Neuro Review – Week 1

Neuroanatomy - Intro
• Functions of Neurological System
o Sensory input – connected by afferent PNS
 Somatic (somatic – with environment) – eg. Touch, pain, pressure
 visceral – (with internal organs) – stretch, pain, hunger, chemical
changes
o Integration – brain and spinal cord (CNS)
o Motor Output – connected by efferent PNS
 Somatic – motor innervation of all skeletal muscles
 Visceral – parasympathetic, sympathetic
• Types of neurons
o Multipolar – 99% of neurons – many dendrites going to cell body, one
axon – motor neurons, interneurons (lie between sensory and motor – only
in CNS)
o Unipolar – only one pole of cell body, cell body removed from axon –
sensory neurons – next most abundant
o Bipolar – special sensory organs (eg. Eye)
• Support cells
o Oligodendrocyte – makes myelin for neurons in CNS
o Astrocyte – support cell in CNS, feeds, takes in toxins,
o Schwann cell – myelin for neurons in PNS
Embryology
• Neural tube forms from neural plate forming neural tube and neural crest
• Neural crest → forms spinal and autonomic ganglia, schwann cells of peripheral
nervous system
• Neural tube → forms 3 brain vesicles and spinal cord
o Prosencephalon → develops into…
 Telencephalon → cerebral hemispheres and basal ganglia
 Diencephalon → thalamus, hypothalamus (and optic disc)
o Mesencephalon → midbrain enclosing narrow cerebral aquaduct (Sylvius)
o Rhombencephalon → develops into…
 Metencephalon → pons, cerebellum
 Myelencephalon → medulla oblongata
• Problems: lack of closure of neuropores (neural tube defects)
o Anencephaly (cranially)
o Spina bifida (caudally)
 Occulta (closed neural tube defect)
 Cystica (open neural tube defect)
Neurophysiology – The Eye
• Two lenses – fixed cornea, adjustable interior lens (controlled by ciliary muscles)
o Ciliary – donut shaped around lens, control taut springs which when
relaxed keep lens flattened.
 Constriction of donut ciliary decreases diameter loosening springs

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 and allowing lens to return to rounded shape (when people get
older the lens loses elasticity and remains more flat – leaves people
hyper-optic = farsighted)
• Myoptic (near sighted) – cannot see far objects
o Lens is too round, or eye is too long
o Correct with concave lens (counteracts roundness of lens)
• Hyperoptic (far sighted) – cannot see near objects
o Lens is too flat (old age), or eye is too short
o Correct with convex lens (counteracts the flatness of lens)
• Lens works to focus wide image onto pinpoint of fovea for clear viewing
o Iris also can focus by letting in a smaller beam – if iris already only lets in
a pinpoint then lens wouldn’t be needed.
• Cells in the retina
o Receptors – cones and rods (produce on graded changes in potential)
 Function: light strikes photosensitive disks (replaced every 12
days) – sets off chain reaction cascading to increased degradation
of cGMP (less cGMP) (amplification) → cGMP not available for
cGMP gated sodium channels to stay open → several thousand
channels close and cell hyperpolarizes.
 Cones: respond primarily to red, green, blue light (colour blindness
due to lack of one or more type of cones)
 Fovea – mostly cones – high acuity, can see colour (low light
conditions cannot read because this area sees nothing)
• Test with letter chart
 Rest of retina – mostly rods – low acuity (many widely spaced
receptors per ganglion – large convergence) – sees in black and
white
• Test with peripheral field test – missing spots are scotomas
• Signals superior colliculus for visual grasp reflex
o Ganglion cells – only output from the eye – produce action potential, and
send signal via coded frequency of action potential firing.
o Bipolar cells – connect receptors to ganglion cells (graded changes in
potential)
o Horizontal cells – determine how many receptors each ganglion cell sees
o Amacrine cells – determine how many peripheral receptors (rods mostly)
that the ganglion sees
• Receptive field of neuron
o Antagonist surround – on centre off outside cell → functions:
 to accentuate edges – outlines of objects
 constancy – removes background changes in light in affecting
sensation of darkness (black letter looks black in dim light and
bright light) – does so only by measuring change across an edge
o Colour – cortical double opponent cell – same colour receptors in centre
and surround but opposite effect on firing. – the centre and surround

