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This document discusses the anatomy and physiology of the nervous system. It covers topics such as:
1. The embryonic development of the brain and spinal cord from the neural tube.
2. The major divisions and structures of the brain and spinal cord, including the cerebral cortex and its primary, secondary, and tertiary areas.
3. The somatosensory organization and motor systems, including the pyramidal and extrapyramidal pathways. It describes lesions of the upper and lower motor neurons.
This document discusses the anatomy and physiology of the nervous system. It covers topics such as:
1. The embryonic development of the brain and spinal cord from the neural tube.
2. The major divisions and structures of the brain and spinal cord, including the cerebral cortex and its primary, secondary, and tertiary areas.
3. The somatosensory organization and motor systems, including the pyramidal and extrapyramidal pathways. It describes lesions of the upper and lower motor neurons.
This document discusses the anatomy and physiology of the nervous system. It covers topics such as:
1. The embryonic development of the brain and spinal cord from the neural tube.
2. The major divisions and structures of the brain and spinal cord, including the cerebral cortex and its primary, secondary, and tertiary areas.
3. The somatosensory organization and motor systems, including the pyramidal and extrapyramidal pathways. It describes lesions of the upper and lower motor neurons.
Zainal Muttaqin, M.D., Ph.D. dnS Department of Neurosurgery, Diponegoro University Embryology : Prosencephalon Mesencephalon Rhombencephalon P. vesicles M. vesicle R. vesicle Telencephalon Diencephalon Mesencephalon Metenceph. Myelenceph.
Cerebral Cortex Diencephalon Mesencephalon Pons-Cereb. MO-MS Lateral ventr. 3rd.ventricle Sylvian aquaeduct 4th.ventricle - central canal Neuroectodermal origin, forming the neural tube, consist of the walls and their respective, fluid- filled space called vesicles dnS Department of Neurosurgery, Diponegoro University CNS Imaging and Anatomy dnS Department of Neurosurgery, Diponegoro University Cortical Divisions dnS Department of Neurosurgery, Diponegoro University Cerebral Cortex - total area about 0.25m2, consist of about 10 billion neurons - cell variation : granular , agranular, fusiform, pyramidal, etc. - cell layers, motor cortex c.o. 6 layers; I-IV sensory function, and pyramidal neurons in layer V and VI - Brodmanns numbering, according to histological studies ; area 4 : primary motor cortex; 1,2,3 : primary sensory cortex - presence of afferen and efferen pathways between thalamus and cortex, cortex is an outgrowth of thalamus dnS Department of Neurosurgery, Diponegoro University Cerebral Cortex Somatotopic Arrangement :
- receptor for each sensory modality represented separately by different neurons in the somatosensory area of the cortex. - somatotopically arranged as each hemisphere controls contra- lateral side of the body; the lower part of the body controlled by neurons located in the upper part of the respective cortex. - number of neurons (so as its cortical area) controlling/ repre- senting a certain body part is proportional to function of the respective body part, not anatomical size of the body part (s). dnS Department of Neurosurgery, Diponegoro University Somatotopic Arrangement dnS Department of Neurosurgery, Diponegoro University Primary, Secondary, and Tertiary cortical areas dnS Department of Neurosurgery, Diponegoro University 3 2 1 I. 1. Primary visual area 2. Primary somatosensory area 3. Primari auditory area just for simple analysis, such as localization F P T O II. Secondary area : association area, for more difficult analysis located just outside or surrounding the specific primary areas : 1a, 2a, 3a. III. Tertiary area : for complex analysis, center of interpretation located between main association areas, only in the dominant hemisphere/cortex : 4 Sensory Functions 1a 2a 3a 4 1 2 3 1. Primary motor cortex the beginning of pyramidal tract 2. Broca area and Hand (Exner) areas coordinating activity of all muscles related to speech & hand movements (located at pre-motor cortex) Motor Functions 3. Prefrontal cortex : additional area for cerebration or thinking - planning the future, planning sequence of movements - postponing planned works related to incoming new information - solving difficult problems, mathematic, datas - diagnosis, etc. - correlating behavior with values, polite or unpolite, good or bad
dnS Department of Neurosurgery, Diponegoro University 2 dnS Department of Neurosurgery, Diponegoro University
Sensory Perception :
Primary area ; - auditory : not deaf, but dont understand what is heard - visual : not blind, but dont understand what is seen - somatosensory : not anesthesia, but dont understand what is felt
Secondary/ association area ; - understood what is heard / seen, but not in a coherent manner; such as reading without understanding the meaning of sentences
Tertiary/ interpretation area ; - a higher brain function / cerebration, mainly developed in the left / dominant side; from birth to 6 year-old right and left side still same - the word dominant is for intellectual /verbal /language function dnS Department of Neurosurgery, Diponegoro University
Cortical networks dysfunction : Agnosia ; - auditory agnosia : not deaf but fails to recognize specific sounds/ speech/ music - visual agnosia : not blind, but fails to recognize object visually, prosopagnosia means failure to recognize familiar faces - tactile agnosia : inability to recognize objects by touch Apraxia ; - ideomotor apraxia: inability to perform complex acts on command, but the same acts can be performed automatically - ideational apraxia: failure to perform sequences of acts, but not individual act - kinetic/ motor apraxia/ gait apraxia: paient has his feet glued to the floor Aphasia ; - Brocas aphasia : comprehend spoken/ written language, but difficult with speech - Wernickes aphasia: poor speech comprehension, incorrect word to express thought, use words without precise meaning, or may substitute words dnS Department of Neurosurgery, Diponegoro University
