Cerebral Hemisphere

Total surface area of the cerebral cortex

- 2.5 sq. ft

Total weight of the brain

Total number of neurons in cerebral cortex Total number of synapses in cerebral cortex

- 1400 gms
- 10 billion - 60 trillion !

Gross Anatomy of the Cerebrum

gyrus
Sagittal view

sulci / fissure

R & L hemispheres separated by Interhemispheric fissure

Lateral view

Cerebral Arteries
Anterior circulation from the internal carotid artery Posterior circulation from the basilar artery

Arteries of the Anterior Circulation

Arteries of the Anterior Circulation

The anterior circulation supplies the cerebral hemispheres

Arteries of the Anterior Circulation

Supraclinoid ICA (ophthalmic) / C6 Clinoid ICA / C5

Cavernous ICA / C4
Lacerum segment of ICA / C3 Petrous segment of ICA / C2 Cervical ICA

Internal Carotid Artery

Supraclinoid segment

Clinoid segment

Cavernous segment

Petrous segment

Ophthalmic artery

Anterior cerebral artery

Middle cerebral artery

Anterior choroidal artery

Posterior communicating artery

Posterior cerebral artery

Anterior Cerebral Artery

Anterior Cerebral Artery

Callosomarginal artery Pericallosal artery

Supplies the medial aspect of the frontal and parietal lobes

Middle Cerebral Artery

Middle Cerebral Artery

Lateral striate (lenticulostriate) arteries

The MCA enters the Sylvian fissure, but not after giving off several small perforating arteries to supply the deep structures of the cerebrum and diencephalon

Middle Cerebral Artery

MCA divides into branches to supply the insula then emerges from the Sylvian fissure to supply virtually the entire lateral surface of the hemisphere

Middle Cerebral Artery

Arteries of the Posterior Circulation

Posterior cerebral artery

Posterior Cerebral Artery

Posterior communicating artery

PCA P1 segment PCA P2 segment

The posterior communicating artery divides the PCA into the precommunicating (P1) and postcommunicating (P2) segments

Posterior Cerebral Artery

The precommunicating (P1) sends perforating arteries into the medial midbrain as well as

Posterior Cerebral Artery

Infarction of the medial midbrain may involve both the corticospinal tract and the red nucleus,

Posterior Cerebral Artery

The postcommunicating (P2) segment sends circumferential arteries around the midbrain

Posterior Cerebral Artery

Thalamogeniculate arteries supply the thalamus Cortical branches of the PCA supply the occipital and medial temporal lobe Infarctions lead to visual disturbances, contralateral loss of pain & temperature sensation, and sometime face blindness (prosopagnosia)

thalamus

Fusiform gyrus
Lingual gyrus

cuneus

Posterior Cerebral Artery

The Circle of Willis

The anterior communicating artery joins the two ACA's The posterior communicating arteries join the ICA with the basilar circulation Normally these communicating arteries have little blood flow unless occlusion in one artery occurs; Also, they are variable in size.

The Circle of Willis

The complete circle is seen in only 20 25% of individuals

The Circle of Willis

One or both Pcom's are hypoplastic in 34%

The Circle of Willis

The precommunicating segment of ACA (A1) may be absent or hypoplastic (25%)

The Circle of Willis

PCA originates from the ICA with absent / hypoplastic P1 segment (17%)

The Circle of Willis

Bilateral hypoplastic P1 segments (11%)

Collateral Circulation

Cerebral Veins

Cerebral veins drain into dural venous sinuses which eventually empty into the internal jugular vein Dural venous sinuses: Superior sagittal sinus Inferior sagittal sinus Sigmoid sinus Straight sinus Transverse sinus Cavernous sinus Major cerebral veins Great cerebral vein of Galen Basal vein of Rosenthal Internal cerebral vein

Superior sagittal sinus

Inferior sagittal sinus

Straight sinus

Sigmoid sinus

Internal cerebral vein

Basal vein (of Rosenthal)

Great vein of Galen

Cavernous sinus

Cerebrospinal Fluid Pathways

CSF production: choroid plexus CSF absorption: arachnoid granulations? Lymphatics? Major compartments: Lateral ventricles 3rd ventricle 4th ventricle Communications within ventricular systems and without Interventricular forament of Munro Cerebral aqueduct (of Sylvius) Foramen of Magendie Foramen of Luschka

Lateral Ventricle
Body
Trigone / atrium Frontal horn

Occipital horn

Temporal horn

Lateral ventricle

C-shape follows the contour of the caudate nucleus, which forms its lateral wall

Third Ventricle

Narrow, slit-shaped, occupies the midline region of the diencephalon

Third Ventricle

Communicates with the lateral ventricles via the foramen of Munro

Foramen of Munro

3rd ventricle

Third Ventricle

Communicates with the fourth ventricle via the cerebral aqueduct in the midbrain - pons.

3rd ventricle

Cerebral aqueduct

Fourth Ventricle

Fourth Ventricle
Sandwiched between the cerebellum posteriorly and the pons and rostral medulla anteriorly Shaped like a tent (3D) Floor is diamond-shaped

Fourth Ventricle

Has 3 apertures through which CSF can freely enter and exit into and from the subarachnoid space One foramen of Magendie (Median) Two foramina of Luschka (Lateral)

Choroid plexus

Found throughout the ventricular system except the cerebral aqueduct Secretes CSF Also has a role in filtering waste products and excess neurotransmitters in CSF

Arachnoid granulations

a.k.a. Arachnoid villi, pacchionian bodies Found on the surfaces of the dural sinuses Act as one-way valves (CSF goes in, but cannot get out) Partly responsible for CSF absorption, although it is now thought that majority of the CSF exits the cranial vault through the extracranial components of the cranial nerves, particularly the olfactory nerve.

