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Clinically oriented anatomy of the brainstem Klára Matesz Department of Anatomy, Histology and Embryology University of Debrecen, Medical and Health Science Center, Debrecen, Hungary 2013 Title of subject: Clinically oriented anatomy of the brainstem Course description: The aim of the course is to teach basic principles of the functional organisation of the brainstem. The information provided by the course can be used in the clinical practice. Organization of the brainstemoverview 1 AGYTÖRZS BRAINSTEM STRUCTURE OF THE BRAINSTEM Similar to the spinal cord (gray and white matter) Vital centers Organization: Nuclei (cranial nerve, other) Pathways (ascending, descending, cerebellar) Reticular formation Vascularization: circumferencial blood vessels Developmental aspects Neural tube alar plate (somatic afferents), basal plate (somatic efferents) border: sulcus limitans COMPONENTS OF BRAINSTEM • Gray matter – Cranial nerve nuclei – Other nuclei – Reticular formation f • White matter – Ascending and descending tracts, pathways – Cerebellar pathways – Connections within the brainstem 2 Base Tegmentum Tectum PARTS OF THE BRAINSTEM Medulla oblongata, myelencephalon Pons Mesencephalon, midbrain Cavity: Central canal, 4th ventricle Cerebral aqueduct Üreg: Canalis centralis IV. agykamra Aqueductus cerebri, Medullospinal border: level of foramen magnum, pyramidal decussation Cranial nerves (12 pairs) Parts of the PNS Connect the brainstem (except the CN I and II) with the body Terminology: specific name and Roman numerals 3 Components of spinal nerves SM: somatomotor. Innervation of skeletal muscles (voluntary movements) VM: visceromotor. visceromotor. Parasympathetic and sympathetic innervation of smooth muscles muscles,, cardiac muscle muscle,, glands (secretomotor). secretomotor). SS: somatosensory. Innervation of skin (cutaneous innervation) and mucosa (pain, temperature, touch, vibration, proprioception). Called also as general sensory innervation. VS: viscerosensory. Sensory innervation of the internal organs: general. Components of cranial nerves SM: somatomotor. Innervation of skeletal muscles (voluntary movements) VM: visceromotor. Parasympathetic innervation of smooth muscles, cardiac muscle, glands (secretomotor). SS: somatosensory somatosensory. Innervation of receptors of skin (cutaneous innervation) and mucosa (pain, temperature, touch, vibration, proprioception). Called also as general sensory innervation. VS: viscerosensory. Sensory innervation of the internal organs: special and general. IV Cranial nerve nuclei 4 Tracts (pathways) of the posterior and anterior funiculus of the spinal cord 1. Fasciculus gracilis (GOLL) 2. Fasciculus cuneatus (BURDACH) 3. Comma tract (of Schultze) 4. Fasciculus proprius 5. Anterior (direct) corticospinal tract 6. Tectospinal p tract 7. Medial longitudinal fasciculus 8. Reticulospinal tract 9. Spinothalamic tract 10. Olivospinal tract 11. Vestibulospinal tract 1 3 2 7 4 5 6 10 9 8 11 Tracts (pathways) of the lateral funiculus of the spinal cord 1. 2. 3. 4. 5. 6. 7. 8. Dorsolateral fasciculus (of Lissauer) Fasciculus proprius Lateral (crossed) corticosapinal tract Rubrospinal tract 5 Posterior spinocerebellar tract 3 Anterior spinocerebellar tract Spinothalamic tract 4 Reticulospinal tract 1 2 8 7 6 IV 6, 7: radix. 9: spinal nerve. 13, 14: ramus 6 10 1 8 3 13 5 14 9 11 4 7 12 2 5 Medulla oblongata Cranial nerve nuclei 1. Glossopharyngeal nerve, CN IX -ambiguus nucleus (SM) -spinal nucleus of trigeminal nerve (SS) -inferior salivatory nucleus (VM) -nucleus of solitary tract (VS) 2. Vagus nerve, CN X -ambiguus nucleus (SM) -spinal nucleus of trigeminal nerve (SS) g (VM); ( ); scattered neurons dorsolatera dorsolaterally llyy to the ambiguus g -dorsal nucleus of vagus nucleus (VM) -nucleus of solitary tract (VS) 3. Accessory nerve, CN XI -motor nucleus of accessory nerve (SM) 4. Hypoglossal nerve, CN XII -motor nucleus of hypoglossal nerve (SM) Exit of cranial nerves 1. CN IX 2. CN X 3. CN XI 4. CN XII Spinal nucleus of trigeminal nerve (V, IX, X) Nucleus of solitary tract Spinal tract of trig. n. Dorsal nucl. of X XI LM motor nucleus of accessory nerve Inferior olive Pyramidal decussation Py motor nucleus of hypoglossal nerve XII MEDULLA OBLONGATA CLOSED PART CRANIAL NERVE NUCLEI 6 Spinal nucleus of trigeminal nerve (V, IX, X) Nucleus of solitary tract Gracil and cuneate nuclei, Dorsal column nuclei Accessory cuneate nucleus Spinal