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 produce opposite responses thus retaining colour constancy. (Film cannot
do this thus blue light affects pictures outside and yellow light inside)
• Diseases of Eye:
o Cataract – vision becomes dull and blurry – proteins in lens clump
together and become opaque (cloudy)
o Glaucoma – peripheral vision lost (tunnel vision) – increased pressure
inside eye puts pressure on and affects function of ganglions (large
peripheral ones first)
o Macular degeneration – central vision affected first – breakdown of light
sensitive cells in fovea or blood vessel growth in macula and fovea
(usually no blood vessels in this area) – distorts retinal sheet.
Neurophysiology - Visual Cortex
• Optic chiasm – images seen on the left are processed on the right side of the brain
– ganglions from the medial side of the eye (medial ganglions see lateral images)
cross the brain at the optic chiasm.
• Optic nerves synapse in thalamus at lateral geniculate nucleus (LGN).
Information from each eye does not mix at this point
o In LGN ganglions synapse at 6 layers – 3 from each eye
 Parvocellular (P) layers receive information from ganglia from
mostly foveal receptors – fine details about what an object is
 Magnocellular (M) layers receive information from peripheral
ganglia – coarse details about where an object is.
• Peripheral Ganglion cells also project to brainstem
(superior colliculus – SC) – causes “visual grasp reflex” –
causes head and eye to turn in the direction of an
interesting visual stimulus
• This centres the image on the fovea and then activates P
layers
• LGN Neurons then travel to the mostly medial primary visual cortex (in fold of
calcarine sulcus) aka V1 – all grey matter
o Fovea represented at posterior portion of primary visual cortex
o Peripheral receptors represented more in the anterior half
o Things above line of sight are represented on lower half of calcarine
sulcus and things below line of sight are represented on upper half of
calcarine sulcus.
• Projects to thin layer of grey matter on outside of sulcus (made of 6 layers) aka
V1, aka striate cortex.
Hypercolumns – areas of retina represented by area on visual cortex
o Input comes into the thick layer 4 of this area (Layer 4 cells have round
receptor fields)
o Monocular cells – only driven by input of one eye
Above and below layer 4 –
o Simple cells – elongated receptive fields – maximally activated by lines of
specific orientation
o Complex cells – receptive fields similar to simple cells but line can lie

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 over larger area and they are more receptive to moving lines
 Simple and complex cells responsible for filling in of lines (in
patients with scotomas)
o Binocular cells appear – contribute to visual depth – by disparity between
the two eyes images – give three dimensional appearance
• Hypercolumns extract the following information (Feature channels)
o Stereo-opsis (depth of vision) – combines input from both eyes in
binocular cells (above and below layer 4) – calculated by disparity
between left and right eye image
o Colour – (blobs) centre of each hypercolumn cube are colour sensitive
double opponent cells to determine colour of object
o Edges - Orientation of line segments – radiating in cubes out from each
blob like spokes of a wheel are simple and complex cells of same
orientation
• If early deprivation of one eye (catarcts, blindness, etc). – The there is an
underrepresentation of that eye in the hypercolumn and overrepresentation of the
other eye – in the normal adult one side becomes dominated by one eye, and the
other side by the other
Problems
o Ambylopia: If severe deprivation the weak eye becomes completely
unrepresented (amblyopia – cortical blindness)
 Critical period – most cortical plasticity – in the first year of life.
o Strabismus: if both eyes work fine but don’t align on the same visual
target
 Both areas of cortex are stimulated but not at the same time so
simple cells remain monocular and depth perception/binocular
vision is deficient
 Because strabismus can cause double vision, the image from one
eye can be suppressed and ambylopia can develop (if double
vision).
• Hebbian Plasticity – connections that are synchronous strengthen at the expense
of connections that fire asynchronously. “cells that fire together, wire together”
• Information is then sent from V1 to V2 then to V3 – the image being mirrored
each time
• Information goes from V3 to over 3 dozen higher order visual areas, each area
showing a different view of the same image, mostly on two main streams
o Where stream (Magnocellular ganglions – peripheral) – dorsal stream -
intraparietal sulcus → aims to select actions to spatial locations
 Lesions: optical ataxia → recognize something but cannot
physically grab it
o What stream (parvocellular gangions – foveal) – ventral stream –
inferior temporal lobe → perception and recognition
 Lesions: can grab something but cannot recognize it
 Lateral occipital complex (LOC) – way point →
• Lesions: visual agnosia → inability to perceive objects