S p i n a l C o r d dnS Department of Neurosurgery, Diponegoro University Motor System Pyramidal / Corticospinal pathway (1 ) : - starts from the pre-central gyrus or motor cortex or Brodmann area 4 or Upper Motor Neuron - efferen fibers descend through ventral part of the brain internal capsule - diencephalic level cerebral peduncle - mesencephalic level basis pontis - pontine level pyramis - medullary level - end at the anterior horn of the spinal cords grey matter, sinaps with LMN / alpha motoneuron, whose axon or efferen fibers end as motor end plate. dnS Department of Neurosurgery, Diponegoro University Pyramidal / Corticospinal pathway dnS Department of Neurosurgery, Diponegoro University Motor system Pyramidal pathway ( 2 ) : - most fibers decussate to the contralateral side at lower medulla, and descend as lateral corticospinal tract ; some fibers descend ipsilaterally as ventral cortico- spinal tract and cross midline at the level of their sinaps with respective LMN . - those fibers that go to the nuclei of the cranial motor nerve ( nn. 3, 4, 6, 7, 12 ), decussate at the level of the respective nuclei in the brainstem/ - some fiber from the motor cortex ends in the brainstem (cortico bulbar tract ) - direct all conscious / purposeful movement of the body (as the driver of a car) dnS Department of Neurosurgery, Diponegoro University
Motor System Extrapyramidal Pathway :
- function as the power steering (providing the power needed) for purpose- ful motion of the muscles (performed by the pyramidal system) - coordinated by many nuclei in the basal ganglia and cerebellum, via the reticular formation of the brainstem, brought to the gamma motoneuron at the anterior horn of the spinal cords grey matter. - efferen fibers of the gamma motoneuron activates muscle spindle, which in turns activates alpha motoneuron. Activation of alphamotoneuron will then facilitate muscle contraction (increase of muscle tone)
* * Muscle fiber Muscle spindle * * Gamma motoneuron Alpha motoneuron dnS Department of Neurosurgery, Diponegoro University Motor system Anterior horn of the spinal cord :
- alpha motoneuron; larger cells, innervate true muscle fibers/ex- trafusal, secondary neuron (LMN) of the corticospinal pathway, with afferen fiber of muscle spindle form stretch reflex circuitry - gamma motoneuron; smaller cells, innervate intrafusal fibers or muscle spindle, which in turns activate alpha motoneuron & in- crease muscle tone, strong effect from extrapyramidal centers (basal ganglia,cerebellum, and reticular formation of brainstem) - motor unit: c.o.a number of muscle fibers innervated by 1 alpha motoneuron ( large: >100 fibers; small: <10 fibers per neuron )
dnS Department of Neurosurgery, Diponegoro University Motor system Distinguishing UMN and LMN lesion :
LMN (starting from anterior horn to the motor end plate) - Destroys the stretch reflex circuitry, there is no muscle tone - Called flaccide paralysis, no physiological reflexes/ areflexia - Quick atrophy of the involved muscles
UMN (from the motor cortex until just before anterior horn) - Stretch reflex circuitry intact & uncontrolled by consciousness (pyramidal pathway) so that muscle tone increases (spastic), - Causing hyperreflexia & the appearance of pathological reflexes - Called spastic paralysis, atrophy occurs only after a long time dnS Department of Neurosurgery, Diponegoro University Sensory System Sensory receptors : Somatosensory (GSA) Viscerosensory (GVA)
Proprioceptive Exteroceptive Interoceptive position sense pain & thermal (anterolateral /spinothalamic) (dorsal/lemniscal) touch & pressure - tactile discrimination (dorsal/lemniscal) - simple touch (anterolateral /spinothalamic) dnS Department of Neurosurgery, Diponegoro University Sensory System Pain ( 1 ) - protect body from noxious stimuli (stimuli that may cause tissue destruction ) - receptors found in skin, periosteum, duramater, arterial wall, and joint surface. - receptors consist of mechanosensitive, thermosensitive, and chemosensitive. - different form of pain: sharp pain, burning pain, and dull pain (bad localization) - pathophysiology of pain sensation; tissue destruction (secretion of bradykinine, prostaglandine, histamine, serotonin) ischemia (decrease of blood flow will result in lactic acidosis) muscle spasm (overcontraction of muscle may cause ischemia)
dnS Department of Neurosurgery, Diponegoro University Sensory system Pain ( 2 ) - pain transmission in the CNS 1. Spinothalamic/ anterolateral (good localization, consciously perceived) 2. Diffuse spino-reticulo-thalamic system ( via reticular formation, then intralaminar & reticular nuclei of thalamus, to bilateral cerebral hemisphere; badly localized, related to mood of suffering) - peripheral pain transmission 1. A delta fiber ( 3 - 20 U, myelinated, for sharp pain) 2. C fiber ( 0.5 - 2 U, unmyelinated, for burning pain & dull pain) - referred pain (fromviscera, felt in body surface, caused by synaptic sharing in the spinal cord between visceral and external/ surface fibers, in gastritis etc.) dnS Department of Neurosurgery, Diponegoro University Sensory System Temperature Sense - Cold receptor ( active at 10-40 0 C, max. at 25 0 C, < 10 0 C activates pain recept.) -Heat receptor ( active at 30-50 0 C, max. at 45 0 C, warm if cold & heat together )
Position Sense - static sensation (awareness of position/orientation of body parts, Ruffini receptor at joint capsules & ligament, activated during motion, long lasting signal) - kinesthetic sensation (awareness of speed of motion, Golgi tendon &Pacini recep- tors, quick adaptation of signal ) dnS Department of Neurosurgery, Diponegoro University Sensory System Anatomy of Transmission (1)
Pain & Temperature
1. sinaps at dorsal horn, cross midline, ascend as lateral spinothalamic tract to thalamic nuclei.