tract of trig. n. Dorsal nucl. of X XI LM Py Inferior olive XII Pyramidal decussation MEDULLA OBLONGATA CLOSED PART OTHER NUCLEI ASCENDING PATHWAYS traveling through the medulla Spinothalamic tract (Anterolateral system) Tr. (spino)cervicothalamicus Tr. spinoreticularis Tr. spinomesencephalicus Tr. spinocerebellaris rostralis Dorsal and ventral spinocerebellar tract Tr. cuneocerebellaris Descending pathways traveling through the medulla Corticobulbar, corticospinal (pyramidal tract) Extrapyramidal tracts: Vestibulospinal Medial longitudinal fascicle Tectospinal Reticulospinal Rubrospinal •Others: Raphespinal Aminerg pathways Peptiderg pathways Fasciculus longitudinalis dorsalis (Schütz) 7 Pathways, originate or terminate in the medulla • • • • • • • • Medial lemniscus Olivocerebellar tract Reticulospinal tract Medial longitudinal fascicle V tib l i l Vestibulospinal Olivospinal Fasciculus tegmentalis centralis Corticobulbar tract (Py) Spinal nucleus of trigeminal nerve (V, IX, X) Nucleus of solitary tract Accessory (external) cuneate nucleus Gracile and cuneate nuclei, Dorsal column nuclei Tr. cuneocerebellaris Spinal tract of trig. n. Dorsal nucl. of X XI Dorsal and ventral spinocerebellar tract Spinothalamic tract (Anterolateral system) Tr. (spino)cervicothalamicus Tr. spinoreticularis Tr. spinomesencephalicus Tr. spinocerebellaris rostralis XII MEDULLA OBLONGATA ASCENDING PATHWAYS traveling through the medulla Spinal nucleus of trigeminal nerve (V, IX, X) Nucleus of solitary tract Nucleus fasciculi gracilis et cuneati Nucl. cuneatus accessorius Tr. cuneocerebellaris Spinal tract of trig. n. Tr. rubrospinalis XI Dorsal nucl. of X EPy Oliva inferior Py Decussatio pyramidum XII MEDULLA OBLONGATA Descending pathways traveling through the medulla 8 Dorsal nucl. of X X., nucl. alae cinereae med. Nucleus ambiguus (N. X.) Abdominal organs Scattered neurons dorsoolatera to the ambiguus nucl. Spinal nucleus of trigeminal nerve (V, IX, X) Thoracic organs Nucleus of solitary tract (Nucl. alae cinereae lat.) Py IO Sensory ggl: ggl. superius and inferius (nodosum) VM axons terminate in the intramural ganglia MEDULLA OBLONGATA OPENED PART N. X., XII. CRANIAL NERVE NUCLEI Inferior vest. nucl. Nucleus ambiguus (N. IX.) Spinal nucleus of trigeminal nerve (V, IX, X) Inferior salivatory nucleus Nucleus of solitary tract Sensory ggl: ggl. superius and inferius (nodosum) IO VM axons (n. tympanicus, n. pertosus minor) terminate in the otic ganglion MEDULLA OBLONGATA OPENED PART N. IX, N. VIII CRANIAL NERVE NUCLEI Gracile and cuneate nuclei, Dorsal. column nuclei Area postrema Py Inferior olive MEDULLA OBLONGATA OPENED PART, OTHER NUCLEI 9 motor nucleus of abducens nerve IV Nucleus of solitary tract (VII) Sup. salivatory nucl. (VII) Spinal nucleus of trigeminal nerve (V, IX, X) Sensory ggl: Geniculate ggl. Py motor nucleus of facial nerve CAUDAL PART OF THE PONS, Cranial nerve nuclei principal (chief) nucleus of trigeminal nerve Sup.cerebellar peduncle IV (Brachium conjunctivum) Middle cerebellar peduncle (Brachium pontis) motor nucleus of trigeminal nerve ROSTRAL PART OF THE PONS, Cranial nerve nuclei PONS, Other nuclei Locus ceruleus IV Sup. cerebellar ped. Parabrachial nucleus Middle cerebellar peduncle Pontine nuclei Raphe pontine nuclei Trapezoid body Superior olive 10 Ascending pathways traveling through the pons •Spinothalamic tract (Anterolateral system) •Medial lemniscus •Anterior spinocerebellar tract Tr. (spino)cervicothalamicus Tr. spinomesencephalicus Descending pathways traveling through the pons •Corticobulbar, corticospinal (pyramidal tract) •Extrapyramidal tracts: Tectospinal Fasciculus tegmentalis centralis Rubrospinal •Others: Fasciculus longitudinalis dorsalis (Schütz) Raphespinal Aminerg pathways Peptiderg pathways Pathways, originate or terminate in the pons Vestibulospinal Medial longitudinal fascicle Reticulospinal Pontocerebellar tract (Epy) Lemniscus lateralis Lemniscus trigeminalis (dorsalis) Raphespinal Aminerg pathways Peptiderg pathways Frontopontine tract (Epy) Temporo-occipito-pontine (Epy) •Corticobulbar tract (Py) 11 Midbrain (Mesencephalon) Cranial nerve (CN) nuclei 1. Oculomotor nerve, CN III -motor nucleus of oculomotor nerve (SM) -EdingerEdinger-Westphal nucleus: (VM) 2. Trochlear nerve, CN IV -motor motor nucleus of trochlear nerve (SM) 3. Trigeminal nerve, CN V mesencephalic nucleus of trigeminal nerve (SS) Exit of cranial nerves from the mesencephalon 1. CN III 2. CN IV Tectum Mesencephalic