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 through vision – can copy, can recognize by touch, but
cannot name.
 Inferior temporal (IT) – cannot recognize classes of things – eg.
Cannot identify people based on faces, but can on other things.
prosopagnosia
• Perception of motion: Middle Temporal
o Neurons have really large receptive fields – poor visual acuity
o Only see black and white
o Can determine direction and speed an object is going

Neuroanatomy – Cerebrum
• Gyri – ridges of brain
o Precentral gyrus – primary motor area
o Postcentral gyrus – primary somatosensory area
o Singulate gyrus – limbic system
• Sulci – grooves in brain
o Central sulcus
o Parietal-occipital sulcus
o Calcarine sulcus – activation of primary visual cortex
• Fissures – deep sulci
o Lateral sylvian fissure (superior to temporal lobe)
• 5 major paired lobes –
o Frontal – primary motor area, premotor cortex, broca’s area, anterior
prefrontal cortex
o Parietal – primary somatosensory area, somatosensory association area
o Occipital – primary visual cortex, visual association area, lingual gyrus
o Temporal – primary auditory cortex, auditory association area,
Wernicke’s area (only on left), Uncus (termination of olfactory tract)
o Insular – gustatory cortex
• Multimodal association areas – take up rest of brain – don’t respect anatomical
boundaries – cover various gyri and areas.
o Anterior – Prefrontal cortex – receives information from Posterior
Multimodal Association Area (PMAA) → integrates with past experience,
evaluates options, chooses most appropriate response,
 Working memory – scratch pad
 All aspects of cognitive function
o Posterior Multimodal Association Area – general interpretation
(Gnostic)
 Awareness of spatial location of body – determines how to move
body through space
 Language comprehension and speech (Wernicke’s area)
o Limbic (on singulate gyrus)– emotions and memory
Neuroanatomy – Cranial Cavity
• Neurocranium – houses the brain

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 o Cranial vault - skullcap
 Frontal bone anteriorly – coronal suture
 Parietal bones (2) – anterior coronal suture – bregma - midline
sagittal suture – lambda - lambdoid suture, pterion - lateral
 Posterior - Occipital bone – lambdoid suture, makes occipital
condyles and large part of the foramen magnum
 Lateral – greater wing of sphenoid bone
 Temporal bone
• Squamous – most of part of lateral neurocranium
• Zygomatic process
• Mandibular fossa
• External auditory meatus
• Mastoid process
• Styloid process
• Viscerocranium + mandible = facial structure
• Cranial fossae
o Anterior – frontal bone, ethmoid (cribriform plate) + cristae galli (attaches
to dural fold – falx cerebri), lesser wing of sphenoid – makes clinoid
process
o Middle – sphenoid bone – pituitary fossa in middle (sella tursica),
temporal bone, squamous and petrous (inner ear)
o Posterior – occipital bone, mastoid temporal bone,
• Meninges
o Pia mater – tight clingy to surface of brain
o Arachnoid mater – covers brain but doesn’t follow all contours, drapes
over sulci – subarachnoid space contains the CSF and arteries and veins
that enter and leave brain
o Dura mater – tough fibrous, adherent to neurocranium, some areas dural
folds extend into fissures to separate parts of brain, some dural folds
contain veins – dural venous sinuses
 Middle meningeal vessels – enter and leave middle cranial fossa
through floor (foramen spinosum) – middle meningial artery arises
from maxillary artery
 Emissary veins go to scalp (important for infection)
o Dural folds –
 Falx (sickle shaped) cerebri – runs between two hemispheres
sagittally – anteriorly attached to crista gali (in anterior fossae)
attaches to other fold at rear of skull
 Tentorium cerebelli – tent shaped sheet horizontal plane forming a
roof of posterior cranial fossa
• Separates cerebrum from cerebellum
• Tentorial notch in middle where brainstem passes
• Anteriorly attached margins to posterior clinoid process
and petrous part of temporal bone and occipital bone