2. area innervated by Vth.nerve, fibers cross the midline at medulla, & then ascend to thalamus as trigemino-tha lamic tract. dnS Department of Neurosurgery, Diponegoro University Sensory System Anatomy of Transmission ( 2 ) Proprioceptive & Tactile discrimination
1. Enters CNS as dorsal root, ascend at the same side as dorsal funniculi (Goll & Burdach or Gracilis & Cuneatus) to dorsal medulla (change neuron/ sinaps) 2. New fiber (from Goll & Burdach) then crosses midline and ascend to thalamus as lemniscal fibers. 3. Some fiber sinaps at dorsal horn, cross midline, ascend as ventral spinocerebel lar tract (contralaterally,subconscious) dnS Department of Neurosurgery, Diponegoro University Sensory System Anatomy of Transmission ( 3 ) Proprioceptive & Tactile discrimination
1. Enters CNS as dorsal root, ascend at the same side as dorsal funniculi (Goll & Burdach or Gracilis & Cuneatus) to dorsal medulla (change neuron/ sinaps) 2. New fiber (from Goll & Burdach) then crosses midline and ascend to thalamus as lemniscal fibers. 3. Some fiber sinaps at dorsal horn, cross midline, ascend as ventral spinocerebel lar tract (contralaterally,subconscious)
dnS Department of Neurosurgery, Diponegoro University Sensory System Differences between anterolateral and dorsal pathways dnS Department of Neurosurgery, Diponegoro University Sensory System Spinal Cord Lesions : 1. s.c. transection: spinal shock (flaccid paralysis) occurs in acute stage, sign of UMN lesion can be detected after several weeks with spasticity and Babinsky (extensor plantar reflex), lesions at C1-C3 disturb respiration 2. s.c. hemisection (Brown-Sequard Syndrome): ipsilateral spastic paralysis, ipsilateral proprioception, and contralateral pain and temperature sensation 3. central gray matter lesion: occurs in Syringomyelia (cavitation around central canal), interupt the crossing spinothalamic fibers affecting pain and temperature sensation of the bilateral upper extremities, with intact proprioception (sensory dissociation) 4. Amyotrophic Lateral Sclerosis (ALS): Progressive and fatal degeneration of LMN, corticobulbar and corticospinal tract bilaterally (weakness and atrophy in some muscles and spasticity and hyperreflexia in other muscles, followed by difficulty in speaking and swallowing) 5. Poliomyelitis: a viral infection, usually in children, affecting LMN of the anterior horn, result in flaccid paralysis of the involved limb, fatal if involves the brainstem dnS Department of Neurosurgery, Diponegoro University Sensory System Spesific Thalamocortical Projections :
- medial geniculate body - auditory area 41, 42 - lateral geniculate body - visual area 17 - VPM nuclei - sensory area I (1, 2, 3 face ) - VPL nuclei - sensory area II,I (1, 2, 3 body) - VL nuclei - motor area (4, 6) - VA nuclei - motor area (6, 8) & orbitofrontal c. - anterior nuclei - limbic cortex - lateral n. & pulvinar - parietal association & occipitotemp.c - dorsomedial nuclei - prefrontal cortex dnS Department of Neurosurgery, Diponegoro University Motor System Basal Ganglia ( 1 ) -a group of subcortical nuclei, in the depth of the cerebral hemisphere -functionally act as one unit, part of the extrapyramidal system, indirectly influence LMN via modulation of cerebral cortex and brainstem -c.o. : 1. Striatal body - lenticular nuclei (putamen &globus pallidus) - caudate nuclei 2. Amygdaloid body 3. Claustrum 4. Subthalamic nuclei 5. Dark nuclei (substansia nigra) dnS Department of Neurosurgery, Diponegoro University Motor System Basal Ganglia ( 2 )
Several basal ganglia circuitry : diffuse BG excitation motor cortex thalamus (VA nuclei) BFA inhibition BIA excitation striatum globus pallidus skeletal muscle tone down BG destruction motor cortex thalamus (VL nuclei) inhibitory effect (-) pontine cerebellum decerebrate rigidity dnS Department of Neurosurgery, Diponegoro University
Motor System Basal Ganglia ( 3 ) BG dysfunction in human causes difficulty in initiating movement, disturbances in continuing or stopping ongoing movements, abnormalities of muscle tone (rigidity), and development of involuntary movement (tremor or chorea) These manifestations can be divided into 3 functional categories : 1. Parkinsonism or Paralysis agitants: bradykinesia (slowness of movement), rigidity, gait instability, and tremor. Masked face, no automatic arm swing 2. Hyperkinetic movement disorders: Ballismus, Chorea (Sydenhams chorea in rheumatic fever, Huntington disease in adult with dementia), & Athetosis 3. Dystonia: common in children with cerebral palsy, frequent focal form in adult is spasmodic torticollis or wryneck dnS Department of Neurosurgery, Diponegoro University