nucleus of trigeminal nerve Edinger--Westphal nucleus Edinger Tegmentum motor nucleus of oculomotor nerve Pedunculus cerebri (crus) MESENCEPHALON, Cranial nerve nuclei, III Ascending pathways traveling through the mesencephalon • • • • Medial lemniscus Trigeminal lemniscus (dorsal) p tract ((Anterolateral system) y ) Spinothalamic Ventral spinocerebellar tract (through the cerebellar peduncle to the cerebellum) 12 Descending pathways traveling through the mesencephalon • • • • Corticobulbar, corticospinal (pyramidal tract) Frontopontine tract (Epy) Temporo-occipito-pontine (Epy) Fasciculus longitudinalis dorsalis, (Schütz) Pathways, originate or terminate in the mesencephalon • Part of the auditory pathway from the inferior collicle to the medial geniculate body • Lateral lemniscus : part of the auditory pathway • Medial M di l longitudinal l it di l fascicle: f i l part of the vestibular system (contains descending fibers, too) • • • • Tr. nigrostriatal, striatonigral (EPy) Tr. tectospinal (EPy) Tr. rubrospinalis (EPy) Fasciculus tegmentalis centralis (EPy, originates in the red nucleus and thalamus) • Dentatorubral, rubrothalamic (Epy) DIAGNOSTICAL CONSIDERATIONS 1. Location of lesions muscle motor-end plate or transmitter peripheral nerve roots , plexus spinal cord brainstem cerebellum diencephalon subcortical white matter subcortical gray matter cerebral cortex meninges bones 13 DIAGNOSTICAL CONSIDERATIONS 2. Nature of lesion anatomic location age gender geographic course of disease others 3. Classification of disorders vascular trauma tumor infection and inflammation toxic, metabolic demyelinating degenerative congenital malformations neuromuscular disorders EXAMINATION OF PATIENTS 1. Case history nature, onset, extent and duration of the chief complaint previous disease, personal and family history , occupational data, social history particularly important: headache, seizures, loss of consciousness, visual disturbances, pain 2. Physical examination 3. Neurological examination cranial nerves motor system coordination reflexes sensory system Positions and organization of eye moving nuclei 14 MESENCEPHALON Periaquaeduct gray matter (PAG) Other nuclei Red nucleus (NR) Substantia nigra (SN) Within the reticular formation: Nucl. interstitialis (Cajal) Interpeduncular nucl. At the mesodeiencephalic junction: Nucleus of posterior commissure (Darkschewitsch) MESENCEPHALON motor nucleus of trochlear nerve 15 PONS Caudal part Fronto-pontine Temporo-occipito-pontine tracts Pontocerebellar trac Pontine nuclei Raphe pontine nn. Musculi bulbi oculi Bal szem Left eye addukció (abdukció) 16 Vestibulo-ocular reflex 17 Gaze centers 18 Right oculomotor paralysis R L Basal position Complete paralysis: mydriasis. No resonse for the light 19 Abducens paralysis 20 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892-1237 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892-1237 Scotoma: transient monocular blindness –amaurosis optic neuropathy (non-toxic, toxic) 21 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892-1237 A 59-year-old man complains of persistent headache. An MRA (Magnetic Resonance Angiography) shows an aneurysm in the interpeduncular f fossa ((and d cistern) i ) arising i i from f the h basilar tip. Which of the following cranial nerves would be most directly affected by this aneurysm? (A) Abducens (VI) (B) Oculomotor (III) (C) Optic (II) (D) Trigeminal, V1 (V) (E) Trochlear (IV) 22 Control of jaw movement and facial expression N. trigeminus 23 Szekely G., Matesz, C.: The efferent system of cranial nerve nuclei: A comparative neuromorphological study. Adv. Anat. Embryol. Cell Biol. 128. 1-92. 1993. FROG Levator bulbi N. V. Jaw closer N. V. Jaw opener N. V. Jaw opener N. VII. Szekely G., Matesz, C.: The efferent system of cranial nerve nuclei: A comparative neuromorphological study. Adv. Anat. Embryol. Cell Biol. 128. 1-92. 1993 RAT N. V. N. VII N. Va N Va N. N. VIIa Szekely G., Matesz, C.: The efferent system of cranial nerve nuclei: A comparative neuromorphological study. Adv. Anat. Embryol. Cell Biol. 128. 1-92. 1993. 