral areas from the body (anterolateral system) \ decussation
(Wallenberg - ipsilateral loss of pain and temperature sensation
syndrome) from the face (involvement of spinal trigeminal tract
and nucleus)
- Nystagmus is irregular movements of the eyeballs
(the vestibular nucleus)
- loss of taste from the ipsilateral half of the tongue
(solitary tract and nucleus)
- hoarseness and dysphagia (nucleus ambiguus or
roots of cranial nerves IX and X)
- Ipsilateral Horner syndrome (hypothalamospinal
fibers)
Vascular lesions - ipsilateral loss of proprioception and vibratory sense
of the posterior (related to PCML system)
spinal artery - ipsilateral loss of pain and temperature sensation
from the face (lateral to the nucleus cuneatus is the
trigeminal nucleus and is affected)
Pons
Foville syndrome Due to • ipsilateral abducens nerve paralysis (the abducent
occlusion of nucleus)
the • contralateral hemiparesis (corticospinal fibers ) \ no
paramedial decussation
branches • variable contralateral sensory loss reflecting various
degrees of damage to the medial lemniscus
Millard-Gubler If the area of damage is shifted the patient has a contralateral hemiparesis and an
syndrome somewhat laterally to include the root ipsilateral paralysis of the facial muscles
of the facial nerve along with
corticospinal fibers
Syndrome of the Due to occlusion of the paramedial • Corticospinal fibers causing contralateral hemiparesis
midpontine base branches and short circumferential • Sensory and motor trigeminal roots (trigeminal
branches nuclei)
• Fibers of the middle cerebellar peduncle (ataxia)

31
AMAL SAEED ODEH
 Midbrain
Weber syndrome Due to occlusion of vessels serving the • Ipsilateral paralysis of all extraocular muscles except
medial portions of the midbrain the lateral rectus (supplied by the abducent) and
involving the superior oblique (by the trochlear)
oculomotor • Paralysis of the contralateral extremities
nerve and (Corticospinal fibers) \ no decussation
the crus • Ipsilateral dilatation of pupil
cerebri • Contralateral weakness of the facial muscles of the
lower half of the face
• Contralateral deviation of the tongue when it is
protruded
Claude syndrome Due to occlusion of vessels serving the • ipsilateral paralysis of most eye movements
central area of the midbrain which • Ipsilateral dilatation of pupil
includes the oculomotor nerve and the • contralateral ataxia, tremor, and incoordination
red nucleus

Yes the picture above have teeth missed !

No one but just dental studemt can’t see
trigeminal nerve without the teeth

32
AMAL SAEED ODEH
 Herniation
Type Definition Causes Symptoms
TONSILLAR There is a part of the cerebellum called any mass in the posterior sudden change in heart
HERNIATION tonsils, when it is pushed out of its cranial fossa (tumor, rate and respiration
normal location the condition is called hemorrhage) hypertension
tonsillar herniation (the direction of increase in intracranial hyperventilation
herniation which is downward towards pressure rapidly decreasing levels of
the foramen magnum), this will cause consciousness
pressure on the medulla oblongata in that If sever, death
area
Arnold-Chiari Congenital anomaly in which there is a It is less severe, and some
Phenomenon herniation of the tonsils of the people may be
cerebellum and the medulla oblongata asymptomatic but as
through the foramen magnum into the people get older symptoms
vertebral cana might start appearing
Central space occupying lesion in the hemisphere elevates intracranial change in respiration, eye
herniation (supratentorial compartment, above the pressure and forces the movements are irregular.
tentorium cerebri) diencephalon downward As the damage progresses
through the tentorial notch downward into the
and into the brainstem brainstem, there is
affecting the midbrain significant change in
mainly respiration (Tachypnea and
apnea)
profound loss of motor and
sensory functions.
probable loss of
consciousness
Decorticate posture may
occur
Upward A mass in the posterior cranial fossa may The result may be accumulation of fluids will
Cerebellar force portions of the cerebellum upward occlusion of branches of lead to an increase in
Herniation through the tentorial notch (upward the superior cerebellar intracranial pressure
cerebellar herniation) and compress the artery with resultant causing vomiting,
midbrain rather than causing tonsillar infarction of cerebellar headache, lethargy,
herniation. structures or obstruction decreased levels of
of the cerebral aqueduct consciousness
and hydrocephalus.
Uncal Movement of the uncus (anteromedial Early signs :
Herniation part of the temporal lobe) downward dilated pupil ipsilateral to the herniation (involvement of
over the edge of the tentorium cerebelli, oculomotor)
causing pressure on the midbrain abnormal eye movements ipsilateral to the herniation
(oculomotor nerve)
double vision ipsilateral to the herniation (loss of
synchrony of movement of the eyes).
Weakness of the extremities (corticospinal fiber
involvement) opposite to the dilated pupil

Later: respiration is affected

33
AMAL SAEED ODEH
Herniation types & directions

34
AMAL SAEED ODEH
 Cerebellum
Functional zones of cerebellum
Vermis influences the movements of the long axis of the body (neck, shoulders, thorax, abdomen and
hips)
Intermediate control muscles of the distal parts of the limbs (hand and feet)
zone
Lateral zone concerned with planning of sequential movements of the entire body , such as speech

Structure of cortex of cerebellum ( outer layer )

molecular layer (outer) stellate cell -basket cell -consisting of axons of granule cells (parallel fibers) and
dendrites of Purkinje cells
Purkinje cell layer (intermediate) large neuronal cell bodies (Purkinje cells) Flask shaped cells
granular layer (inner) -small neurons called granular cells - Golgi cells: (Inhibitory)

Input Output

Climbing fibers: terminal fibers of the
olivocerebellar tracts , excitatory to
purkinje cells , a single purkinje neuron
makes synaptic contact with only one
climbing fiber and one climbing fiber
makes contact with one to ten purkinje
neurons
Mossy fibers: terminal fibers of all other
cerebellar afferent tracts ( anterior &
posterior spinocerebullar tracts ) ,
excitatory to purkinje cells , a single
mossy fiber may stimulate thousands of
purkinje cells through the granule cells
Purkinje Cells - the only output neuron
from the cortex utilizes GABA to inhibit
neurons in deep cerebellar nuclei
Granule Cells- intrinsic cells of cerebellar
cortex; use glutamate as an excitatory
transmitter; excites Purkinje cells via
axonal branches called “parallel fibers”
Basket Cells and stellate cells- inhibitory
interneuron; utilizes GABA to inhibit
Purkinje cells

35
AMAL SAEED ODEH
Type Parts of More info. Fun. Pathways
cerebellum
Spinocerebellum comprises the - projects through controls First one :
vermis + fastigial and posture and the vermis will send efferents
intermediate interposed nuclei. movement through fastigial n. TO Inferior
hemisphere of -has a somatotropic of trunk and cerebellar peduncles TO EITHER
the cerebellar organization. limbs Medial descending pathways
cortex, as well -it receives major (vestibulospinal tract ,reticulospinal
as the fastigial inputs from the tract) OR VL (Medial (anterior)
and interposed spinocerebellar tracts. Corticospinal tract)
nuclei. -Its output projects to Second one :
rubrospinal, The intermediate hemisphere will
vestibulospinal, and send efferents through interposed
reticulospinal tracts n. TO Superior cerebellar peduncle
-It is involved in the TO EITHER Red nucleus (Globose-
integration of sensory emboliform-rubral pathway
input with motor (Rubrospinal tract) OR VL (Lateral
commands to produce corticospinal tract)
adaptive motor
coordination
Cerebrocerebellum Located in the participates Afferent input : from entire
lateral in the contralateral cerebral cortex TO
hemisphere , planning of pontine nuclei. TO Middle cerebellar
projects to the movement peduncle TO Contralateral
dentate ,It is cerebellar cortex
nucleus involved in Efferent pathway : Dentate n. TO
the planning superior cerebellar peduncles
and timing Decussation of SCP TO VL TO
of corticospinal tract
movements
Vestibulocerebellu located in projects to vestibular functions in Afferent input: vestibular nerve and
m flocculonodular nuclei. maintaining vestibular nuclei.
lobe it is involved in balance and Efferent path vestibular nuclei TO
vestibular reflexes controlling EITHER VS tract OR Med longitud
(such as the head and Fasciculus (eyes, head)
vestibuloocular reflex) eye
and in postural movements
maintenance
Keep Calm
Stop trying to calm the storm

Calm yourself

The storm will pass

36
AMAL SAEED ODEH
 Cerebellar afferent fibers Cerebellar efferent fibers

From cerebral From spinal cord From vestibular Dentothalamic

cortex nerve pathway
1. Anterior
1.Corticopontocere spinocerebellar Other afferents • Globose-
bellar pathway tract emboliform-rubral
1. Red nucleus pathway
2. Cerebro- 2. Posterior
olivocerebellar 2. Tectum • Fastigial
spinocerebellar
pathway tract vestibular pathway

3.Cerebroreticuloce 3. Cuneocerebellar • Fastigial reticular

rebellar pathway tract pathway

inferior cerebellar peduncle afferent fibers from the efferents to the vestibular
medulla nuclei
middle cerebellar peduncle afferents from the pontine -------------
nuclei
superior cerebellar peduncle afferents from the efferent fibers from the
spinocerebellar tract cerebellar nuclei

Nystagmus: Hypotonia: Tremors: Postural Failure of Progression :

rhythmic decrease in involuntary changes and Dysdiadochokinesia (difficulty
oscillations of muscle tone: oscillations of alteration of gait performing rapid alternating
the eyes. (Loss of the limbs (“intention movements) due to failure to
to compensate
tremor”), results
deep cerebellar for loss of predict where the different parts
from cerebellar
nuclei, muscle tone of the body will be at a given
overshooting and
Ataxia particularly of time during rapid motor
failure of the
(inaccuracy and the interposed Dysmetria movements.
cerebellar system
disturbances of nuclei) to “damp” the (past pointing)
voluntary Dysarthria: Disorders of speech
motor
movement) movements