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  Diaphragma selli – roof of pituitary fossa with opening for
pituitary stalk
 Falx cerebelli – runs between cerebellar hemispheres on
undersurface of tentorium cerebelli
o Sinuses
 Superior Sagittal sinus – superior margin of fixed portion of falx
cerebri – has outcroppings to gather CSF from subarachnoid,
called subarachnoid granulations → forms right transverse sinus
→ sigmoid sinus → internal jugular vein
 Inferior sagittal sinus – inferior margin of falx cerebri – joins
great vein of Galen → forms straight sinus → left transverse
sinus runs along attached border of tentorium cerebelli →
becomes the sigmoid sinus → internal jugular vein
 Cavernous Sinus – each side of pituitary fossa – communicate
around pituitary gland
• Communicate with ophthalmic vein of eye (orbit
infections)
• Nerves associated with cavernous sinus – Oculomotor (III),
Trochlear (IV), ophthalmic (trigeminal branch – V1),
abducens (VI) – any that exit superior orbital fissure
 Occipital sinus – attached part of falx cerebelli – drains into
vertebral venous plexus
• Cranial Nerves
o (I) Opthalmic – originates at olfactory bulb, exits at cribriform plate
(ethmoid)
o (II) Optic – originates at optic chiasm, exits at optic foramen
o (III) Oculomotor – originates at midbrain - ventral, exits at superior orbital
fissure
 ciliary focus, iris constriction (parasympathetic), eye movement
(all muscles except, superior oblique, lateral rectus)
o (IV) Trochlear - originates at midbrain - dorsal, exits at superior orbital
fissue
 eye movement (superior oblique)
o (V) Trigeminal – originates at the pons (lateral)
 V1 – ophthalmic – exits at superior orbital fissure
• Sensory – scalp, upper eyelid, cornea, nose, iris dilation
(sympathetic)
 V2 – maxillary – exits at foramen rotundum
• Sensory – upper teeth, cheek, lip, lower eyelid
 V3 – mandibular – exits at foramen ovale
• Sensory – tongue, teeth, chin
• Motor - mastication
o (VI) – Abducens – originates at pons/medulla, exits at superior orbital
fissure

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  eye movement (lateral rectus)
o (VII) – Facial – originates at pons/medulla, exit internal auditory meatus
Branches: “Tell Zoe, Bisch Made Chili” “To Zanzibar by Motor Car”
• Temporal
• Zygomatic
• Buccal
• Mandibular
• Cervical
 Motor: for facial expression
 Autonomic: salivary and lacrimal glands
 Sensory: taste – anterior 2/3 of tongue
o (VIII) – Vestibulocochlear – originates at pons/medulla, exit internal
auditory meatus
o (IX) – Glossopharyngeal – originates medulla, exit jugular foramen
 Motor: swallowing
 Autonomic: parotid gland
 Sensory: taste – posterior 1/3 tongue
o (X) – Vagal – originates medulla, exit jugular foramen
 Nucleus of solitary tract – parasympathetic
 Motor: pharynx and larynx
 Autonomic: heart, lung, gut, etc.
 Sensory: taste, viscera (gut pains)
o (XI) – Accessory – originates spinal cord, exit jugular foramen
o (XII) – hypoglossal – originates medulla, exit hypoglossal foramen
• Blood Supply to Brain
o Vertebral artery – off subclavian artery, ascend through foramina
transversaria (upper 6 cervical vertebrae) → enter subarachnoid space by
piercing dura and arachnoid → enter foramen magnum (legs) → unite to
form basilar artery (body of teletubby) – runs up brainstem to form
posterior cerebral arteries (arms)
 Supplies temporal and occipital lobes (calcarine artery to visual
cortex)
 Pontine arteries come off basilar artery (chest hair of teletubby) –
to pons
o Internal Carotid arteries – off common carotids in neck. → enter base of
skull by carotid canal in temporal bone → through cavernous sinus →
wraps around clinoid process of sphenoid bone by tursica sellae →
branches to:
 Ophthalmic artery, - passes with optic nerve to supply eye and
orbit contents
 Anterior cerebral artery – supplies inferior and medial frontal
lobe (olfactory bulb and tract), and medial parietal lobe
• Medial striate artery – supplies basal ganglia and internal
capsule