24 Stapedius (N. VII) Tensor tympani (N. V) Distribution and morphology of trigeminal and facial motoneurons in the frog D M D L ORBITALIS OPENING D CLOSING L Morphology of trigeminal and facial motoneurons in the frog, lizard and rat: evolutionary consideration V V VII VII Béka Gyík Va VIIa V VII Patkány 25 CENTRAL PATTERN GENERATOR (CPG) J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892-1237 26 A facialis somatomotoros neuronok supranuclearis beidegzése Homlok, szem körüli izmok Homlok, szem körüli izmok Száj körüli izmok Száj körüli izmok N. VII N. VII A facialis somatomotoros neuronok supranuclearis beidegzése Centralis lézió Homlok, szem körüli izmok Homlok, szem körüli izmok Száj körüli izmok Száj körüli izmok N. VII N. VII A facialis somatomotoros neuronok supranuclearis beidegzése Homlok, szem körüli izmok Száj körüli izmok N. VII Perifériás lézió Homlok, szem körüli izmok Száj körüli izmok N. VII 27 Peripheral facial palsy Central facial palsy Szekely G., Matesz, C.: The efferent system of cranial nerve nuclei: A comparative neuromorphological study. Adv. Anat. Embryol. Cell Biol. 128. 1-92. 1993. 28 Organization of the sensory trigeminal system N. trigeminus 29 Trigeminal nerve Somatotopy: Circum oro-nasal Dorsoventral V/3 V/2 V/1 Spinothalamic tract Trigeminal lemniscus Principal (chief) nucleus of trigeminal nerve Spinal nucleus of trigeminal nerve Medial lemniscus – dorsal column pathway 30 Examiantion of sensation: Primary sensations: pain, i touch, t h vibration, ib ti joint j i t position, iti thermal th l sensation, ti both b th cold ld and d hot. h t Secondary (cortical sensation): two-point discrimination, touch localization, stereognosis, graphesthesia. General remarks: 1. the examiner is depending on the subjective patient response. 2. sensory examination should not be pressed if the aptient is fatigued. 3. sensory examination of patient without neurological problem should be abbreviated 4. patient should be tested with their eyes closed or covered Abnormal sensory phenomenon: positive or negative. Positive: Not necessarily associated with any demonstrable sensory deficit in the PNS or CNS. Negative : accomopanied by abnormal findings on sensory examiantion. Terminology of abnormal sensations: Two terminologies 1: rereferring to symptoms of which patients complain (both positive or negative phenomena) 2. describing abnormalities found on examiantion (only negative phenomena). 31 Signs and symptoms Structures involved Which of the following cranial nerves contain the afferent and efferent limbs of the corneal reflex? (A) II and III (optic and oculomotor) (B) III, IV, VI (oculomotor, trochlear, abducens) (C) V and VII (trigeminal, facial) (D) VIII and IX (vestibulocochlear, glossopharyngeal) (E) IX and X (glossopharyngeal, vagus) 32 Selected clinical cases_1 EXAMINATION OF PATIENTS 1. Case history nature, onset, extent and duration of the chief complaint previous disease, personal and family history , occupational data, social history particularly important: headache, seizures, loss of consciousness, visual disturbances, pain 2. Physical examination 3. Neurological examination cranial nerves motor system coordination reflexes sensory system MOTOR SYSTEM 33 A 57-year-old obese man is brought to the emergency department by his wife. The examination reveals that cranial nerve function is normal but the man has bilateral weakness of his lower extremities. He has no sensory deficits. MRI shows a small infarcted area in the general region of the cervical spinal cord-medulla junction. Which off the th following f ll i represents t the th mostt likely lik l location l ti off this thi lesion? l i ? _ (A) Caudal part of the pyramidal decussation _ (B) Lateral corticospinal tract on the left _ (C) Pyramids bilaterally _ (D) Pyramid on the right _ (E) Rostral part of the pyramidal decussation Duane E. Haines: Neuroanatomy. An Atlas of Structures, Sections,and Systems. 6th ed. MEDULLA OBLONGATA CLOSED PART MEDULLA OBLONGATA CLOSED PART 34 A 57-year-old obese man is brought to the emergency department by his wife. The examination reveals that cranial nerve function is normal but the man has bilateral weakness of his lower extremities. He has no sensory deficits. MRI shows a small infarcted area in the general region of the cervical spinal cord-medulla junction. Which off the th following f ll i represents t the th mostt likely lik l location l ti off this thi lesion? l i ? _ (A) Caudal part of the pyramidal decussation _ (B) Lateral corticospinal tract on the left _ (C) Pyramids bilaterally _ (D) Pyramid on the right _ (E) Rostral part of the pyramidal decussation Duane E. Haines: Neuroanatomy. An Atlas of Structures, Sections,and Systems. 