37
AMAL SAEED ODEH

Sympathetic nervous system
“fight or flight”
Major regulator of the smooth
muscle of the cardiovascular
system, it has a wider
distribution as blood vessels
are located everywhere in the
body.
thoracolumbar system: all its
neurons are in lateral horn of
gray matter from T1-L2
sweat, hair stands on end ,
blood pressure rises
(vasoconstriction , Also causes:
dry mouth, pupils to dilate,
increased heart & respiratory
rates to increase O2 to skeletal
muscles, heart and brain
acetylcholine in preganglionic ,
Norepinephrine is for
postganglionic
ANS
parasympathetic nervous
system
“rest & digest”
Synapse in a paravertebral Major regulator of the smooth The myleinated efferent
ganglion ,that have white muscle of the digestive and fibers of the craniosacral
ramus communicans AND respiratory systems , Only outflow are preganglionic
gray ramus communicans innervate internal organs and synapse in peropheral
ganglia located close To
SUPPLY Then out through
the viscera they innervate
the spinal nerve toward
the skin ( mainly targets Craniosacral , Cranial nerves leave the sacral nerves
like the arrector pili III,VII, IX and X , In lateral horn and form the pelvic
muscles and blood vessels of gray matter from S2-S4 splanchnic nerves
and glands)
Pupils constrict , Stimulates
Synapse in a collateral digestive glands , Increases
ganglion (Prevertebral) , motility of smooth muscle of
Bypasses paravertebral digestive tract , Decreases
ganglion to continue to heart rate , Causes bronchial
project away from the constriction
spinal cord in a separate
nerve (splanchnic nerves)
influence the deeper acetylcholine in preganglionic ,
visceral organs (heart, Norepinephrine is for
kidneys, and digestive postganglionic
system)
38
AMAL SAEED ODEH
 Splanchnic nerves
Greater splanchnic 5th-9th thoracic ganglia Pierces the crus of the Synapse in the ganglia of the
diaphragm celiac plexus, the renal plexus,
and the suprarenal medulla
Lesser splanchnic 10th -11th thoracic ganglia Pierces the diaphragm Synapses in lower part of the
celiac plexus
The lowest splanchnic 12th thoracic ganglion Pierces the diaphragm Synapses in the ganglia of the
renal plexus

39
AMAL SAEED ODEH
 Anatomy ?

Natural teeth

Clinical !!!
EXTRACTION

Surgery ……

All this noise just to be a ?

Work until you no longer

have to introduce yourself

40
AMAL SAEED ODEH
Upward Cerebellar Herniation

A mass in the posterior fossa may force portions of the cerebellum upward through the tentorial notch
(upward cerebellar herniation) and compress the midbrain

The result may be occlusion of branches of the superior cerebellar artery with resultant infarction of
cerebellar structures or obstruction of the cerebral aqueduct and hydrocephalus.

The latter is seen as signs characteristic of an increase in intracranial pressure

vomiting, headache, lethargy, decreased levels of consciousness).

Signs and symptoms of cerebellar disease

A lesion in one cerebellar hemisphere gives rise to signs and symptoms that are limited to the same side
of the body

Hypotonia: decrease in muscle tone: (Loss of the deep cerebellar nuclei, particularly of the interposed
nuclei)

Dysmetria (past pointing): movements ordinarily overshoot their intended mark; then the conscious
portion of the brain overcompensates in the opposite direction for the succeeding compensatory
movement.

Ataxia (inaccuracy and disturbances of voluntary movement)

Tremors: involuntary oscillations of limbs (“intention tremor”), results from cerebellar overshooting and
failure of the cerebellar system to “damp” the motor movements

Postural changes and alteration of gait (wide-based gait) to compensate for loss of muscle tone

Failure of Progression

Dysdiadochokinesia (difficulty performing rapid alternating movements) due to failure to predict where the
different parts of the body will be at a given time during rapid motor movements.

Dysarthria: Disorders of speech

Nystagmus: rhythmic oscillations of the eyes. It occurs especially when the flocculonodular lobes of the
cerebellum are damaged;

Anterior Cerebral Artery Occlusion

Occlusion distal to the communicating artery may produce the following signs and symptoms:

1. Contralateral hemiparesis and hemisensory loss involving mainly the leg and foot (paracentral lobule of
cortex).

2. Inability to identify objects correctly, apathy, and personality changes (frontal and parietal lobes).
Middle Cerebral Artery Occlusion

1. Contralateral hemiparesis and hemisensory loss involving mainly the face and arm (precentral and
postcentral gyri)

2. Aphasia if the left hemisphere is affected (rarely if the right hemisphere is affected)

3. Contralateral homonymous hemianopia (damage to the optic radiation)

4. Agnosia if the right hemisphere is affected (rarely if the left hemisphere is affected)

Posterior Cerebral Artery Occlusion

1. Contralateral homonymous hemianopia with some degree of macular sparing (damage to the calcarine
cortex, macular sparing due to the occipital pole receiving collateral blood supply from the middle
cerebral artery).

2. Visual agnosia (ischemia of the left occipital lobe)

3. Impairment of memory (the medial aspect of the temporal lobe)

Internal Carotid Artery Occlusion

1. The symptoms and signs are those of middle cerebral artery occlusion, including contralateral
hemiparesis and hemianesthesia.

2. There is partial or complete loss of sight on the same side, but permanent loss is rare (emboli dislodged
from the internal carotid artery reach the retina through the ophthalmic artery).

Vertebrobasilar Artery Occlusion

1- Ipsilateral pain and temperature sensory loss of the face and contralateral pain and temperature
sensory loss of the body.

2. Attacks of hemianopia or complete cortical blindness.

3. Ipsilateral loss of the gag reflex, dysphagia, and hoarseness as the result of lesions of the nuclei of the
glossopharyngeal and Vagus nerves.

4. Vertigo, nystagmus, nausea, and vomiting

5. Ipsilateral Horner syndrome

6. Ipsilateral ataxia and other cerebellar signs.

7. Unilateral or bilateral hemiparesis.

8- Comma
Congenital Malformations of spinal cord development

1) Spina bifida occulta: Absent vertebral arch with normal spinal cord. It affects the lumbosacral area & is
usually covered with hairy skin.

2) Spina bifida cystica:

- Meningocele: The meninges herniates through the spina bifida to form subcutaneous sac filled with CSF.

- Meningomyelocele: The spinal cord herniates through the meningocele.

- Myelocele (Rachischisis): Failure of obliteration of the neural tube.

Congenital Malformations of brain development

1) Hydrocephalus: It is of 2 types

- Internal hydrocephalus: Excessive accumulation of CSF within the ventricles of the brain.

- External hydrocephalus: Excessive accumulation of the CSF between the brain & arachnoid mater.

2) Exencephaly: It is due to failure of closure of anterior neuropore. The vault of the skull is absent & the
brain is exposed. When the brain is degenerated the anaomaly is known as Anencephaly.

3) Menigocele: the meninges herniated through a deficient part of the skull.

4) Meningoencephalocele: part of the brain herniated through the meningocele.

5) Meningo-hydro-enecephalocele: part of the ventricle is found within the brain tissue which herniated
through the meningocele.

6) Holoprosencephaly: Results from degeneration of midline structures leading to fusion of lateral

ventricles, orbital & nasal cavities.

Arnold-Chiari Phenomenon

Congenital anomaly in which there is a herniation of the tonsils of the cerebellum and the medulla
oblongata through the foramen magnum into the vertebral canal
Syringomyelia: Cavitation of the central canal in the spinal cord (increase in size of the canal) could be
due to any reason, this cavitation will damage the fibers crossing in the anterior white commissure in
both directions, this will cause bilateral loss of pain and thermal sensations.

In some cases this cavitation extends to the anterior horns, causing muscle weakness and even paralysis
sometimes, if the syrinx (cavity) extends to one anterior horn, this will cause an ipsilateral weakness if
both anterior horns are involved, the weakness will be bilateral.

Brown-Séquard Syndrome: Functional hemisection of the spinal cord (damage that involved half the
spinal cord), this will cause damage to the corticospinal tract, ALS, posterior columns.

1) Contralateral loss of nociceptive and thermal sensations over the body below the level of the lesion.

2) Ipsilateral loss of discriminative tactile, vibratory, and position sense over the body below the level of
the lesion.

3) Ipsilateral paralysis or weakness (hemiparesis, hemiplegia).

Central cord syndrome :Occurs in case of occlusion in the blood supply of the anterior spinal artery,
which often occur in the case of neck hyperextension.

This results in bilateral weakness in extremities, more in upper than lower extremities(we have one
anterior spinal artery that supply both right and left side)

Also, its characterized by bilateral pain and thermal sensation loss, bladder dysfunction.

Compromise of blood flow in the posterior spinal artery results in: Ipsilateral reduction or loss of
discriminative, positional, and vibratory tactile sensations at and below the segmental level of the injury.

Parkinson's disease is caused by the death of neurons in the substantia nigra

Oculomotor Nerve injury

• Complete lesion – All of the muscles are paralyzed except lateral rectus and superior oblique

– Symptoms: • External strabismus • Diplopia • Ptosis: drooping of the upper eyelid.

• The pupil is widely dilated and nonreactive to light

• Accommodation of the eye is paralyzed.

