Download Clinically oriented anatomy of the brainstem

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