6th ed. An inherited (autosomal recessive) disorder may appear early in the teenage years. These patients have degenerative changes in the spinocerebellar tracts, posterior columns, corticospinal fibers, cerebellar cortex, and at select places in the brainstem. The symptoms of these patients may include ataxia, paralysis, dysarthria, and other clinical manifestations. This constellation of deficits is most characteristically seen in which of the following? _ (A) Friedreich ataxia _ (B) Huntington disease _ (C) Olivopontocerebellar degeneration (atrophy) _ (D) Parkinson disease _ (E) Wallenberg syndrome MEDULLA OBLONGATA OPENED PART 35 Wallenberg syndrome Answer A: This inherited disease is Friedreich ataxia; it initially appears in children in the age range of 8–15 years and has the characteristic deficits described. Huntington disease is inherited, but appears in i adults; d l olivopontocerebellar li b ll atrophy is an autosomal dominant disease and gives rise to a different set of deficits. The cause of Parkinson disease is unclear, but it is probably not inherited; the Wallenberg syndrome is a brainstem lesion resulting from a vascular occlusion. A 45-year-old man complains to his family physician that there seems to be something wrong with his mouth. The examination reveals a weakness of the masticatory muscles, a deviation of the jaw to the left on closure, and a sensory loss on the same side of the lower jaw. MRI shows a tumor, presumably a trigeminal schwannoma, in the foramen ovale. Compression of which of the following structures would most likely be the cause of the deficits experienced by this man? _ (A) Maxillary and mandibular nerves on the left _ (B) Motor fibers and mandibular nerve on the left _ (C) Motor fibers and mandibular nerve on the right _ (D) Motor fibers and maxillary nerve on the left _ (E) Motor fibers and maxillary nerve on the right 36 N. trigeminus A 49-year-old man visits his ophthalmologist with what the man interprets as “trouble seeing”. The history reveals that the trouble “seeing” started after this sudden sickness. The examination reveals a loss of abduction and adduction of the right eye and a loss of adduction of the left eye. MRI confirms an infarcted area in the caudal and medial pontine tegmentum. Which of the following most specifically identifies this man man’ss clinical problem? _ (A) Horizontal gaze palsy _ (B) Internuclear ophthalmoplegia _ (C) One-and-a-half syndrome _ (D) Parinaud syndrome _ (E) Vertical gaze palsy MESENCEPHALON Other nuclei Periaquaeducta gray matter (PAG) Red nucleus (NR) Substantia nigra (SN) Within the reticular formation: Nucl. interstitialis (Caj Interpeduncular nucl. : At the meso-diencephalic border Nucleus commissurae posterioris (Darkschewitsch) 37 PONS Caudal part Fronto-pontine Temporo-occipito-pontine tracts Pontocerebellar tract Pontine nuclei Raphe pontine nn. Answer C: The loss of abduction and adduction in one eye and of adduction in the opposite eye (the one-and-a-half syndrome) indicates a lesion in the area of the paramedian pontine reticular formation and abducens nucleus (in this case on the right side) and the adjacent medial longitudinal fasciculus (MLF). The lesion d damages th the ipsilateral i il t l abducens bd motor t neurons, internuclear i t l neurons passing to the contralateral MLF, and internuclear axons in the ipsilateral MLF coming from the contralateral abducens nucleus. Parinaud syndrome is a paralysis of upward gaze, and gaze palsies tend to be toward one side and may result from cortical lesions. Internuclear ophthalmoplegia is a deficit of medial gaze in one eye, assuming a one-sided lesion. 38 Collaterals of ascending anterior (ventral) trigeminothalamic fibers that contribute to the vomiting reflex would most likely project into which of the following brainstem structures? _ (A) Dorsal motor vagal nucleus _ (B) F Facial i l nucleus l _ (C) Nucleus ambiguus _ (D) Superior salivatory nucleus _ (E) Trigeminal motor nucleus Dorsal nucl. of X X., nucl. alae cinereae med. Nucleus ambiguus (N. X.) Abdominal organs Scattered neurons dorsoolateral t the ambiguus nucl. Spinal nucleus of trigeminal nerve (V, IX, X) Thoracic organs Nucleus of solitary tract (Nucl. alae cinereae lat.) Py IO Sensory ggl: ggl. superius and inferius (nodosum) VM axons terminate in the intramural ganglia MEDULLA OBLONGATA OPENED PART N. X., XII. motor nucleus of abducens nerve IV Nucleus of solitary tract (VII) Sup. salivatory nucl. (VII) Spinal nucleus of trigeminal nerve (V, IX, X) Sensory ggl: Geniculate ggl. Py motor nucleus of facial nerve CAUDAL PART OF THE PONS, Cranial nerve