•Incomplete lesions: •Internal ophthalmoplegia: loss of the autonomic innervation of the sphincter
pupillae and ciliary muscle

•External ophthalmoplegia.: paralysis of the extraocular muscles

In cases of (diabetic neuropathy), the autonomic fibers are unaffected, whereas the nerves to the
extraocular are paralyzed ( related to oculomotor nerve injury )

muscles are paralyzed

Trochlear Nerve injury • Symptoms:

– Diplopia – Difficulty in turning the eye downward and laterally.

– Difficulty in descending stairs

– Head tilt to the side opposite the paralyzed eye (compensatory adjustment)

Abducent Nerve injury • Symptoms: – Diplopia – Difficulty in turning the eye laterally.

– internal strabismus. unopposed medial rectus pulls the eyeball medially

Facial Nerve injury Location of the lesion:

Abducent and the facial nerves are not functioning: lesion in the pons

Vestibulocochlear and the facial nerves are not functioning: lesion in the internal acoustic meatus

Loss of taste over the anterior two-thirds: damaged to the chorda tympani branch

Lesion in UMN → paralysis of contralateral lower part of the face

Lesion in A LMN → paralysis of ipsilateral part of the face

Bell’s palsy → usually unilateral , lower motor neuron type of paralysis ( cold , tumor , AIDS , diabetic
complication )

lesion of the glossopharyngeal nerve:

• Loss of pharyngeal reflex (gag reflex).

• Loss of carotid sinus reflex.

•Loss of taste in the posterior third of tongue (Vallate papillae).

Lesion of Vagus:

•Uvula deviates to the healthy side. •Hoarseness of voice

• Dysphagia and nasal regurgitation •Arrhythmia in heart and irregularity in GI tract because
Weber syndrome

Due to: Occlusion of vessels serving the medial portions of the midbrain involving the oculomotor nerve and
the crus cerebri.

• Ipsilateral paralysis of all extraocular muscles except the lateral rectus and superior oblique

• Paralysis of the contralateral extremities

• Ipsilateral dilatation of pupil

• Contralateral weakness of the facial muscles of the lower half of the face

• Contralateral deviation of the tongue when it is protruded

Benedikt syndrome

Large lesion that includes the territories of both the Weber and Claude syndromes

TONSILLAR HERNIATION

Causes:

mass in the posterior fossa (tumor, hemorrhage)

increase in intracranial pressure

The major concern in acute herniation is damage to the ventrolateral reticular area (heart rate and respiration)

Symptoms

sudden change in heart rate and respiration ,hypertension ,hyperventilation

rapidly decreasing levels of consciousness

If sever death

Central herniation

space occupying lesion in the hemisphere (supratentorial compartment) elevates intracranial pressure and
forces the diencephalon downward through the tentorial notch and into the brainstem

Symptoms: change in respiration, eye movements are irregular

As the damage progresses downward into the brainstem, there is significant change in respiration

Tachypnea and apnea

profound loss of motor and sensory functions,

probable loss of consciousness.

Uncal Herniation

movement the uncus) downward over the edge of the tentorium cerebelli

Early signs: dilated pupil ipsilateral to the herniation

abnormal eye movements ipsilateral to the herniation

double vision

Weakness of the extremities (corticospinal fiber involvement) opposite to the dilated pupil.

Later: respiration is affected

The 3 cranial nerves related to the eyeball movement:

Oculomotor Nerve (III) Trochlear Nerve (IV) Abducent Nerve (VI)

At the level of sup. colliculus: - In the caudal part of the

- In the midbrain at the level pons beneath the floor of
Nuclei

1- Main oculomotor nucleus.

of the inf. colliculus: Motor the fourth ventricle, close
2- Accessory parasympathetic nucleus trochlear nucleus. to the midline: Motor
(Edinger-Westphal nucleus) Abducent nucleus

1- Extrinsic muscles: All except lateral

Supplies

rectus and sup. oblique.

- Superior oblique muscle. - Lateral rectus.
2- Intrinsic muscles: The constrictor
pupillae of the iris and ciliary muscles.

- Lifting the upper eyelid, turning the eye

Action

upward, downward, and medially, - Turning the eye downward

- Turning the eye laterally.
constricting the pupil (light reflex), and and laterally.
accommodating the eye.
- External strabismus; unopposed lateral
rectus pulls the eyeball laterally.
- Diplopia (double vision).
- Ptosis: drooping of the upper eyelid.
- The pupil is widely dilated and
nonreactive to light. - Diplopia.
- Accommodation of the eye is paralyzed. - Difficulty in turning the eye - Diplopia.
Lesion Symptoms

downward and laterally.

- Incomplete lesions: - Difficulty in turning the
- Difficulty in descending eye laterally.
a- Internal ophthalmoplegia ‫شلل‬: loss stairs.
of the autonomic innervation of the - Internal strabismus;
sphincter pupillae and ciliary muscle. - Head tilt to the side opposite unopposed medial rectus
the paralyzed eye pulls the eyeball medially.
b- External ophthalmoplegia: (compensatory adjustment).
paralysis of the extraocular muscles.
In cases of (diabetic neuropathy),
usually the autonomic fibers are
unaffected, whereas the nerves to
the extraocular muscles are
paralyzed.
 Nuclei Supplies Lesions

1- Spinal nucleus: C2 – main nucleus (ALS

Trigeminal Nerve (V)

modalities). - Motor: muscles of

2- Main nucleus: post. in the cranial part of the mastication, tensor
pons (PCML modalities). tympani, tensor veli
palatini, mylohyoid, ant. -
3- Motor nucleus: same as the main nucleus. belly of the digastric
* 4- Mesencephalic nucleus: lateral to the muscle
cerebral aqueduct in the midbrain (reflexes
and impulses).

1- Main Motor Nucleus: caudal part of the Bell’s Palsy:

pons. Fibers form facial colliculus.
- Usually unilateral.
Facial Nerve (VII)

2- Parasympathetic Nuclei: posterolateral to

the motor nucleus. - Lower motor neuron
Superior salivatory and Lacrimal nuclei. - Parasympathetic: type of facial paralysis.
lacrimal, submandibular, - Unknown cause; can be
3- Tractus solitarius nucleus: central grey and sublingual glands.
matter at the level of the olives in the exposure of the face to a
medulla (special sensory; taste of ant. 2/3). cold draft, complication
of diabetes, or as a
4- Spinal nucleus of V (general sensation). result of tumors / AIDS
Cell bodies are in the geniculate ganglion.
1- Main Motor Nucleus: in the nucleus
Glossopharyngeal Nerve (IX)

ambiguous at the level of the olives in the

medulla. - Motor: Stylopharyngeus
- Loss of taste in the
muscle.
2- Parasympathetic Nuclei: Inferior posterior third of tongue
salivatory nucleus. - Parasympathetic: (Vallate papillae).
parotid salivary gland.
3- Tractus solitarius nucleus: (special - Loss of carotid sinus
sensory; taste of post 1/3). Cell bodies are in - Sensory: middle ear, reflex.
the inferior ganglion of IX. auditory tube, and the
- Loss of pharyngeal
pharynx -except
4- Spinal nucleus of V (general sensation). reflex (gag reflex).
nasopharynx.
Cell bodies are in the superior ganglion of
IX.
1- Main Motor Nucleus: in the nucleus
ambiguous at the level of the olives in the
medulla. - Motor: constrictor
muscles of the pharynx
Vagus Nerve (VIII)

2- Parasympathetic Nuclei: central grey

and the intrinsic muscles
matter at the level of the olives in the
of the larynx.
medulla.
- Sensory: outer ear, -
3- Tractus solitarius nucleus: lower part of it
mucosa of the larynx,
(special sensory; taste from epiglottis). Cell
dura of post. cranial
bodies are in the inferior ganglion of vagus.
fossa.
4- Spinal nucleus of V (general sensation).
Cell bodies are in the superior ganglion of
vagus.
Note 1: all motor cranial nerves efferent are received bilateral,
except for the lower face and genioglossus muscle - they receive
fibers from the contralateral side.

Note 2: fibers from the motor facial nucleus supply the face; upper
part of the face receives corticonuclear fibers from both
hemispheres, whereas the lower part of the face receives only
corticonuclear fibers from the opposite cerebral hemisphere. Thus,
cutting the LMN affects the lower face ipsilaterally, whereas
cutting the UMN affects contralaterally.

Note 3: we need to know the nuclei, in which ganglia

the synapse, and the target.

Trigeminal Nerve:
 CNS Motor Tracts

Pyramidal Tracts
Motor Tracts Extrapyramidal Tracts
(Corticospinal Tracts)
Origin Cerebral Cortex Brainstem
Cortex Area Mainly from area 6
(they both start (Premotor area: uses external cues)
Mainly from area 4
from areas (Supplementary motor area: uses
internal cues)
4,6,312)
Under the
Cerebral Cortex Cerebral Cortex
control of
Subconscious regulation of balance,
Conscious control of skeletal
Control Type muscles
muscle tone, eye, hand and upper
limb position
-Lateral Corticospinal Tract -Vestibulospinal tract
-Anterior Corticospinal Tract -Reticulospinal tract
Contents -Corticoneuclear Tract -Rubrospinal tract
(Corticobulbar) -Tectospinal tract