Motor System Basal Ganglia ( 3 cont.) 1. Chorea : continuous uncontrolled contraction of many muscles, named as st. vituss dance,and piano-playing,related to wide destruction of striatal body causing disinhibition of thalamocortical neurons. If one side only: hemichorea 2. Athetose : fine & slow motion of distal muscles, mainly superior extremities, usually rythmic, worm like and aggravated by emotion, destruction of globus pallidus (& striatum), related to feed back deficit from BG to thalamus & cortex 3. Hemiballismus : severe uncontrolled contraction of proximal muscles unilate- rally, person my be thrown. Lost of subthalamic nuclei excitation on the internal globus pallidus resulted in disinhibition of thalamocortical neurons. 4. Parkinson disease (paralysis agitans) : degeneration in substansia nigra and locus ceruleus (and lewy bodies in the remaining neurons),lead to depletion of dopamine in the striatum, causing enhanced pallidothalamic & nigrothalamic inhibition of thalamocortical neurons. dnS Department of Neurosurgery, Diponegoro University
Cerebellum (1)
Maintains fine control and coordination of both simple & complex movements: Coordinating posture and balance in walking and running Executing sequential movements in eating, dressing, and writing Producing rapidly alternating repetitive movements & smooth-pursuit movements Controlling certain properties of movements, including trajectory, velocity, and acceleration Voluntary movements can proceed without cerebellum, but such movements will be lack of precision and appear clumsy and disorganized. Functional division of cerebellum consist of Vermal region with fastigial nuclei, Paravermal region or the intermediate zone, and the Lateral Hemisphere region with dentate nuclei Means : little cerebrum Volume : 10% of the brain Neurons : 50% of the brain dnS Department of Neurosurgery, Diponegoro University
Cerebellum (2) Cerebellar inputs : Sensory information about muscle length, tension, limb position, brought by posterior root, synapse at Clarkes nuclear column (for lower limbs) and lateral cuneate nucleus (for upper limbs and head), project to ipsilateral cerebellar nuclei. Other fibers synaps at posterior horn & double cross to reach ipsilateral cerebellum. These peripheral information enter cerebellum via inferior cerebellar peduncle Feedback information from cerebral cortex, projected to ipsilateral neuron at basis of the pons, then cross the midline to reach contralateral cerebellum. These higher cortical information enters via middle cerebellar peduncle Cerebellar outputs : Outputs from cerebellum originates from its deep nuclei (Fastigial, Globose, Emboliform, & Dentatus or Fat Girls Eat Donut). These neurons receive excitatory signals from various cerebellar inputs, & inhibitory signal from Purkinye neurons (output of cerebellar cortex is only inhibitory from GABAergic Purkinye neurons) These outputs project mainly top the contralateral Red nucleus & Thalamus. From here, the signals transmitted to both cerebral cortex and to the lower brainstem and spinal cord dnS Department of Neurosurgery, Diponegoro University
Cerebellum (3) Cerebellar Functional Divisions Vestibulo Cerebellum : oldest and most primitive, main component is flocculus and nodulus (the lowest folia of vermis). Essential for the control of balance (vestibulospinal tracts) and eye movements (inputs into eye muscle nuclei) Spino Cerebellum : main component is most of vermis & intermediate lobe. Essential for axial stability (gait), tracking movement (finger to nose testing), and control of fine movements. Vermis control the body, while paravermal region (intermediate hemispheres) control the limbs. Cerebro Cerebellum : most developed in human species, the lateral hemispheres, receives input from the cerebral cortex via relay neurons at basis pontis, and output fron dentate nucleus to both red nucleus and thalamus. Its function is the least understood, might has role in cognition and personality dnS Department of Neurosurgery, Diponegoro University
Motor System Cerebellar Dysfunction (1)
Midline Zone dysfunction 1. Disorders of stance and gait; patients stands on a broad base, truncal ataxia, tandem walking impossible, without limb ataxia 2. Titubation (rhytmic tremor of the body or head, several times per second) 3. Rotated or tilted postures of the head (the head may be maintained rotated or tilted to left or right). The side does not indicate the site of the disease 4. Ocular motor disorders (most prominent is spontaneous nystagmus 5. Affective disturbances (flattening or blunting of emotional expression, and disinhibited or inappropriate behavior) dnS Department of Neurosurgery, Diponegoro University
Motor System Cerebellar Dysfunction (2)
Lateral (Hemispheric) Zone dysfunction (1) 1. Decomposition of movement (motor act is jerky and irregular, not smooth) 2. Gait disturbances accompanied by limb ataxia 3. Hypotonia (decrease in resistance to passive limb manipulation at joints) 4. Dysarthria (slow, slurred, and labored speech, but comprehension intact) 5. Dysmetria (hypo or hypermetria, failure of placement of body part at motion) 6. Dysdiadochokinesis and dysrhytmokinesis (decomposition of movements) 7. Ataxia (veers from side to side, difficulty in walking in a staight line 8. Tremor (intentional tremor, nose-finger test, there is static& kinetic tremors) dnS Department of Neurosurgery, Diponegoro University