nuclei 39 PONS, Other nuclei Locus ceruleus IV Sup. cerebellar ped. Parabrachial nucleus Middle cerebellar peduncle Pontine nuclei Raphe pontine nuclei Trapezoid body Superior olive Answer A: Anterior trigeminothalamic collaterals that project into the dorsal motor nucleus of the vagus are an important link in the reflex pathway for vomiting. The h superior i salivatory li nucleus l is involved in the tearing or lacrimal reflex, the nucleus ambiguus in the sneezing reflex, and the facial nucleus in the corneal reflex. Collaterals of primary afferent fibers to the mesencephalic nucleus that branch to enter the trigeminal motor nucleus mediate the jaw reflex Part 1 A 34-year-old woman presents with the complaint of seeing “two of everything” (diplopia). The history reveals that the woman becomes tired during the workday to the point where she frequently must leave her workplace early. The woman said that her vision problems appeared first, and later she noticed that, when she drank, it would “go down the wrong pipe”. The examination reveals weakness of the ocular muscle, difficulty in swallowing (dysphagia), and mild weakness of the upper extremities. extremities Sensation is normal normal. Further laboratory tests indicate that the woman has a neurotransmitter disease. Based on the history and symptoms experienced by this woman, which of the following is the most likely cause of her medical condition? _ (A) Amyotrophic lateral sclerosis _ (B) Huntington disease _ (C) Myasthenia gravis _ (D) Multiple sclerosis (E) Parkinson disease 40 Part 2 A 34-year-old woman presents with the complaint of seeing “two of everything” (diplopia). The history reveals that the woman becomes tired during the workday to the point where she frequently must leave her workplace early. The woman said that her vision problems appeared first, and later she noticed that, when she drank, it would “go down the wrong pipe”. The examination reveals weakness of the ocular muscle difficulty in swallowing (dysphagia), muscle, (dysphagia) and mild weakness of the upper extremities. Sensation is normal. Further laboratory tests Which thewoman following the mostdisease. likely location of the indicate thatofthe has represents a neurotransmitter neurotransmitter dysfunction in this woman? _ (A) At the termination of corticonuclear fibers _ (B) At the termination of corticospinal fibers _ (C) At the neuromuscular junction _ (D) Within the basal nuclei _ (E) Within the cerebellum Part 3 A 34-year-old woman presents with the complaint of seeing “two of everything” (diplopia). The history reveals that the woman becomes tired during the workday to the point where she frequently must leave her workplace early. The woman said that her vision problems appeared first, and later she noticed that, when she drank, it would “go down the wrong pipe”. The examination reveals weakness of the ocular muscle difficulty in swallowing (dysphagia), muscle, (dysphagia) and mild weakness of the upper extremities. Sensation is normal. Further laboratory tests indicate that the of woman has a neurotransmitter disease. Which the following represents the neurotransmitter most likely affected in this woman? (A) Acetylcholine (B) Dopamine (C) Glutamate (D) GABA (E) Serotonin A 16-year-old boy is brought to the family physician by his mother. The mother explains that her son is having trouble in school even though he is a hard worker and is well behaved. The examination reveals that the boy has a sensorineural hearing loss in his right ear. He has no other deficits. Which of the following represents p the most likelyy location of the lesion in this boy? y _ (A) Auditory cortex _ (B) Cochlea _ (C) External ear _ (D) Inferior colliculus _ (E) Middle ear 41 A 70-year-old woman is brought to the emergency department by members of the volunteer fire department of a small town. She primarily complains of weakness. The examination reveals a hemiplegia involving the left upper and lower extremities, sensory losses (pain, thermal sensations, and proprioception) on the left side of the body and face, and a visual deficit in both eyes. MRI shows an area of Infarction consistent with the territory served by the anterior choroidal artery. Which of the following visual deficits is seen in this woman? _ (A) Left homonymous hemianopsia _ (B) Left nasal hemianopsia _ (C) Left superior quadrantanopia _ (D) Right homonymous hemianopsia _ (E) Right superior quadrantanopia C, D: homonym hemianopsia A 