1
 Motor Tract Pyramidal Tracts (Corticospinal Tracts)
Tract Type Lateral
Corticospinal Tract
Fibers Origin Precentral gyrus of the cerebral cortex
-In Midbrain: Middle 3/5 of basis pedunculi
-In Medulla Oblangata: Pyramids (decussate)
-In Spinal Cord: Descends the full length of the
Fibers Pathway spinal cord synapsing mainly by interneurons in
laminae: IV, V, VI, VII, VIII (mainly).
Exception: 3% originate from the fifth layer of
area 4 (giant cells of betz) synapse directly
without interneurons (accurate movements).
-Fibers cross over (decussate) to the opposite
side in the pyramidal decussation, the lower
Decussation part of the medulla, where they continue to
descend in the lateral funiculus of the spinal cord
as the lateral corticospinal tract (LCST).
-For fine skilled movement
Function
-LCST fibers synapse with alpha and gamma
nuclei of:
Additional Notes The Cervical region (55%) (great effect on the
upper limb), Thoracic 20%, Lumbar and Sacral
25%
Anterior
Corticospinal Tract
Precentral gyrus of the cerebral
cortex
-Those corticospinal fibers which
do not decussate in the medulla
continue descending on the same
(ipsilateral) side of the cord and
become the anterior corticospinal
tract (ACST)
-Cross over at the level of the
spinal cord (fibers leave the tract
at various levels to cross over in
the anterior white commissure to
synapse on interneurons in the
anterior gray horn)
-Acts on the proximal muscles of
upper limb (shoulder muscle) of
the ipsilateral and contralateral
sides
Corticoneuclear Tract
(Corticobulbar)
Precentral gyrus of the lower
quarter of the motor cortex
-The descending fibers terminate
in the motor nuclei of cranial
nerves:
Midbrain: III, IV
Pons: V, VI, VII
Medulla: IX, X, XI, XII
-The corticobulbar fibers from
one side of the brain project to
the motor nuclei on both sides of
the brainstem (bilateral input)
-Supplies upper motor neuron
innervation to the cranial nerves
supplying head and face
The corticoneuclear input is
bilateral EXCEPT:
1- Part of 7th (which supplies
LOWER facial muscle)
2- Part of 12th (which supplies
genioglossus muscle)
2
Motor Tract Pyramidal Tracts (Corticospinal Tracts)

Motor Type Lateral Anterior Corticoneuclear Tract

Corticospinal Tract Corticospinal Tract (Corticobulbar)

Image

3
Motor Tract Extrapyramidal Tracts

Vestibulospinal Reticulospinal Tract Rubrospinal Tectospinal

Tract Type Tract Tract Tract
Pontine Medullary
-In the pons and medulla
-Red nucleus in the
beneath the floor of 4th
midbrain at the level
ventricle
of superior colliculus -Nerve cells in
-Receives afferent fibers
Fibers Origin from the inner ear
Pons Medulla -Receives afferent superior colliculus
fibers from cerebral of the midbrain
through the vestibular
cortex and
nerve and from the
cerebellum
cerebellum
-The tract descends
in the anterior
white column close
-Lateral white -Lateral white column to Anterior median
-Anterior white column
Fibers -Anterior white column column -Synapses with alpha fissure
-Synapse with neuron in
-Medial reticulospinal -Lateral and gamma through -Majority of fibers
Pathway the anterior gray column
tract (MRST) reticulospinal tract interneurons terminate in the
of the spinal cord
(LRST) anterior gray
column of upper
cervical segments of
spinal cord

-Axons descend -Axons of RF neurons -Axons of RF neurons

-Crossed (at the level
Decussation uncrossed through descend uncrossed into descend crossed and
of the nucleus)
-Crossed
medulla and through the the spinal cord uncrossed into the
length of spinal cord spinal cord

4
Motor Tract
Vestibulospinal
Tract Type
Tract
-Facilitate the activity of
extensor muscles and
inhibit the activity of
Function flexor muscles in
association with the
maintenance of balance
-It maintains balance by
facilitating the activity of
Additional the extensor muscles
-Together with the
Notes pontine reticulospinal
tract → responsible for
stranding upright.
Extrapyramidal Tracts
Reticulospinal Tract Rubrospinal Tectospinal
Pontine Medullary Tract Tract
-Facilitate the activity
-Activate the axial and of flexors and inhibit
-Inhibit the axial and Responsible for
proximal limb extensors the activity of
proximal limb reflex movement of
(Antigravity muscles) extensors
-Responsible for
extensors
-Supply the distal
head & neck in
(Antigravity response to visual
standing upright (with flexors muscles mainly
muscles) stimuli
the vestibulospinal tract) with little effect on
the proximal muscles
-Tonically active -NOT tonically active
-normally under -normally under
inhibition from cortex cortex stimulation
-Rubrospinal tract is
very close to the
-Have also descending autonomic fibers lateral corticospinal
tract in the spinal
providing a pathway by which the
hypothalamus can control the sympathetic and cord. Together they
sacral parasympathetic outflow form the lateral motor
-Most of these fibers are derived from the system.
lateral reticulospinal tract (medullary)
5
Motor Tract Extrapyramidal Tracts

Vestibulospinal Reticulospinal Tract Rubrospinal Tectospinal

Tract Type Tract Tract Tract
Pontine Medullary

Image

Made by: Zina Smadi

Corrected by: Rama Abbady

6
 Medulla Oblongata

Decussation of the - Spinal nucleus of the trigeminal nerve.

pyramids - Dorsal nuclei start appearing.
Closed Medulla

- Internal arcuate fibers.

- Decussation takes place post. to
pyramids, ant. to central canal.
Decussation of the
lemnisci - Spinal nucleus of the trigeminal nerve
(lateral to the internal arcuate fibers).
- The spinocerebellar, vestibulospinal, and
the rubrospinal tracts (anterolateral).

- Beneath 4th V floor: central gray matter

(Hypoglossal > Vagus > Solitary >
vestibular nuclei).
- Midline: MLF, Tectospinal, ML.
Level of the Olives - Olivary nuclear complex.
- Nucleus Ambiguous in RF.
- Inferior cerebellar peduncle.
Open Medulla

- Spinal nucleus of trigeminal and its tract

(anteromedial to ICP).

- Same, except for:

- Lateral vestibular nucleus replaced the
inferior vestibular nucleus.
Level inf. to Pons
- Cochlear nuclei are visible on the
anterior and posterior surfaces of the
inferior cerebellar peduncle.

Blood Supply of the Medulla

- Midline: ant. spinal artery.

- Lateral: vertebral artery
- Most lateral and posterior: PICA, while PSA Ant. Spinal artery Post.
contributes to posterior structures in closed medulla. Spinal artery
Vertebral artery
PICA
 Pons
- Medial lemniscus most anterior.
- Facial motor nucleus posterior to ML, while
facial parasymp. nuclei are posterolateral to it
(sup salivatory + lacrimal).
Tegmentum - Spinal nucleus of trigeminal.
(Facial colliculus)

- Beneath 4th V floor: MLF in the midline >

Caudal Part

abducent nucleus > Medial vestibular nucleus

‘replaced lateral’.
- Superior cerebellar peduncles.

- Corticopontine fibers terminate in - Scattered

pontine nuclei – give transverse axons – leave
Basilar through MCP into the cerebellum.
- Intersection between ponto-cerebellum and
corticospinal fibers.

- Motor nucleus of trigeminal n: beneath the

lateral part of the 4th ventricle within the RF.
(Trigeminal nuclei)
Cranial Part

- Main Sensory nucleus of trigeminal n (lateral).

Tegmentum
- SCP is posterolateral to the motor nucleus of the
trigeminal nerve.
- Medial, lateral, and spinal lemnisci

Basilar Same as the caudal part

Blood Supply of the Pons

- Midline: paramedian branches (purple).

- Lateral: supplied by the circumferential branches
(green) and AICA (blue).
- At the upper, trigeminal nuclei level: branches from
the superior cerebellar arteries (yellow) aid in the
supply of the posterior part with the circumferential
branches.
 Midbrain
- The mesencephalic nucleus of trigeminal
(lateral to cerebral aqueduct).
- The trochlear nucleus lies close to midline in
the central gray matter (posterior to MLF).
Level of inf. colliculus

- Trochlear nerves decussate in the superior

medullary velum. It is the only cranial nerve
emerging from the post. aspect.
- Decussation of sup. cerebellar peduncles (central
part of the tegmentum anterior to the cerebral
aqueduct); RF is lateral.
- Medial, spinal, trigeminal, and lateral lemnisci
(post. to Substantia nigra).
- Crus cerebri: Corticospinal and corticonuclear
fibers (middle 3/5), Frontopontine fibers (medial
1/5), and Temporopontine fibers (lateral 1/5).

- Edinger-Westphal nucleus: parasymp. nucleus

of the oculomotor nerve.
Level of sup. colliculus

- Pretectal nucleus: close to the lateral part of the

superior colliculus.
- Red nucleus; decussation of rubrospinal tract is
immediate at the level of the red nucleus.
- Oculomotor motor nucleus (posterior to MLF);
emerges through the red nucleus.
- Medial, trigeminal, spinal lemniscus (no lateral
lemniscus as it terminated in the inf. colliculus).
- Crus cerebri: same as the level of inf. colliculus.

Blood Supply of the Midbrain

- Midline (purple): paramedian branches.