Motor System Cerebellar Dysfunction (2)
Lateral (Hemispheric) Zone dysfunction (2) 9. Impaired check and rebound (extended arm is easily displaced & overshoot inreturning to original position 10. Ocular motor disorder: most common is nystagmus 11. Disturbance of executive functioning: consist of deficient shifting, abstract reasoning, working memory, and decreased verbal memory 12. Impaired spatial recognition (disorganized & impaired visuospatial memory) 13. Personality change: flattening or blunting of affect, and disinhibited or inappropriate behavior 14. Linguistic difficulties: abnormalities in rhythm and intonation of speech and language (dysprosody), and naming disorder (anomia) dnS Department of Neurosurgery, Diponegoro University Limbic System (1) Limbic system integrates our experience of external world with the fundamental physiologic processes (endocrine system, autonomic nervous system, and behavior) to maintain our internal environment within normal limit, a process called homeostasis Behavior serves as the primary mechanism to achieve homeo- stasis, such as in regulation of water balance & thermoregulation by eating food, drinking fluids, seeking a more comfortable environment. Social behavior (reproduction, parenting behavior, territorial aggression) is controlled directly by limbic telencephalon Department of Neurosurgery, Diponegoro University dnS Limbic System (2) Anatomy of the limbic structures (extend from cortex to brainstem) 1. Limbic structures in telencephalon (paralimbic cortex or mesocortex), consist of parahippocampal, cingulate, paraterminal gyri, and posterior orbitofrontal, insular, and temporal pole cortices 2. The limbic cortex or allocortex, consist of hippocampal formation and primary olfactory cortex 3. The corticoid areas, consist of amygdala, septal area, and substantia innominata There are 2 fundamental connection for limbic functions: 1. Intracortical networks (particularly with association cortices) for cognitive function (emotion, comportment, attention, and memory) 2. Subcortical pathways through hypothalamus and brainstem that regulate homeo- stasis and social behaviors. LS is the only major route connecting hypothalamus to the neocortex (and therefore external environment) Department of Neurosurgery, Diponegoro University dnS Limbic System (3) Hippocampal Formation 1. Includes three parallel zones (Subiculum, Hippocampus or Ammons horn, and Dentate gyrus) which are folded at the medial side of temporal lobe 2. Important role in learning & memory, its integration with amygdala & other limbic areas builds cognitive maps (recognizing owns location in space & time and owns relation to external objects and events, past and present) 3. Hippocampal sclerosis is the most common pathology found in Temporal Lobe Epilepsy (Psychomotor or Complex Partial Epilepsy), cured with Amygdalo-hippocampectomy MRI Department of Neurosurgery, Diponegoro University dnS Limbic System (4) Amygdala 1. Spherical mass of gray matter in the antero-superior of hippocampus, medially bulging into mesencephalic cistern as Uncus 2. Important in linking emotion, motivation & autonomic responses to external stimuli, regulates fear & stress, modulates & integrates pituitary function & social behaviors (via its connections with hypothalamus) Role of Prefrontal Cortex 1. Functional imaging studies strongly support the importance of prefrontal cortex and its connections with amygdala for emotions and affective behaviors 2. Working hypothesis: activity in the dorsolateral prefrontal cortex of the left hemisphere generates a state of happyness or positive affect, and activation of the right prefrontal cortex, especially in the ventromedial orbital area, leads to sadness or disgust ( so that these functions are lateralized within the brain ) dnS Department of Neurosurgery, Diponegoro University Memory Types & their physiological mechanisms :
1. sensory memory (<1 sec.), present while the event occurs. 2. short term/primary memory (<1 min.), the event just occurred; theories : reverberatory circuitry, post-tetany/ electrotonic potential; cellular membrane is more sensitive for a very short time. 3. long term memory, long after the event had finished ; secondary: until years, difficult to recall & tertiary: last for life, easy to recall. synaptic change theory (permanent/semipermanent, increase of neuronal faci- litatory, more often being recalled deepen the memory); RNA function theory (analogy); extraneuronal theory (changes of glial cells / mocopolysaccharides surrounding neuronal synaps). dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Hypothalamus & Limbic system - maintain homeostasis of the internal environment by hormon secretions, autonomic nervous system, emotion and motivation.