70-year-old woman is brought to the emergency department by members of the volunteer fire department of a small town. She primarily complains of weakness. The examination reveals a hemiplegia involving the left upper and lower extremities, sensory losses (pain, thermal sensations, and proprioception) on the left side of the body and face, and a visual deficit in both eyes. MRI shows an area of Infarction consistent with the territory served by the anterior choroidal artery. y Which of the following most specifically identifies the pattern of sensory deficits experienced by this woman? _ (A) Alternating hemianesthesia _ (B) Hemianesthesia _ (C) Paresthesia _ (D) Sensory level _ (E) Superior alternating hemiplegia 42 MEDULLA OBLONGATA OPENED PART MEDULLA OBLONGATA CLOSED PART A 70-year-old woman is brought to the emergency department by members of the volunteer fire department of a small town. She primarily complains of weakness. The examination reveals a hemiplegia involving the left upper and lower extremities, sensory losses (pain, thermal sensations, and proprioception) on the left side of the body and face, and a visual deficit in both eyes. MRI shows an area of Infarction consistent with the territory served by the anterior choroidal artery. y The weakness of the extremities in this woman is most likely due to damage to which of the following? _ (A) Corticospinal fibers on the left _ (B) Corticospinal fibers on the right _ (C) Somatomotor cortex on the right _ (D) Thalamocortical fibers to motor cortex on the right _ (E) Thalamocortical fibers to sensory cortex on the right 43 Deglutition and phonation. The accessory and hypoglossal nucleus. The cranial parasympathetic outflow Glossopharyngeal nerve J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 Glossopharyngeal nerve: Disorders: glossopharyngeal neuralgia. Intense and paroxysmal pain, originates in the tonsillar fossa, in the throat, in the ear. Can radiate from the throat to the ear. Dyaphagia, loss of gag reflex, curtain movement of post wall of phary Case history: trauma, tumor, aneurysm, herpes zoster. 44 Vagus nerve J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 Examination of the accessory nerve 45 Jugular foramen syndrome: Difficulty in swallowing, hoarseness, deviation in soft palate, weakness in the upper part of trapezius and in sternocleidomastoideus, anaesthesia in the post. part of pharynx. Hypoglossal: genioglossus receives only contralateral supranuclear innervation. Each genioglossus muscle pulls its half of the tongue anteriorly and slightly medially. When they function together and symmetrically, the tongue protrudes straight out of the mouth. The lesion of corticobulbar fibers will cause the tongue to deviate toward the weak side , when protruded, because of the unopposed pull of the intact muscle. Genioglossus 46 47 Signs and symptoms Structures involved Total unilateral medullary syndrome (occlusion of vertebral artery) Combination of lat. and med. syndromes Segregation of motoneurons within the nucleus Hypoglossal nucleus HYOGLOSSUS (retractor) obex 1 Rostral Caudal STERNOHYOIDEUS (retractor) HYO GEN GGL DM INT GENIOGLOSSUS (protractor) IM GGL OMO INT 3 STE GEN INT OMO VL 1500 1000 500 500 1000 um DM: DORSOMEDIAL, IM: INTERMEDIER, VL: VENTROLATERAL Matesz, C., I. Schmidt, L. Szabo, A. Birinyi, G. Szekely: Eur. J. Morphol. 37: 129‐133. 1999. 48 STE Muscles of tongue: retractor, protractor, inner OMO GGL HYO INN Birinyi A, Szekely G, Csapo K, Matesz C. J Comp Neurol. 470: 409-421. 2004. Are there any differences between the motoneurons of hypoglossal nucleus? 4 MORPHOLOGY Diameter of stem dendrites Length of dendritic segments Diameter of cell body 3 INNER CAN 2 2 1 0 -1 RETRACTOR PROTRACTOR -2 -3 -3 -2 -1 0 CAN 1 1 2 3 4 4 3 CAN 2 ORIENTATION ellipse with major and minor axes describes the shape of the dendritic arborization In X-Y, X-Z, Z-Y planes PROTRACTOR 2 1 0 -1 INNER RETRACTOR -2 -3 -3 -2 -1 1 0 CAN 1 2 3 4 Birinyi A, Szekely G, Csapo K, Matesz C. J Comp Neurol. 470: 409-421. 2004. Hypoglossal nucleus Nervus hypoglossus h y p o XII XII XII XII XII XII Szekely G., Matesz, C.: Adv. Anat. Embryol. Cell Biol. 128. 1‐92. 1993. 49 Cranial parasympathetic outflow Szekely G., Matesz, C.: Adv. Anat. Embryol. Cell Biol. 128. 1‐92. 