- Anterolateral (blue): circumferential
branch of the quadrigeminal and posterior
choroidal arteries.
- Posterolateral (green): medial posterior
choroidal arteries.
- Posterior / Tectum (yellow):
quadrigeminal artery and superior
cerebellar artery.
- At the level of the sup. colliculus: the
most lateral (red) parts are supplied by
the Thalamogeniculate artery, a branch of
the posterior cerebral artery.
 Brain Syndrome
Medulla Oblongata
Medial medullary
syndrome
Lesion in anterior spinal
artery
(Dejerine syndrome)
Lateral medullary
syndrome / PICA
syndrome Lesion in PICA
(Wallenberg syndrome)
Vascular lesions of the
- - Spinal trigeminal nucleus: ipsilateral loss of pain and
posterior spinal artery
Foville syndrome Occlusion of the
paramedial branches
Damage to the root of the
Millard-Gubler
facial nerve along with
syndrome
corticospinal fibers.
Syndrome of the Paramedial branches and
midpontine base short circumferential
branches
Occlusion of vessels
serving the medial
Weber syndrome portions of the midbrain
involving the oculomotor
nerve and the crus cerebri.
Occlusion of vessels
serving the central area of
Claude syndrome the midbrain which
includes the oculomotor
nerve and the red nucleus.
Benedikt syndrome - - It is a combination of Weber + Claude syndrome.
Symptoms
- Contralateral hemiparesis.
- Contralateral loss of PCML sensations.
- Deviation of the tongue to the ipsilateral side when it is protruded.
- Alternating hemiplegia: upper and lower limbs are paralyzed in the
contralaterally, whereas the face is paralyzed ipsilaterally.
- Symptoms related to the cranial nerve (ipsilaterally)
- Contralateral loss of ALS sensations.
- Spinal trigeminal nucleus: ipsilateral loss of pain and
temperature sensation from the face.
- Vestibular nuclei: vertigo and nystagmus.
- Solitary nucleus: loss of taste from the ipsilateral half of the
tongue.
- Nucleus ambiguous: hoarseness and dysphagia.
- Hypothalamospinal fibers: ipsilateral Horner syndrome.
- Ipsilateral loss of PCML sensations.
temperature sensation from the face.
Pons
- Ipsilateral abducens nerve paralysis.
- Corticospinal fibers: contralateral hemiparesis.
- Symptoms related to cranial nerves ipsilaterally.
- Contralateral hemiparesis.
- Ipsilateral paralysis of the facial muscles.
- Corticospinal fibers: contralateral hemiparesis.
- Ipsilateral cranial nerve sign.
- Sensory and motor trigeminal nuclei: ipsilateral loss PCML
sensations and paralysis of the masticatory muscles.
- Fibers of the middle cerebellar peduncle: ataxia.
Midbrain
- Ipsilateral paralysis of all extraocular muscles except the lateral
rectus and superior oblique.
- Paralysis of the contralateral extremities.
- Oculomotor nerve: ipsilateral dilatation of the pupil.
- A contralateral weakness of the facial muscles of the lower half of
the face.
- Ipsilateral paralysis of most eye movements; the eye is directed
down and out (laterally).
- Oculomotor nerve: ipsilateral dilatation of the pupil.
- Red nucleus: contralateral ataxia, tremor, and incoordination.
Tala Saleh
Neuroanatomy
Dr. Maha ELBeltagy
Associate Professor of Anatomy
Faculty of Medicine
The University of Jordan
2021
Blood Supply of Brain and Spinal Cord
 Arterial Supply of Brain
The brain receives blood from two sources: the internal carotid
arteries, which arise at the point in the neck where the common
carotid arteries bifurcate, and the vertebral arteries
The internal carotid arteries branch to form, the anterior and
middle cerebral arteries
70% blood is delivered to ICA

The right and left vertebral arteries come together at the level of
the pons on the ventral surface of the brainstem to form the
midline basilar artery
The basilar artery joins the blood supply from the internal carotids
in an arterial ring at the base of the brain (in the vicinity of the
hypothalamus and cerebral peduncles) called the circle of Willis
The posterior cerebral arteries arise at this confluence, as do two
small bridging arteries, the anterior and posterior communicating
arteries
 Physiological Significance
Circle of Willis

The arrangement of the brain's arteries

into the Circle of Willis creates collaterals
in the cerebral circulation
If one part of the circle becomes blocked
or narrowed (stenosed) or one of the
arteries supplying the circle is blocked or
narrowed, blood flow from the other
blood vessels can often preserve the
cerebral perfusion well enough to avoid
the symptoms of ischemia
 Internal Carotid Artery

Arises from common carotid artery in

the neck, entering head at skull base
via the carotid canal, and terminates at
bifurcation into the anterior cerebral
artery (ACA) and middle cerebral artery
(MCA)
 Internal Carotid Artery

•Branches:
•Ophthalmic A
• A to the anterior pituitary and stalk

•posterior communicating artery.

•anterior choroidal artery (AChA)

•bifurcating into the ACA and MCA

Branches of Internal Carotid Artery
The anterior cerebral artery(ACA):
Runs medially & forwards in the longitudinal fissure along corpus callosum & ends by passing
upwards near the parieto-occipital fissure.
Branches:
- Cortical branches: For the medial surface back to the parieto-occipital fissure. To a strip one
inch below the superomedial border on the lateral surface back to the parieto-occipital fissure
& to the medial ½ of the orbital surface.
- Central branches: to the anterior part of corpus striatum & part of anterior limb of internal
capsule.
- Septal branches for septum lucidum.
- Callosal branches for corpus callosum except the splenium.

Anterior
cerebral artery
The middle cerebral artery (MCA):
Runs laterally in the lateral fissure to the insula where it divides into
terminal branches which appear on the lateral surface.
Branches:
- Cortical branches: supply the superolateral surface back to the parieto-
occipital fissure (except the upper one inch below the superomedial
border which is supplied by ACA), the lateral ½ of orbital surface & the
temporal pole.
- Central branches: Supply posterior part corpus striatum & internal
capsule. MCA
The posterior cerebral artery (PCA):
Curves backwards around the midbrain & comes below the splenium of corpus callosum where it
divides into branches which run in the calcrine & parieto-occipital fissure.
Branches:
- Cortical branches: to the lateral & medial surface behind the parieto-occipital fissure & to
the tentorial surface except the temporal pole.
- Short medial central branches: pierce the posterior perforated substance & supply the
cerbral peduncles, mammillary bodies & anterior part of thalamus.
- Long lateral central branches: Curve around the midbrain to supply the midbrain, geniculate
bodies & back of thalamus.
- Posterior choroidal artery: arises from the PCA below the splenium of cc & supplies the
choroid plexuses of the 3rd & lateral ventricles & the dorsum of thalamus.
Vertebral arteries
Arises from the 1st part of the
subclavian artey.

Inside the skull, the two

vertebral arteries join up to
form the basilar artery at the
base of the medulla oblongata

The basilar artery is the main

blood supply to the brainstem
and connects to the Circle of
Willis to potentially supply the
rest of the brain if there is
compromise to one of the
carotids
 VERTEBRAL ARTERY
BRANCHES:
1. ANTERIOR + POSTERIOR SPINAL A.
2. PICA (posterior inferior cerebellar artery)
3. Medullary branches

BASILAR ARTERY BRANCHES:

1. AICA (Anterior inferior cerebellar artery)
2. INTERNAL AUDITORY A.
3. SUPERIOR CEREBELLAR A.
4. POSTERIOR CEREBRAL A.
5. MEDULLARY AND PONTINE PERFORATING
ARTERIES
Vertebrobasilar arteries angiogram
 Circulus Arteriosus (Circle of Willis)
It is found around the interpeduncular fossa & is formed by the following arteries:
- Right & left anterior cerebral arteries which are connected by anterior communicating
artery.
- Right & left internal carotid arteries .
- Right & left posterior cerebral arteries.
- Right & left posterior communicating arteries which connect the internal carotid arteries
with the posterior cerebral arteries.
anterior communicating artery
Anterior cerebral artery

Posterior
communicating
artery

Posterior
cerebral artery
Blood supply of the internal capsule
Blood supply of the basal ganglia
Blood Supply to Cerebellum
Superior cerebellar
artery (SCA) from
basilar artery
Anterior inferior
cerebellar artery (AICA)
from basilar artery
Posterior inferior
cerebellar artery (PICA)
from vertebral artery
Blood Supply to Spinal Cord
The spinal cord is supplied with blood by three arteries that
run along its length starting in the brain, and many arteries
that approach it through the sides of the spinal column
The three longitudinal arteries are called the anterior spinal
artery, and the right and left posterior spinal arteries
These travel in the subarachnoid space and send branches
into the spinal cord
They form anastomoses via the anterior and posterior
segmental medullary arteries, which enter the spinal cord at
various points along its length
Supply blood up to cervical segments
 NOT FOR EXAM

Blood Supply to Spinal Cord

Arterial blood supply below the cervical region comes from the
radially arranged posterior and anterior radicular arteries, which run
into spinal cord alongside the dorsal and ventral nerve roots
These intercostal and lumbar radicular arteries arise from the aorta,
provide major anastomoses and supplement the blood flow to the
spinal cord.
Largest of the anterior radicular arteries is known as the artery of
Adamkiewicz (abodomial aorta) which usually arises between L1 and
L2
Impaired blood flow through these critical radicular arteries,
especially during surgical procedures that involve abrupt disruption
of blood flow through the aorta for example during aortic aneursym
repair, can result in spinal cord infarction and paraplegia
Arterial Supply to Spinal Cord
 NOT FOR EXAM

Extra-dural Hemorrhage
It results from injuries of the meningeal arteries or veins
The most common is the anterior branch of the middle meningeal artery.

A minor blow to the side of the head result in fracture of the anteroinferior
portion of the parietal bone (pterion)

The intracranial pressure rises. The blood clot exerts local pressure on the
underlying motor area in the precentral gyrus.

Blood may pass out through the fracture line to form a soft swelling under
the temporalis muscle

The burr hole through the skull wall should be placed 2.5 to 4 cm above
the midpoint of the zygomatic arch to ligate or plug the torn artery or vein
 NOT FOR EXAM

Sub-dural Hemorrhage
It results from tearing of the superior cerebral veins at their
entrance into the superior sagittal sinus.
Cause is a blow on the front or back of the head causing
anteroposterior displacement of the brain within the skull.
Blood under low pressure begins to accumulate in the space
between the dura and arachnoid.
Acute symptoms in the form of vomiting due to rise in the
venous pressure may be present. In the chronic form, over a
several months, the small blood clot will attract fluid by
osmosis so a hemorrhagic cyst is formed and gradually
expands produces pressure.
MRI showing fronto temporal Subdural haemorrage
Sub-dural Hemorrhage
 NOT FOR EXAM

Subarachnoid Hemorrhage
It results from leakage or
rupture of a congenital
aneurysm on the circle of
Willis
The sudden symptoms
include severe headache;
stiffness of the neck and
loss of consciousness
The diagnosis is
established by
withdrawing heavily
blood- stained CSF fluid
through a lumbar
puncture ( spinal tap )
 NOT FOR EXAM
Difference between subdural and epidural haemorrages
 Cerebral artery syndromes
Anterior Cerebral Artery Occlusion
Occlusion distal to the communicating artery may produce the
following signs and symptoms:
1. Contralateral hemiparesis and hemisensory loss involving
mainly the leg and foot (paracentral lobule of cortex).
2. Inability to identify objects correctly, apathy, and personality
changes (frontal and parietal lobes).