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  Middle cerebral arteries (MCA) (teletubby ears). – enters lateral
(sylvian) fissure
• supplies lateral frontal, lateral parietal and temporal lobes
• Lateral striate artery – supplies basal ganglia and internal
capsule
• Circle of Willis (basal surface of brain) (head of
teletubby)– arterial anastomoses around pituitary stalk and
optic chiasma
o Formed by two anterior cerebral arteries (go to
olfactory tract and frontal lobe) (teletubby antennae)
o Two posterior cerebral arteries (go around pons)
(arms)
• Choroidal supply hippocampus and thalamus
• 4 communicating arteries (may or may not be used)
attaching the previous.
o Form central arteries (facial hair) – supply
thalamus, basal ganglia, hypothalamus, midbrain
Higher Function and Limbic System
• Aphasia – damage to the language areas (left hemisphere) or their connections
o Broca’s – inability to produce sounds, comprehension of language normal
o Wernicke’s – can produce incomprehensible sounds, cannot comprehend
language.
• Aphonia – inability to produce sounds
• Agnosia – a defect in understanding sensory information
• Apraxia – impairment in the performance of learned movements
• Connections of the cerebral cortex
o Long association fibres – connections between different lobes (eg.
Wernicke’s to Broca’s area)
o Short association fibres – connections within same lobe, one gyrus to
another
o Projection fibres (eg. Corona radiata) – connections between cortex and
other areas (eg. Diencephalons, cerebellum, spinal cord) – through internal
capsule
o Commissural fibres – between hemispheres (eg. Corpus callosum)
• Basic pathway:
o “Raise right (contralateral) hand”: primary auditory cortex (hear
command) → Wernicke’s area (comprehend command) → premotor cortex
(plan to do) → primary motor cortex (do)
o “Name an object”: Optic tract → Lateral Geniculate Nucleus (LGN)
(thalamus) → primary visual cortex (V1 - see elements) → higher order
visual cortex (V2, V3 - put elements of image together) → parietal-
temporal occipital (PTO) association cortex (gnostic/awareness region –
associate shapes with previous experiences – know what it is) →
Wernicke’s (formulate comprehensible name for object) → broca’s area

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 (say that name for object) → facial area of motor cortex (articulate sounds
with muscles) → descending tract from motor cortex to brain stem
• Limbic System – emotional responsiveness, learning and memory
o Hippocampal formation (learning and memory)
• Retention of short term memory → xfer into long term
memory (main declarative memory: semantic facts, and
episodic experiences, events)
 Hippocampus
 Dentate gyrus
 Parahippocampal gyrus
o Cingulate gyrus (emotions)
o Amygdala (emotions)
 Emotional interpretation of external sensory information and
internal states
 Generating changes in internal states (visceral response) through
hypothalamus to external stimuli
o Hypothalamus (emotions visceral response – change internal state)
o The gyrii (dentate, parahippocampal, cingulate) are the cortical limbic,
all other parts are subcortical
Neurophysiology – Association and Memory
• Short loop reflexes – rapid, simple responses
• Long loop reflexes – utilize complex processing from multiple association areas
• Prefrontal association area –
o planning, spatial memory, and working memory – (eg. Kids lack of object
permanence – due to lack of frontal development)
o Decision making and emotion – orbitofrontal region – (frontal lobotomies
to cure aggression, also got rid of initiative)
• Parietal-Temporal-Occipital Association area (PTO)
o Polymodal convergence of senses
 Right PTO – specializes in spatial representation of objects by
touch, sight and sound
• Neglect: lesion of right PTO causes a failure to recognize
and create left side of an image, and neglects thing on left
side of body
 Left PTO – specializes in language: sound of words, written words
and Braille
• Lesion of left PTO: doesn’t cause visual neglect or neglect
of right side of body when drawing – the right contains a
bilateral image, the left only a unilateral image
o Attention – allows us to focus on one or two things at once while
neglecting the rest (like a flashlight), limit is 3-5.
o Inferior Temporal lobe – involved in long-term memory
• Hemisphere specialization (right = representation, left = language)
o Dominant: Usually left – for sequential or serial tasks (eg. Language,