cerebral cortex amygdala & hippocampus coordination of visceral hypothalamus function and behaviour SURVIVAL visceral & somatic sensation, reticular formation dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Regulatory mechanism of Hypothalamo-Pituitary axis 1. Direct mechanism : (Neuroendocrine products directly secreted to systemic circulation)
supraoptic & paraventricular nuclei oxytocin & vasopressin (ADH) production hypothalamo-hypophyseal tract Posterior pituitary/ neurohypophysis ADH & oxytocin secretion dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Regulatory mechanism of Hypothalamo-Pituitary axis 2. Indirect mechanism : (secretion of releasing hormones/factors that affect adeno hypophysis, except for prolactin/ inhibiting factor) arcuate & ventromedial nuclei a variety of releasing hormone
capillary of the pituitary portal system secretion of trophic hormones adenohypophyseal cells (subpopulation) (TSH, FSH, LH, GH, ACTH, PRL) dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Endocrine disturbance from pituitary disease Acromegaly - Gigantism GH producing pituitary adenoma, gigantism in children and acromegaly in adult, produces diabetes mellitus and cardiovascular diseases Cushing Disease ACTH producing pituitary adenoma, causing secondary adrenal hyperplasia leading to hypertension, hyperglycemia,central obesity (buffaloo hump), hirsutism/ hypertrichosis, amenorrhea and impotence, osteoporosis, linea atrophica/ striae Amenorrhea - Galactorrhea Prolactin producing pituitary adenoma (30-40% of all adenoma), causing infertility TSH producing adenoma, LH & FSH producing adenoma Very rare Vasopressin (ADH) Diabetes Insipidus in deficiency, and Syndrome of Inappropriate secretion of ADH (SIADH) in excess dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Endocrine disturbance from pituitary disease Cushing Disease Acromegaly - Gigantism Amenorrhea - Galactorrhea dnS Department of Neurosurgery, Diponegoro University Neuroendocrine physiology Hypothalamic Nuclear groups & their functions
Preoptic Area Sexual & parental behavior, thermoregulation, sleep-waking cycles Anterior Hypothalamic Area - Suprachiasmatic : primary circadian clock for sleep, locomotion, hormones - Supraoptic & Paraventricular : secrete oxytocin and vasopressin ( axons terminate in posterior pituitary), regulate water balance Tuberal Area - Ventromedial nucleus & Arcuate nucleus: regulating anterior pituitary, control sexual behavior and food intake - Dorsomedial nucleus and Lateral tuberal nucleus Histaminergic neurons, with preoptic area integrates sleep-waking cycles Mamillary Area Cholinergic projections to isocortex, & noncholinergic projections to allocortex dnS Department of Neurosurgery, Diponegoro University Neuroendocrine Physiology Coordination between hormonal secre- tion and behaviour by hypothalamus
- between sexual function /behaviour with neuroendocrine regulation of gonads & reproductive organs - between eating /dringking behaviour, feeling of hungry/ thirsty, with gastrointestinal & renal function - between body metabolism, vascular tone, sweating, and thermoregulatory behaviour - hypothalamus & limbic system influence many aspects of emotional expression (acceleration of heart rate, elevation of blood pressure, flushing or pallor of the skin, sweating, dryness of the mouth, disturbances of gastrointestinal tract) cortex limbic system hypothalamus pituitary target organ & its secretions dnS Department of Neurosurgery, Diponegoro University Thermoregulatory mechanism set point 37.6 C (-) (+) Hipothalamic thermostat symphatetic center skin: vasodilatation muscle:shivering inhibited sweat gland: evaporation (heat loss , heatproduction ) skin: vasoconstriction, piloerection sweat gland: evaporation hypothalamus: - TRF (chemical thermogenesis) - shivering center facilitated (heat loss , heat production ) C up C down set point affected by: - peripheral temperature receptors heat : set point 0.1-0.3 0 C cold : set point 0.1-1.0 0 C - fever producing agent/pyrogen set point - dehydration, set point up (if outside) dnS Department of Neurosurgery, Diponegoro University Thermoregulatory mechanism Important notes :
1. - shivering increases heat production (5 times) better compared to muscle contraction only (1.5 times). - chemical thermogenesis ( increase of epinephrine/norepinephrine ), will increase cellular metabolism 10% per 1 degree Celcius. - brown fat plays important role in animal & infant. 2. Pyrogen increases the set point, and antipyretics will bring it down. 3. Most important factor in thermoregulation : human behavioral control. 4. During extreme body temperatures ( > 42 0 C , < 34 0 C ) thermostat doesnt work, creating a vicious cycle (positive feed-back) in temp. regulation. dnS Department of Neurosurgery, Diponegoro University Autonomic Nervous System Symphatetic nerve 1. Composed by 2 neurons, pre and post ganglionic; - pre-ganglionic neurons located at the spinal cord, it is cholinergic - post-ganglionic neurons form the symphatetic trunc, most is adrenergic, and secretes norepinephrin (short pre-ganglionic fiber, long post-ganglionic fiber) 2. Adrenal medulla is analog to post-ganglionic neuron, secretes epinephrine (80%) and norepinephrine (20%). 