Middle Cerebral Artery Occlusion

1. Contralateral hemiparesis and hemisensory loss involving mainly the
face and arm (precentral and postcentral gyri)
2. Aphasia if the left hemisphere is affected (rarely if the right
hemisphere is affected)
3. Contralateral homonymous hemianopia (damage to the optic
radiation)
4. Agnosia if the right hemisphere is affected (rarely if the left
hemisphere is affected)
 Posterior Cerebral Artery Occlusion

1. Contralateral homonymous hemianopia with some degree of

macular sparing (damage to the calcarine cortex, macular sparing due to
the occipital pole receiving collateral blood supply from the middle
cerebral artery).
2. Visual agnosia (ischemia of the left occipital lobe)
3. Impairment of memory (the medial aspect of the temporal lobe)

Internal Carotid Artery Occlusion

1. The symptoms and signs are those of middle cerebral artery

occlusion, including contralateral hemiparesis and hemianesthesia.

2. There is partial or complete loss of sight on the same side, but

permanent loss is rare (emboli dislodged from the internal carotid
artery reach the retina through the ophthalmic artery).
 Vertebrobasilar Artery Occlusion
1- Ipsilateral pain and temperature sensory loss of the
face and contralateral pain and temperature sensory loss
of the body.

2. Attacks of hemianopia or complete cortical blindness.

3. Ipsilateral loss of the gag reflex, dysphagia, and

hoarseness as the result of lesions of the nuclei of the
glossopharyngeal and vagus nerves.

4. Vertigo, nystagmus, nausea, and vomiting

5. Ipsilateral Horner syndrome

6. Ipsilateral ataxia and other cerebellar signs.

7. Unilateral or bilateral hemiparesis.

8- Comma
THANK YOU
 Neuroanatomy
Dr. Maha ELBeltagy
Associate Professor of Anatomy
Faculty of Medicine
The University of Jordan
2021

10/15/17 Prof Yousry

Development of the Central
Nervous System
 Development of the nervous system
Development of the neural tube:
- At the beginning of the 3rd week an ectodermal thickening appears in the middle of
the trilaminar germ disc known as the neural plate.
- The neural plate invaginates to form a neural groove.
- The lips of the neural groove approach each other & fuse together transforming the
groove into a neural tube with an anterior & posterior neuropores which are obliterated
on day 25 & 27 respectively transforming the neural tube into a closed tube.
 Development of the spinal cord
The neural tube is lined by one cell layer called
matrix.

This epithelium, which extends from the cavity of

the tube to the exterior, is referred to as the
ventricular zone.

Repeated division of the matrix cells results in an

increase in length and diameter of the
neural tube.

cells migrate peripherally to form the

intermediate zone (grey matter).

The neuroblasts give rise to nerve fibers that grow

peripherally and form a layer external to the
intermediate zone called the marginal zone
(myelinated white matter).

neuroblasts give rise to astrocytes and

oligodendrocytes .

Microglia is derived from surrounding

mesenchym
the cells in the lateral wall of the neural tube proliferate & are differentiated into 3 layers:
- Inner ependymal Layer: forms the ependymal lining of the central canal &
ventricles.
- Middle Mantle Layer: Cellular layer which forms the grey matter of the spinal cord.
- Outer Marginal Layer: forms the white matter of the spinal cord.
• The thick lateral walls are connected together by thin roof plate (dorsal) & floor plate
(ventral).
• A groove (sulcus limitans) appears in the lateral wall dividing it into:
- Dorsal part (Alar Plate) which expands to form the dorsal (sensory) horn.
- Ventral part (basal plate) which expands to form the ventral (motor) horn.
• The cavity of the tube remains narrow & forms the central canal of the spinal cord.
Development of sensory and motor roots
 Development of the Meninges
The pia, arachnoid and dura maters are
formed from the mesenchyme.
(sclerotome) that surrounds the neural
tube.
The subarachnoid space develops as a
cavity in the mesenchyme, which becomes
filled with cerebrospinal fluid.

During the first 2 months of intrauterine life,

the spinal cord is the same length as the
vertebral column.

at birth, the coccygeal end of the cord lies

at the level of the third lumbar vertebra.

In the adult, the lower end of the spinal

cord lies at the level of
the lower border of the body of the first
lumbar vertebra.
The oblique spinal nerves below L1 form
the cauda equina.
Congenital Malformations of spinal cord development
1) Spina bifida occulta: Absent vertebral arch with normal spinal cord. It
affects the lumbosacral area & is usually covered with hairy skin.
2) Spina bifida cystica:
- Meningocele: The meninges herniates through the spina bifida to form
subcutaneous sac filled with CSF.
- Meningomyelocele: The spinal cord herniates through the meningocele.
- Myelocele (Rachischisis): Failure of obliteration of the neural tube.
 Development of the brain
The cranial part of the neural tube forms 3 brain vesicles:
- Forebrain vesicle(Prosencephalon): forms 2 lateral evaginations which develop to
form the 2 cerebral hemispheres (their cavities form the lateral ventricles)& the
median part develops to form the diencephalon (its cavity forms the 3rd ventricle.
- Midbrain vesicle (Mesencephalon): develops to form the midbrain & its cavity
forms cerebral aqueduct.
- Hindbrain vesicle (Rhombencephalon): develops to form pons, medulla &
cerebellum. Its cavity forms the 4th ventricle.

Prof Yousry
 Embryonic (developmental) divisions of the Brain
Primary vesicle Secondary vesicle Derivatives

Prosencephalon telencephalon Cerebral cortex

Cerebral white matter
Basal ganglia
diencephalon Thalamus
Hypothalamus
Subthalamus
Epithalamus

Mesencephalon mesencephalon Midbrain

Rhombencephalon metencephalon Cerebellum

Pons

myelencephalon Medulla oblongata

 DEVELOPMENT OF THE MEDULLA
OBLONGATA
• As in the development of the spinal cord the medulla will have an alar plate & a
basal plate separated by a sulcus limitans & connected by a thin roof plate & a
floor plate.
• The lateral walls move away from each other stretching the roof plate & enlarging
its cavity which forms the 4th ventricle.
The alar plate forms the sensory nuclei of the medulla & the basal plate forms the
motor nuclei.
Between the fourth and fifth months, local resorptions of the roof plate
occur, forming lateral foramina of Luschka, and a median foramen of
Magendie.
 Development of the pons & cerebellum
• The same steps in the development of the medulla occur but the alar plates bend
medially to form 2 rhombic lips.
• The rhombic lips approach each other & fuse together forming a cerebellar plate.
• The cerebellar plate differentiates into a median part which forms the vermis & 2
lateral masses which form the cerebellar hemispheres.
• The cavity forms part of the 4th ventricle.
 Development of Midbrain
• As in the development of the spinal cord & the medulla the midbrain will have an alar plate &
a basal plate separated by a sulcus limitans & connected by a thin roof plate & a floor plate.
• The alar plates develop to form the tectum which is divided by a vertical & transverse
grooves into 4 colliculi.
• The basal plate forms the motor nuclei in the tegmentum of midbrain
• The marginal layer of the basal plate enlarges greatly to form the crus cerebri.
• It cavity remains narrow & forms the cerebral aqueduct.

Prof Yousry
Development of the Diencephalon
It develops from the median part of the forebrain. It consists of 2 lateral walls
connected by a roof plate & a floor plate, its cavity is called the 3rd ventricle.
The roof plate:
- Its anterior part forms the choroid plexus of the 3rd ventricle.
- Its posterior part forms the pineal body.
A hypothalamic sulcus appears in the lateral wall which separates the thalamus above
from the hypothalamus below.
The floor plate forms the posterior lobe of the pituitary gland.
Development of the cerebral hemisphere
The 2 cerebral hemispheres arise as 2 evaginations from the lateral wall of the
forebrain.
The cavity of each of them expands to form the lateral ventricle.
The wall of the hemisphere consists of 3 layers: ependymal, mantle & marginal.
The mantle layer at the base of the hemisphere forms the basal ganglia.
The hemispheres enlarge & overlaps the brain stem & cerebellum.
 Congenital Malformations of brain development
1) Hydrocephalus: It is of 2 types
- Internal hydrocephalus: Excessive accumulation of CSF within the ventricles of the
brain.
- External hydrocephalus: Excessive accumulation of the CSF between the brain &
arachnoid mater.
2) Exencephaly: It is due to failure of closure of anterior neuropore. The vault of the
skull is absent & the brain is exposed. When the brain is degenerated the
anaomaly is known as Anencephaly.
3) Menigocele: the meninges herniated through a deficient part of the skull.
4) Meningoencephalocele: part of the brain herniated through the meningocele.
5) Meningo-hydro-enecephalocele: part of the ventricle is found within the brain
tissue which herniated through the meningocele.
6) Holoprosencephaly: Results from degeneration of midline structures leading to
fusion of lateral ventricles, orbital & nasal cavities.
THANK YOU
 Neuroanatomy
Dr. Maha ELBeltagy
Associate Professor of Anatomy
Faculty of Medicine
The University of Jordan
2021

Dr Maha ELBeltagy
 NOTE
These modified slides don't contain
everything the doctor mentioned in
the lectures, I've only added some
notes and some lines on the
pictures so they would be easier to
study
 THE NERVOUS SYSTEM (NS)
It is divided into 2 major divisions:
1) Central Nervous System (CNS): found within bones & consists of:
* The Brain: within the skull
* The spinal cord: within the vertebral canal.