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 analytic math)
o Non-dominant: Usually right – for parallel processing, (eg. spatial tasks,
intuitive, geometry, music)
o Sectioning of corpus callosum will lead to two independent brains
working in same body
• Learning (the storage process) and Memory (information that is stored)
o Remembering: the retrieval of stored information
o Short Term Memory: scratch pad of memory, temporary, limited to
about nine digits, tonic activity of neurons in prefrontal cortex
o Long Term Memory:
 Declarative (knowing that): Hippocampal formation
Characteristics
• Conscious of memory
• Can be rapid, after one exposure
• Started only after the age of 2 yrs
• Affected by amnesia
• Learning requires Hippocampus in medial temporal
• Memory of faces/places occurs in inferior temporal lobe
o Episodic – remembering particular objects and
places in one’s personal past – composed of several
semantic memories
 Associated who and what with where and
when
o Semantic –
 remembering faces and places
• familiar places recognized in
parahippocampal place area
(medial inferior temporal lobe)
• familiar faces recognized in
fusiform face area (lateral inferior
temporal lobe) – conscious
identification of face (lesion here
leads to prosopagnosia – feeling of
familiarity without being able to
identify someone)
o Also involves activation of
amygdala – familiar “glow”
(accompanied by autonomic
responses) (eg. Lesion here
kid could recognize parents
but felt they were replaced by
aliens)

 facts and concepts

Encoding Long-term Declarative Memory

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 • Ventral “what” stream (extracts visual features) → encodes
them as objects → stores temporarily in working memory
(frontal cortex)
• Hippocampus (receives input from all association areas)
consolidates working memory into long term memory (only
area in cortex that continuously generates new neurons)
• Eg. Patient HM – medial temporal lobe removed and
hippocampus removed
o Old memories are all ok
o Cannot form new memories past short term working
memory (anterograde amnesia)
o Retrograde amnesia is lost due to damage to
temporal lobe connections or widespread damage
(alzheimer’s)
 Reflexive/Procedural (knowing how):
Characteristics
• Includes skills like skiing, dialing telephone
• Established slowly
• Not conscious of skill
• Starts to develop at birth
• Not affected by amnesia
• Involves most of the CNS, including cerebellum, primary
visual cortex (V1)
Neuroanatomy – Brainstem and Cerebellum
• Cranial Nerve Nucleii – “III and IV are from the midbrain floor”, “6 to eight are
the pons/medulla debate – pontomedullary junction”, “9 to 12 (minus 11) – the
medulla is as deep as you need to delve”
• Midbrain – controls eyes (CNIII , pupil constriction (parasympathetic running
through ciliary ganglion), CNIII,IV – eye movment)
Upper Midbrain
o Lateral geniculate nucleus (LGN) – visual relay
o Medial geniculate nucleus (MGN) – auditory relay
o Superior colliculi – visual*reflexes (visual grasp reflex) and auditory
reflexes
 Deep: Nucleus of oculomotor nerve (CNIII)* → exit ventral
o Eidinger-Westfal nucleus – pupillary constriction due to light reflex (via
CNIII)
Lower Midbrain
o Substantia nigra
o Exit of trochlear nerve (IV) – exit dorsal
o Inferior colliculus – visual* and auditory reflexes (ocular grasp reflex
– response to auditory cue)
 Deep: Nucleus of trochlear nerve (CNIV)* - superior oblique
muscle