3. Norepinephrines neutralization: reuptake/active transport/ 50-80%, diffusion to surrounding fluid, by MAO & COMT 4. Adrenergic receptors (in organ may have excitatory or inhibitory effect) alpha: strongly affected by both norepinephrin and epinephrine beta: strong effect of epinephrine, but weak effect of norepinephrine dnS Department of Neurosurgery, Diponegoro University Autonomic Nervous System Parasymphatetic nerve 1. Composed by 2 neurons, pre and post ganglionic; - pre-ganglionic neurons located at brainstem & sacral cord ; post-ganglionic neurons located close to the target organ (long pre-ganglionic fiber, & short post-ganglionic fiber). - both are cholinergic, secretes acetylcholine (neutralized by cholinesterase) 2. Distributed to cranial nerves III, VII, IX, and mainly X (75%), and 2nd. and 3rd. sacral nerve (nervi erigentes). 3. Cholinergic receptors (may have excitatory or inhibitory effect in organ) - muscarinic : present in all parasympathetic effector & symphatetic choliner- gic neuron (preganglionic) - nicotinic : present in neuronal membrane of parasymphatetic post-ganglio nic nerve, and in skeletal muscle fibers (motor end-plate)
dnS Department of Neurosurgery, Diponegoro University Consciousness (1) 1. Defined as awareness of self and environment ; - content of consciousness (function of cerebral hemisphere) - level of consciousness (function of ARAS, mainly brainstem structures) 2. ARAS (Ascending Reticular Activating System) a function of brainstems reticular formation, diffusely & polysynaptically integrates signals from all sensory organs, via thalamic non-specific nuclei, toward neurons of the cerebral cortex bilaterally. 3. Activity of ARAS (may be monitored by electroencephalogram/EEG) maintains sleep-awake cycle & level of consciousness ( a certain level of hemispheric tone is needed to keep the conscious or awake state). dnS Department of Neurosurgery, Diponegoro University Consciousness (2) Cerebral hemispheres : Content of Consciousness ARAS (including bilateral hemispheres) : Level of Consciousness (L o C) Content of consciousness could only be evaluated if the level of consciousness is good or there is enough hemispheric tone to process and respond to all incoming stimuli properly. Decrease of L o C will disturb this process and stronger stimuli will be needed dnS Department of Neurosurgery, Diponegoro University bilateral cortex brainstem thalamus nonspecific nuclei specific nuclei sensory organs Reticular formation Consciousness (3) Nonspecific Thalamocortical Projection : - RAS receives collateral signals from all sensory receptors passing through. - these signals go to nonspecific thala- mic nuclei, then relayed diffusely to bilateral cerebral hemispheres to ma- intain hemispheric tone needed for conscious state (alpha or beta waves) - if RAS activity decreases to minimum cerebral cortex cant maintain its ex- citability (cortex becomes its own pa- cemaker, EEG : slow/delta waves). dnS Department of Neurosurgery, Diponegoro University Consciousness Electroencephalogram :
- spontaneous rythmic/ fluctuating potential recorded from cortex - an amplification of synchronized activation of cortical neurons below the electrode ( at scalp recording, an electrode recieves extracellu- lar electrical activity from about 1 million neurons closest to the electrode ). - resting with closed eyes : there is synchronization of waves with fre- quency of 8-14 cycle/second, or ALPHA wave. Opening eyes causes desyn- chronization and creates BETA wave ( 15- 30 cycle/second). - deep sleep causes strong synchronization, creates DELTA wave (4 / second). dnS Department of Neurosurgery, Diponegoro University Consciousness Electroencephalogram : 1. Routine examination in patients with epilepsy or sleep disturbances 2. Recorded from scalp electrodes, 30 minute duration, interictally ( between epileptic/ seizure attack ) 3. Long term monitoring (between 3-14 days), using video EEG sometimes needed to determine seizure foci, by observing several attacks (ictal EEG) 4. Intracranial recording (subdural, and intracerebral) sometimes needed (electrodes inserted via craniotomy or stereotactic frame) dnS Department of Neurosurgery, Diponegoro University Consciousness Sleep 1. Deep slow wave sleep - RAS activity decreases to minimum, and cannot maintain the cortical exci- tability. EEG shows high voltage delta wave, cortically indigenous wave. - most of the night sleep, starts after 30-60 minutes, restfull &dreamless, vas- cular tone decreases, so as blood pressure, respiration, and basal metabolism. 