2) Peripheral Nervous System (PNS): Consists of:

A) Autonomic nervous system: which is divided into:
* Sympathetic nervous system.
* Parasympathetic nervous system.
B) Somatic nerves:
* Cranial nerves (12 pairs): Connected to the brain.
* Spinal nerves (31 pairs): Connected to the spinal cord.

Dr Maha ELBeltagy
Dr Maha ELBeltagy
 THE CENTRAL NERVOUS SYSTEM
It consists of: Brain

1) The brain: Within

the skull.
2) The spinal cord:
Within the Spinal cord
vertebral canal.

Dr Maha ELBeltagy
 THE BRAIN
It consists of:
1) Cerebrum:
- 2 Cerebral hemispheres
separated from each other
by median fissure
- Diencephalon.
2) Brain Stem:
- Midbrain
- Pons
- Medulla
3) Cerebellum:
- 2 cerebellar hemispheres
- Vermis
Functional Classification of Neurons:
1) Afferent (sensory) neurons: convey
information from tissues and organs into the
central nervous system (CNS).
2) Efferent (motor)neurons: transmit signals
from the CNS to the effector organs (muscles
& glands).
3) Interneurons: connect neurons within specific
regions of the CNS.

Dr Maha ELBeltagy
 THE CEREBRAL HEMISPHERES
• 4 lines divide each
hemisphere into 4 lobes:
- The central sulcus.
- Posterior ramus of lateral
fissure.
- Imaginary line between
Parieto-occipital fissure &
Preoccipital notch.
- Imaginary line connecting
the posterior ramus of
lateral fissure to the Occipital
previous line. lobe
• Each hemisphere is divided
into 4 lobes:
- Frontal lobe.
- Parietal lobe.
- Temporal lobe.
- Occipital lobe.

Dr Maha ELBeltagy
 Components of the cerebral hemisphere
It consists of:
1) Grey matter. Median fissure
2) White matter.
3) Basal nuclei. 1 2

4) Lateral ventricle. 4
3

Dr Maha ELBeltagy
 SURFACES OF THE CEREBRAL HEMEISPHERE
Each hemisphere has 3
surfaces:
• Superolateral surface.
• Medial surface.
• Inferior surface. Medial
surface

Dr Maha ELBeltagy
Inferior
surface
• The surfaces of the cerebral hemisphere show elevations called
GYRI & grooves called SULCI.
• Deep sulci are called fissures.
• The surface of the hemisphere is divided into different areas.
• Each area contains a group of cells that perform a specific
function.

sulcus
gyrus

Dr Maha ELBeltagy
 THE SUPEROLATERAL SURFACE
Important sulci & gyri:

Central sulcus (of Rolando):

Extends from the superomedial border at a point a little behind the midpoint between the frontal
& occipital poles. It ends slightly above the middle of the posterior ramus of lateral fissure.

Lateral fissure (of Sylvius):

It begins on the inferior surface & extends laterally to reach the lateral surface

Parieto – occipital fissure: Between Parietal & occipital lobes.

Central sulcus

Parieto-occipital
fissure

Dr Maha ELBeltagy Posterior

Lateral fissure ramus
 Sulci & Gyri of the frontal lobe
Precentral sulcus
- Precentral sulcus: Parallel to & one
Superior frontal sulcus
finger in front of the central
sulcus.
- Superior Frnontal sulcus
- Inferior frontal sulcus
Gyri of the Frontal lobe:
Inferior
It is divided by the sulci of the frontal
sulcus
frontal lobe into: Central
sulcus
A) Precentral gyrus: Between
central & precentral sulci.
B) Superior & inferior frontal sulci
divide the remaining part
equally into superior, middle &
inferior frontal gyri
Lateral fissure

Dr Maha ELBeltagy
 Sulci & Gyri of the Temporal lobe
• It contains 2 sulci : Superior & inferior temporal sulci.
• The 2 sulci divide the temporal lobe into 3 gyri:
superior, middle & inferior temporal gyri.

Superior
temporal
sulcus

Inferior
Dr Maha ELBeltagy temporal
sulcus
 The insula (Island of Reil)

• It lies at the bottom of the lateral

fissure.
• Taste sensation

Dr Maha ELBeltagy
 Sulci & Gyri of the Parietal lobe

central sulcus Postcentral sulcus

• Postcentral sulcus: parallel to
& one finger behind the central
sulcus.
• Postcentral gyrus: Between the
central & postcentral sulci

Dr Maha ELBeltagy
 The Occipital Lobe

Dr Maha ELBeltagy
 Sulci & Gyri of the medial surface

- Callosal sulcus surrounds CC.

- Cingulate sulcus runs parallel to CC & terminates by turning
upwards.
- Cingulate gyrus lies between CC & cingulate sulcus.
- Parieto-occipital fissure between the parietal & occipital lobes.
- Calcarine sulcus (visual centre).
Central sulcus
Parieto - occipital
fissure

Corpus callosum
Callosal
sulcus Calcarine sulcus
Cingulate
sulcus
Dr Maha ELBeltagy
 Sulci & Gyri of the inferior surface of the brain

The inferior surface is divided by

the stem of the lateral fissure orbital
into a smaller anterior part surface
known as the orbital surface
& a posterior part known as
the tentorial surface.
tentorial
surface

Dr Maha ELBeltagy
 Functional Localization of Cerebral Cortex
Sensory area
primary sensory area (post centeral gyrus)

Motor area
primary motor area (precenteral gyrus)
secondary motor area (premotor area 6)

Association area
*parietal, occipital and temporal cortex
*prefrontal (frontal) cortex

Dr Maha ELBeltagy
Primary Sensory area
3,1,2
• postcentral gyrus of lateral
surface of opposite side.
• Body is represented upside
down.
• Lower limb and genital areas
extend to the medial surface
• Lesion sensory loss on the
opposite side.

Dr Maha ELBeltagy
 Visual Cortex

V I ----- 17 (primary visual center) around calcarine sulcus.

visual field defect on the opposite side

Lesion: contralateral hemianopia (loss of half of the field of vision

on the other side)
V II ---- 18, 19 (visual association area) rest of occipital lobe.
integration of vision with past experience
Lesion: visual agnosia

Dr Maha ELBeltagy
 Visual
A reas

Dr Maha ELBeltagy
 Visual
association
areas

V4
(color) Face
recognition
Perceive
Facial Expression

Dr Maha ELBeltagy
 Auditory Cortex

A I ----- 41, 42 (middle of superior temporal gyrus) primary

hearing center
When a lesion happens :
Slight diminution in auditory acuity (not a complete loss)
mainly on the contralateral side.

Auditory association areas

*A II ---- 22 rest of temporal gyrus

*(Wernike's area) 39 around posterior ramus of lateral

fissure.

Dr Maha ELBeltagy
lesion auditory agnosia - sensory aphasia
 Auditory Areas (SUPERIOR TEMPORA L GY RUS)

A I primary auditory
----- 41, 42
Lesion: hearing
defect

A II auditory
association---- 22
Lesion : auditory
agnosia

Dr Maha ELBeltagy
Dr Maha ELBeltagy
 Motor Areas

primary Motor Area (M I) area 4

Premotor Area (PM) area 6

Frontal Eye Field area 8

Broca’s area of speech 44,45

Dr Maha ELBeltagy
 Primary Motor Area

M I ------- 4
• precentral gyrus of lateral surface of
opposite side.
• Body is represented upside down.
• Lower limb and genital areas extend to the
medial surface
• Controls fine movements of hands and feets.

lesion (contralateral hemiplagia)

Dr Maha ELBeltagy
Motor Homunculus

Dr Maha ELBeltagy
 Other Motor Areas

Secondary Premotor Area 6 (PM) ------ In front

of primary motor area 4.
Controls trunk and proximal parts of both limbs

Frontal Eye Field ---------- 8 (in front of area 6)

voluntary tracking movement (conjugate movements
of both eyes to the opposite side

Dr Maha ELBeltagy
 Speech area 44,45

Dr Maha ELBeltagy
 THE MAIN FUNCTIONAL AREAS OF
THE DIFFERENT LOBES OF THE BRAIN
The Frontal lobe:
• Contains motor area (4) which
controls muscles of the
opposite half of the body.
Premotor area (6), Frontal eye
field (8) & Broca’s (motor)area
for speech (44,45)
The parietal lobe:
- Contains the sensory area (3,1,2)
for the opposite half of the
body.
- Wernicke’s area (39)
The temporal lobe:
Contains hearing center (41,42,22).
The occipital lobe:
Contains center for vision
(17,18,19).