1993. Selected clinical cases_2 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 50 51 Wallenbergg syndroma y occlusio of left post. inf. cerebell artery J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 Case 9 cont. 52 Case 9 cont. IV Tegmentum pontis Basis pontis ROSTRAL PART OF THE PONS, Cranial nerve nuclei PONS Caudal part Fronto-pontine Temporo-occipito-pontine tracts Pontocerebellar trac Pontine nuclei Raphe pontine nn. 53 stenosis of basilar arteryy J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 54 Case 10 cont. PONS Caudal part Fronto-pontine Temporo-occipito-pontine tracts Pontocerebellar trac Pontine nuclei Raphe pontine nn. J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 55 vestibularis ideg tumor Schwannoma J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 A facialis somatomotoros neuronok supranuclearis beidegzése Homlok, szem körüli izmok Száj körüli izmok N. VII Homlok, szem körüli izmok Száj körüli izmok N. VII 56 A facialis somatomotoros neuronok supranuclearis beidegzése Centralis lézió Homlok, szem körüli izmok Homlok, szem körüli izmok Száj körüli izmok Száj körüli izmok N. VII N. VII A facialis somatomotoros neuronok supranuclearis beidegzése Homlok, szem körüli izmok Száj körüli izmok N. VII Perifériás lézió Homlok, szem körüli izmok Száj körüli izmok N. VII 57 Case 12 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 Differential diagnosis: Slow –growing tumor Bleeding Unusual type of choronic infection Degenerative disorder J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 58 B: bitemporal hemianopsia C, D: homonymous hemianopsia A. CAROTIS INTERNA CIRCULUS ARTERIOSUS WILLISi A. VERTEBRALIS Differential diagnosis: Pituitary adenoma Craniopharyngeoma Tumor of hypothalamus Aneurysm of anterior communicating artery 59 41 old man. Progressive weakness and unsteadiness of his leg. Case history: weight lost, alcoholism Motor deficite: Ankle, biceps, knee jerk reflexes diminished. Sensory deficite: sock-and gloves type J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 60 J. deGroot, J.G.Chusid: Correlative Neuroanatomy: ISBN: 0892‐1237 Vestibular pathways p y 61 Vestibular system: peripheral, central BECHTEREW DEITERS (ROLLER) SCHWALBE Vestibular nuclei SVN – superior vestibular nucleus MVN – medial vestibular nucleus LVN – lateral vestibular nucleus IVN – inferior (descendens) vestibular nucleus McCall AA, Yates BJ (2011) Front Neurol 2:1‐13. Connections of vestibular nuclei Vestibular receptors Proprioceptors and related Receptors of skin pathways and related Visual system pathways Cortex Hippocampus Thalamus Cerebellum Ipsi- and contralateral vestibular ib l nuclei l i Vestibular nuclei Reticular formation Acoustic system Others Visceromotor neuron Somatomotor neurons of brainstem and spinal cord (extensor muscles, eye moving muscles, others) 62 GAZE CONTROL Cerebellum Cerebellum POSTURE CONTROL Dorsal column-medial lemniscus pathway Brodal, A: Neurological Anatomy in Relation to Clinical Medicine. Third edition. New York, Oxford University Press, 1981 Straka H, Dieringer N. Prog Neurobiol. 2004 4:259-309. Vestibulospinal neuronal circuit: chemical and electrical synapses Rácz E, et al. J Comp Neurol. 496: 382‐394. 2006. 63 Impulse transmission in the vestibular system gap junction postsynaptic neuron primary afferent neuron Dieringer N. Prog Neurobiol. 1995. 46:97‐129. Matesz, C. Acta biol. Hung. 39: 267‐277. 1988. Vestibular lesion Static and dynamic disorders Dieringer N. Prog Neurobiol. 1995. 46:97‐129. Vestibular compensation Halasi G et al,. Brain Structure and Function. 212: 321-334. 2007 Cheryl Schiltz lost her sense of balance after taking an antibiotic. Then she tried Bach-y-Rita's tongue gear. An accelerometer in her hat transmits data on her movements to a receptor on her 64 Central auditory y system y Bipolar cells of the spiral ganglion Dorsal and ventral cochlear nucleus H. R. Ross: Histology ISBN 978 963 226 052 5 DCN VCN H. R. Ross: Histology ISBN 978 963 226 052 5 65 Spiral ganglion Vestibulocochlear nerve Dorsal and ventral cochlear nucleus Superior oliveLemniscus lateralis Brachium of inferior collicle Inferior collicle Auditory radiation, post. limb of internal capsule Medial geniculate body Br 41, 42 Heschl gyrus Nucleus of lateral lemniscus Haines: Fundamental Neurosicence 2006, ISBN 0-443-06751-1 Sound localisation: Hangforrás lokalizálása: Oliva superior bipolaris neuronjai Bipolar neurons of superior olive Commissuralis rostok a kétoldali Commissural fibers between the a) oliva superior a) superior olives b) nucl. lemnisci lateralis b) nuclei of lateral lemnisci c) colliculus inferior c) inferior colliculi között Midline 66