2. Rapid Eye Movement (REM) or Paradoxical sleep - last for 5-20 minutes every 90 minutes interval, last shorter in tired state. - EEG shows desynchronization, low voltage beta wave, like awake state. - irregular muscle contraction, eye shows REM, difficult to be awakened. dnS Department of Neurosurgery, Diponegoro University Vestibular system ( 1 ) Function ; - maintaining stability of the body - coordinating movement of eyes, head, and body, to enable eye fixation while the head is moving. - dynamic portion (semicircular canals); detect head movement in space. - static portion (utricle);detect position of the head & the body in space, to enable postural positioning of the body. dnS Department of Neurosurgery, Diponegoro University Vestibular system ( 2 ) Anatomy ; c.o. membranous & bony labirynth, with perilymph in between and endolymph inside. In the membranous labirynth, there are utricle, saccule, & 3 semicircu- lar canals (anterior, lateral/horisontal, and posterior). In the base of the utricle (within the macule) hair cells receptors were covered by gelatinous materials filled with CaCO3 crystals or otocony. Physiological principles ; In neutral/horisontal position, otocony is just above the hair cells. During head movement, otocony compresses hair cells, inducing action potential transmitted to the peripheral branches of vestibular ganglion. dnS Department of Neurosurgery, Diponegoro University Vestibular system ( 3 ) Tests of vestibular function : 1. Nystagmus ; repeated pendular movement of the eye ball - continuous excitation to the ampula of semicircular canal causes the eye to move slowly to one side, then quickly to the other side. - direction of nystagmus is named according to fast component (opposite direction of movement caused by semicircular canal stimulation) 2. Vertigo ; feeling like moving around, or rotated; related to stimulation of the vestibu- lar apparatus ; occurred during motion sickness, or sea sickness 3. Rotation test ( Barany chair ); after nystagmus or nystagmus post-rotatory, for about 30 seconds.
dnS Department of Neurosurgery, Diponegoro University Vestibular system ( 4 ) Vestibulospinal pathways : 1. Lateral vestibulospinal tract from lat. vestibular n., uncrossed; descend ipsilaterally cervical to lumbosacral. 2. Medial vestibulospinal tract from medial vestibular n., crossed & uncrossed, descend bilaterally to cervical r. Function : 1. Highly facilitatory to motoneurons of postural muscles & extensors (antigravity) 2. Support the myotatic reflex. Decerebrate rigidity : Loss of cerebral function, strong facilitation of brainstem activity affecting gamma motoneuron (via vestibulospinal & reticulospinal tract), all extremities extended. dnS Department of Neurosurgery, Diponegoro University Vestibular system Vestibuloocular & Vestibulospinal Pathways dnS Department of Neurosurgery, Diponegoro University Vestibular system ( 5 ) Vestibuloocular pathway : - Fiber projections from superior vestibular n. (uncrossed) & from other vesti- bular n. (crossed & uncrossed), via medial longitudinal fascicle, to reach cra- nial nerves III, IV, and VI. - important for regulating conjugate eye movement, in response to head positi- on and head movement in space. Vestibular and ocular reflexes will keep eye fixed in a stationary object, while the head/ body is moving in space. - head move to right, endolymph move to left (horisontal canal), creates action potential from ampular receptors to vestibular n., then to MLF ( activation of lt. VI n. & rt. III n., inhibition of lt. III n. & rt. VI n. so eye moves to the left. dnS Department of Neurosurgery, Diponegoro University Cerebral Blood Flow
1. Supplied by bilateral carotid arteries anteriorly (80%) and bilate- ral vertebral arteries posteriorly (20%), to form the Willis circle. 2. Regional CBF 50-80 cc/100g/minute. Brain weight is 1500g, each minute about 1 litre of blood is pumped in (20% of cardiac output). 3. This amount of blood is provided by cerebral perfusion pressure (CPP=MAP- ICP), about 95-100 mmHg. Decrease in CPP is compen- sated by vasodilation, this mechanism is maximum at CPP> 55 - 60 mmHg. Below this level, ischemia ensues. 4. Brain metabolism uses only glucose provided by the blood flow. dnS Department of Neurosurgery, Diponegoro University Cerebral Blood Flow dnS Department of Neurosurgery, Diponegoro University Cerebrospinal Fluid dnS Department of Neurosurgery, Diponegoro University Cerebrospinal Fluid
- ultrafiltrat of the serum, almost 100% water, fills the ventricles, cerebral & spinal subarachnoid spaces, its volume is 90-150cc. - produced 70% by ventricular choroid plexus, the other results from constant motion of interstitial fluid toward ventricles. - direction of flow: lateral ventricle 3rd.ventricle aquaeduct 4th ventricle subarachnoid spaces absorption at SSS. - about 20ml/hour or 500 ml/day is produced or absorbed, absorption is passive process, caused by pressure gradient across arachnoid granulations, & depends on permeability state of the membrane. dnS Department of Neurosurgery, Diponegoro University Disturbances of CSF Dynamics