Dr Maha ELBeltagy
THANK YOU

Dr Maha ELBeltagy
Neuroanatomy
Dr. Maha ELBeltagy
Associate Professor of Anatomy
Faculty of Medicine
The University of Jordan
2021

Dr Maha ELBeltagy
 NOTE

These modified slides do not

contain everything the doctor
mentioned in the lectures, I've only
added some notes and some lines
on the pictures so they would be
easier to study
 Dr Maha ELBeltagy

THE WHITE MATTER OF THE BRAIN

The white matter of the brain

consists of:
1) Association fibers:
Connect different areas
in the same hemisphere.
2) Commissural fibers:
Connect similar areas
between the 2
hemispheres.
3) Projection fibers: Fibers
from & to the cerebral
cortex.
Corpus Callosum: Dr Maha ELBeltagy

It is the great transverse commissure that connects

the cerebral hemispheres & roofs the lateral
ventricle. It is divided into 4 parts ; rostrum, Body
genu, body & splenium.
Fibers of the genu curve forwards to connect frontal
lobes forming “Forceps minor”. Genu
Fibers of splenium curve backwards to connect Rostrum
occipital lobes forming “Forceps Major”.
Blood Supply: It is supplied by anterior cerebral
artery except the splenium by the posterior
cerebral artery
 Dr Maha ELBeltagy

Projection
A) Projection fibers TO the cortex:
fibers
Include all thalamo-cortical fibers (thalamic radiation).
- Sensory radiation: From the ventral posterolateral nucleus of the
thalamus (PLVNT) to area 3,1,2 in the postcentral gyrus.
- Visual radiation: from lateral geniculate body (in the thalamus) to
the visual area 17 in the occipital lobe.
- Auditory radiation: from the medial geniculate body (in the
thalamus) to the auditory area in the temporal lobe.
 Dr Maha ELBeltagy

B) Projection fibers FROM the cortex:

Include the following fibers:
- Pyramidal tracts.
- Extrapyramidal tracts.
- Cortico-pontine fibers.
- Cortico-thalamic fibers.
 Internal Capsule Dr Maha ELBeltagy

It is a V-shaped bundle of
projection fibers between
thalamus, caudate (medially) &
lentiform nuclei (laterally). It is Internal
divided into anterior limb, genu, capsule
Caudate nucleus
posterior limb, retrolentiform &
sublentiform parts. 1.Anterior limb
Lesions lead to loss of sensation
and motor functions on the
opposite side 3. Posterior External
limb capsule

Lentiform
nucleus

thalamus

Lentiform
Dr Maha ELBeltagy
 Dr Maha ELBeltagy

SUBDIVISIONS OF Basal Ganglia

A. Caudate nucleus
B. Lentiform nucleus

- Putamen(Lateral part)

- Globus Pallidus (medial part)

C. Amygdela
D. Substantia nigra (midbrain)
E. Claustrum
 Dr Maha ELBeltagy

Horizontal section , Basal ganglia and lateral ventricle

 Dr Maha ELBeltagy

Caudate nucleus

• C-shaped
• Head, body, tail
• Large head, tapering curved tail
• Head-frontal lobe
• Tail-occipital lobe
• End of tail-temporal lobe
-terminates in amygdaloid nucleus
 Dr Maha ELBeltagy

Lentiform
nucleus
• Lens-like nucleus which
consists of 2 parts: large
lateral dark part called
“putamen” & small medial
pale part called “globus
pallidus”. It is surrounded
by external capsule
(laterally) & internal
capsule (medially).
 Dr Maha ELBeltagy

Amygdaloid
Nucleus
In the temporal lobe
Responsible for sense of fear

Subtantia Nigra
Midbrain and Diencephalon
Substantia Nigra
(Dopamine/inhibitory)

Claustrum
UNKNOWN FUNCTION
 Dr Maha ELBeltagy

FUNCTIONS OF Basal Ganglia

• Voluntary movement
Initiation of movement
Change from one pattern to other
Programming and correcting movement while in progress of
learning skills (football,drawing,singing,…)

• Postural control
Automatic associated movement (walking)
Control axial and girdle movements

No direct connection with spinal cord or brain stem

(no tracts), it functions through neurotransmitters.
 Dr Maha ELBeltagy

Disease of basal ganglia

Hypokinetic
• Parkinsonism
• Effect on the opposite side
– Degeneration of dopamine-producing
cells in substantia nigra-depletion of
dopamine in striatum
 Dr Maha ELBeltagy

Disease of basal ganglia

Hyperkinetic
•Huntington’s disease
– hereditary disease of unwanted movements. It
results from degeneration of the caudate and
putamen, and produces continuous dance-like
movements of the face and limbs –choreoathetosis
Dr Maha ELBeltagy
 Dr Maha ELBeltagy

Interventricular
The lateral ventricle foramen
It is Y-shaped cavity in the cerebral
hemisphere with the following parts:
1) A central part (body): Extends from the
interventricular foramen to the splenium
of corpus callosum.
2) 3 horns:
- Anterior horn: Lies in the frontal lobe in
front of the interventricular foramen.
- Posterior horn : Lies in the occipital lobe.
- Inferior horn : Lies in the temporal lobe.
It is connected to the 3rd ventricle by
interventricular foramen (of Monro).

Interventricular
foramen
 Dr Maha ELBeltagy

The lateral ventricle

Corpus
Body callosum

Choroid
plexus

anterior
horn

Interventricular
Posterior horn foramen
Bulb of post horn
Calcar avis Thalamus Caudate
Inferior
Choroid plexus nucleus
horn

Superior view
 The Diencephalon Dr Maha ELBeltagy

• The cavity of the 3rd ventricle divides the diencephalon into 2 halves.
• Each half is divided by the hypothalamic sulcus (which extends from the
interventricular foramen to the cerebral aqueduct) into ventral & dorsal parts:
Dorsal part includes:
- Thalamus, Epithalamus & Metathalamus.
Ventral part includes:
- Hypothalamus & Subthalamus
Interventricular foramen
(posterior to the anterior
column of the fornix)

Thalamus
Hypothalamic
sulcus
Hypothalamus

cerebral aqueduct
(its blockage causes
accumulation of CSF in
tissues -> hydrocephalus
Thalamic Nuclei
Dr Maha ELBeltagy
 Dr Maha ELBeltagy
The Thalamus:
It is a large egg shaped mass of grey matter which forms the main sensory relay station for the cerebral cortex.
It forms part of the lateral wall of the 3rd ventricle & the part of the floor of the body of the lateral
ventricle. The 2 thalami are connected by interthalamic adhesion.
The epithalamus:
Consists mainly of the pineal body & posterior commissure.
Metathalamus:
Consists of lateral & medial geniculate bodies which lie at the junction of the posterior & inferior surfaces of
the thalamus.
-The Lateral geniculate body is connected in front with the optic tract & behind it gives optic radiation to the
occipital lobe.
- The medial geniculate body is connected receives brachium of inferior colliculus which transmits auditory
sensations.

Thalamus Pineal
Interthalamic
body
adhesion

posterior
commissure
 Dr Maha ELBeltagy
Hypothalamus: It includes:
- Mammillary bodies.
- Tuber cinereum & infundibulum.
- optic chiasma
- lamina terminalis

Subthalamus:
Lies between thalamus & tegmentum of midbrain. Substantia Red nucleus
nigra

lamina
terminalis

Mammillary
Tuber body
optic chiasma
cinereum
 The third ventricle Dr Maha ELBeltagy

Anterior
Roof

wall
It is a narrow slit like cleft
between the 2 halves of the Posterior
diencephalon. wall
Floor
Boundaries:
- Roof: Thin layer of
ependyma (1).
- Anterior wall: Columns of
fornix (2), anterior
commissure (3), Lamina
terminalis (4) &
- Floor: Hypothalamus [ optic 1 Roof
chiasma (5), tuber cinereum 2
(6) Mammillary body (7)] & Thalamus
Anterior 3
tegmentum of midbrain.
wall
- Posterior wall: Pineal body 4 8
(8), posterior commissure (9) Hypothalamus 9 Posterior
& aqueduct of sylvius (10). wall
- Lateral wall: Thalamus & 6 7 tegmentum
hypothalamus. 5 of midbrain
Floor 10
 Dr Maha ELBeltagy

Connections:
The 3rd ventricle is connected with the lateral
ventricle through interventricular foramen
(foramen of Monro) & with the 4th ventricle
through cerebral aqueduct.
 Dr Maha ELBeltagy

The Meninges
The brain is covered with 3 layers (meninges):
1) Pia mater: It is a delicate membrane which is adherent to the brain & dips into its sulci.
In certain areas the wall of the ventricles is formed of thin layers of ependyma. In these
regions the pia mater is invaginated into the cavities forming vascular tufts known as
“Choroid Plexus” which secretes CSF into the ventricles.

Tela Choroidea

Lateral ventricle
Choroid plexus
Thalamus

Choroid
plexus
3rd ventricle
 Dr Maha ELBeltagy

2) Arachnoid Mater: It is a thin membrane

which covers the pia mater from which it
is separated by subarachnoid space which
contains CSF & blood vessels.
The subarachnoid space is located under
it.
3) Dura mater: The outermost cover of the
brain. It consists of 2 layers.
- Outer fibrous (periosteal) layer: adherent to
the bones of the skull.
- Inner (meningeal) layer: covers the brain &
forms dural folds & sinuses.
- The space between the 2 layers of the dura
(the outer fibrous and inner layers) is
known as the epidural space ..
- The space between the dura & arachnoid
mater is known as the subdural space. Cerebello-
medullary
cistern
Dr Maha ELBeltagy

Falx Cerebri

Tentorium
cerebelli

Outer layer of dura

mater
 The Cerebrospinal Fluid (CSF) Dr Maha ELBeltagy

It is the fluid filling the ventricles & central canals of the CNS
(about 135 ml).
Production of CSF: It is secreted by the choroid plexuses in
the medial wall of the lateral ventricles & the roof of the
3rd & 4th ventricles
Circulation of CSF: It circulates in the ventricles & central
canals of the CNS. It leaves the lateral ventricle through
interventricular foramen to the 3rd ventricle then to the
4th ventricle through cerebral aqueduct of midbrain &
leaves the 4th ventricle through its 3 apertures to the
subarachnoid space forming a water cushion to protect
the brain & spinal cord.
Absorption of CSF: It is absorbed by arachnoid villi &
granulations to be excreted into the dural venous
sinuses.
THANK YOU