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 o Periaqueductal grey – site of production of endogenous opioids – suppress
pain during physical activity
o Red nucleus – non-essential motor control
• Pons – facial muscles, hearing and balance, major relay station to cerebellum
Upper Pons
o Cerebral peduncle – connects cerebrum (esp. motor cortex) to pontine
nuclei (then cross) → connect to cerebellum via middle cerebellar
o Parabrachial nerve – control of respiration
o Pontine Nucleii – surround Corticospinal tract, fibres from cerebrum cross
here go to cerebellum
o Superior cerebellar peduncle – connects midbrain/diencephalons to
cerebellum
Lower Pons
o Middle cerebellar peduncle – connects fibres from cerebral
peduncle/pontine nuclei to cerebellum
o Abducens (VI) nucleus – lateral rectus muscle eye
o Facial nerve exit/facial nerve nucleus (CNVII) – control of facial muscles
o Inferior cerebellar peduncle – connects cerebellum to medulla and
spinal cord
o Trigeminal (V) sensory nerve – sensation in face
o Trigeminal (V) motor nerve – muscles of mastication
• Medulla Oblongata – controls speech, swallowing, taste, tongue and autonomic
functions
Upper Medulla
o Vestibulo-cochlear nerves (VIII)
o Glossopharyngeal (IX)
o Spinothalamic tract (pain, temp, crude touch) – contralateral loss of pain
below neck
o Abducens nerve (CNVI)
o Facial Nerve (CNVII)
o Olivary nucleus – cerebellar control
Lower Medulla
o Dorsal Columns – vibration, proprioception and light touch → travels up
to thalamus after crossing here
 Gracile (medial) nucleus (inner) and fasciculus (outer) – legs
 Cuneate nucleus (lateral) and fasciculus (outer) - arms
o Pyramid – decussation of pyramids (corticospinal tract) beginning of
central canal of spinal cord – spinal cord crosses here
o Hypoglossal (XII) – tongue control
o Solitary Nucleus – parasympathetic autonomic functions (vagus nerve –
CNX) – all information from internal organs
• Cerebellum – proprioception, smoothing and control of motor signals, vestibular
inputs (balance) – drunkenness is cerebellar ataxia (loss of learned movements)
o Vestibulo-cerebellum – input from otolithic organs (inner ear)

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  Balance (flocculonodular lobe of cerebellum))
o Cerebro-cerebellum –
 Input: cerebral cortex (descending from motor cortex → pontine
nuclei → crosses contralateral → pontocerebellar tract via middle
cerebellar peduncle → lateral hemisphere of cerebellum)
 Smoothing muscle movements (lateral hemisphere lobe of
cerebellum)
 Output: to motor cortex (lateral hemisphere → superior cerebellar
peduncle → thalamus → motor cortex)
o Spino-cerebellum – input from spinal cord
 Proprioception (vermis and intermediate hemisphere middle)
Neuroanatomy – Diencephalon – medial to lentiform nucleus (putamen)
• Thalamus
o 3rd ventricle separates two sides of thalamus
 connected by interthalamic adhesion
A relay station – integration and filtration of information
o Relays all sensory information (except olfactory) to the cortex
o Relays information from basal ganglia to cortex
Categories of Thalamic Nucleii (V= ventral, A = anterior, P = posterior, M =
medial, L = lateral, D = dorsal)
o Modality specific – primary cortical areas (sensory and motor)
 Globus pallidus (basal ganglia) → VA → premotor cortex
 Cerebellum → VL → primary motor cortex
 Optic tract → lateral geniculate body → primary visual cortex
 Auditory tract → medial geniculate body → primary auditory
cortex
 Somatosensory (body) (dorsal column – gracile and cuneate,
spinothalamic tract) → VPL → Primary somatosensory cortex
 Somatosensory (head) (trigeminothalamic tract, taste) → VPM →
primary somatosensory cortex
o Multimodal Association and Non-specific
 Hypothalamic and limbic → anterior nuclei → cingulate gyrus
(emotions)
 Amygdala and other subcortical regions → MD → Multimodal
association cortex
• Hypothalamus – hormonal control
• Epithalamus (pineal) – light input from suprachiasmatic nucleus,
o Secretes melatonin, circadian cycles, sleep
• Subthalamus (subthalamic nucleus)
Approach to Altered/Loss of Consciousness
• Alertness (Crude Consciousness) – wakefulness and arousability –
o due to functioning brainstem (reticular activating system - RAS) “aka
lightswitch” and medial thalamus
o Sleep/wake cycles involve hypothalamus and connections to brainstem

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 o Without cortex, can still have eye opening, arousability,
• Awareness (Full Consciousness) – requires cerebral cortical “aka the lightbulb”
activity
o Consists of: sensation/perception, attention, memory,
executive/motivational functions, self-awareness
o Must also have alertness (functioning brainstem)
• Disturbances in consciousness require:
o Lesion of RAS (can be small) or,
 Occasionally: small directed destruction of RAS, lesion in upper
brainstem (eg. Bleed, infarct, tumour)
 More often: large cortical lesion → indirect damage to RAS via
herniation or direct extension
o Bilateral damage to cortex (usually extensive)
 Most common are metabolic or toxic (normal pupillary function)
 Occasionally large bilateral lesions
 Unilateral lesions can cause by herniation (shift of brain tissue
from high pressure to low pressure) – usually lateral displacement
of diencephalon
• Normal consciousness – aware of self and environment, responsive to stimuli,
• Disordered consciousness – mild confusion to deep coma
o Delirium – clouding of consciousness
 Inability to think at normal speed and clarity
 Inattentiveness, perseveration (repeating same thing to different
questions), distractibility
 Fluctuation and variation in degree of severity (worse at night)
 Sleep-wake disturbed
 Hallucinations, delusions, agitation
 Cranial nerve abnormalities, focal signs – indicate likely structural
cause.
 Physical: asterixis (flapping hands = metabolic), multifocal
myoclonus (twitch), tremor
 Risk factors:
• limited brain reserve
• old age, dementia
• hyponatremia, hypoalbuminemia
• Hx neurological disease
• Systemic infection, fever
• Uremia, operative hypotension
o Stupor – patient rousable with vigorous stimulation (nail bed press,
sternal rub) but lapses into unconsciousness when stimulation ceases
o Coma – patient cannot be roused to consciousness.
 Causes:
• Intoxication – Don’t miss – treatable - Drug intox.
• Withdrawal syndromes (often agitated delirium)

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 • Metabolic disorders (diabetic ketoacidosis,
hypoglycemia)
• Seizures
• Infection (CNS - bacterial/fungal meningitis, herpes
simplex encephalitis, brain abscess, and systemic -
shock/hypotension,)
• Vascular (stroke – in RAS or causing herniation –
hypertensive encephalopathy)
• Neoplasm (herniation process)
• Craniocerebral trauma (one of largest causes of sudden) -
subdural, epidural hematoma
 DDx:
• Locked-in syndrome (muscle activating parts of brain)
• Severe neuromuscular disease (Guillain-Barre, myasthenia
gravis)
• Neuromuscular blocking agents
• pseudocoma
 Ix: Pupillary features
• Normal and responsive usually in metabolic, toxic coma
(except pinpoint pupils on opioids)
• Dilated unreactive pupils – midbrain lesions (damage to
CNIII-parasympathetic)
• Pinpoint pupils – pontine lesions (loss of sympathetic
tract in CNV – ophthalmic tract to ciliary ganglion)
• Unilateral dilated pupil – herniation (compression or
stretching of oculomotor nerve)
o Assess brainstem by: ocular movement
(vestibulocochlear reflexes – water in ear), corneal
reflexes (midbrain), cough, gag (medulla)
 Ix: Look for asymmetries in limb function (assess supratentorial
lesions, esp. if brainstem normal – lesion often rostral)
 Ix: metabolic screen, CBC, toxin, cultures
• CT, MRI if focal signs, brainstem
• CSF analysis if indicated
• EEG if suspect seizures
• Brain death
o Etiology established – with reversible causes excluded
o Cranial nerve reflexes absent (gag reflex, corneal reflex, unreactive pupils
CN3, CN5, Eidinger-Westfall n. – pupil constriction on light reflex)
o No movements arising from brain present
o Patient apneic off ventilator
• Persistent Vegetative state – wakefulness without alertness, (survivors of severe
cerebral trauma
o Lesions: cortical, white matter, thalamic

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 o No evidence of awareness of self or environment; inability to interact
o No voluntary response to noxious stimuli, or visual, auditory, taste
o No language comprehension or expression
o Sleep-wake cycles
o Bowel and bladder incontinence
o Variably preserved cranial and spinal nerve reflexes
o Sufficient hypothalamic and autonomic functions to survive with medical
and nursing care
o Condition persists for at least one month.
•

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