Cerebral Cortex Organization

1.

Cytoarchitectonic organization based on studies of stained cells Myeloarchitectonic organization based on studies of myelinated fiber preparations

2.

Cortical Layers: Cytoarchitectonic Organization

Layer Cytoarchitectonic Principal Number Name Cells
I II Molecular External granular Axons & dendrites Small pyramidal cells Medium pyramidal cells Stellate cells Large pyramidal cells Fusiform cells

Principal fibers
Association and commisural fibers Source of corticocortical fibers Association and commisural fibers Source of corticocortical fibers Association and commisural fibers Source of corticocortical fibers Thalamocortical Where most incoming signals go to Corticobulbar, corticospinal & corticostriatal Mostly outgoing fibers Source of corticothalamic fibers

III

External Pyramidal

IV V

Inner Granular Inner Pyramidal

VI

Polymorph

Cortical Layers: Myeloarchitectonic Organization

Layer Number Myeloarchitectonic Name Fibers

I
II III IV V VI

Tangential
Dysfibrous Suprastriatal External Baillarger Internal Baillarger Infrastriatal

NA
NA Cortico-cortical Thalamic projection Lines of Gennari Corticostriate Cortico-thalamic

Surface Features of the Brain

Gyri convolusions Sulci (fissures) - to increase total cortical area by 2.5 sq ft of cortex 1. Central sulcus ( Rolando)ulcus 2. Lateral sulcus (Sylvian fissure) 3. Parietooccipital sulcus 4. Calcarine sulcus

Major Sulci and Gyri

Medial view of the right cerebral hemisphere

Major Sulci and Gyri

Lateral view of the Left hemisphere

Major Sulci and Gyri

Ventral surface

Major Cerebral Lobes & Sulci

Central Sulcus of Rolando Frontal Lobe

Parietooccipital Sulcus

Lateral fissure of Sylvius Temporal Lobe

Occipital Lobe

Preoccipital Notch

Lateral view of the left hemisphere

Major Cerebral Lobes & Sulci

Frontal Lobe
4 General Functional Areas

1.

Primary motor cortex (pre-central gyrus) initiation of voluntary movements

2. Pre-motor area (pre-central + superior and middle frontal gyri) voluntary movements 3.Brocasarea(inferiorfrontalgyrus,dominantlobe) motor control of speech

4. Prefrontal cortex personality, insight and foresight, emotion

Functional Localization
Brodmann Number 4 6 8 44, 45 Location Precental gyrus, paracentral lobule Superior, middle frontal gyri, precentral gyrus Superior and middle frontal gyri Opercular/ triangular region, inferior frontal gyrus Other Name 1 motor area Premotor area Frontal eye field Brocasarea

Parietal Lobe
3 General Functions 1. Primary somatosensory cortex - postcentral gyrus - initial cortical processing of tactile and propioceptive (sense of position) info 2. Language Comprehension - angular gyrus - dominant inferior parietal lobule 3. Spatial and temporal orientation - nondominant parietal lobe

Functional Localization
Brodmann Number 3,1,2 Location Post-central gyrus, paracentral lobule Other Name Primary somatosensory area

5,7

Superior parietal lobule, precentral gyrus

Inferior parietal lobule Inferior parietal lobule Parietal operculum

Secondary Somatosensory association area

Anglar gyrus Supramarginal gyrus Primary gustatory cortex

39 40 43

Temporal Lobe
1.Primary

3 General Functions
auditory cortex - superior temporal gyrus 2.Limbic system - parahippocampal gyrus and hippocampus - emotional and visceral response 3. Learning and memory recall orientation - hippocampus

Functional Localization
Brodmann Number 41 42 22 Location Superior temporal gyrus, paracentral lobule Superior temporal gyrus Superior temporal gyrus Other Name Primary auditory area (A1), Heschls gyrus Auditory association area Auditory association area, Wernickis area

Occipital Lobe
Includes lateral occipital gyri, cuneus and lingual gyrus

General Functions 1.Primary visual cortex - site of the calcarine sulcus and surrounding cortex 2.Visual association cortex - Higher cortical processing of visual information

Functional Localization
Brodmann Number 17 18, 19 Location Banks of calcarine fissure Surrounding area Other Name Primary visual area (V1) Visual association area (V2, V3)

Frontal lobe
Primary Motor Region (MI)
LESIONS immediate effects
paresis of contralateral musculature hypotonia diminished muscle stretch reflexes

delayed effects
partial motor recovery spasticity enhanced muscle stretch reflexes extensor plantar response (Babinski sign)

Frontal lobe
Supplementary Motor Area (MII)
medial surface of frontal lobe (Brodmann area 6), anterior to MI complete somatotopic representation of the body advance planning of movements

Frontal lobe
Premotor Area
Brodmann area 6 immediately in front of area 4 on lateral surface of hemisphere neurons projecting into the primary motor cortex inputs to pyramidal tract, extrapyramidal system LESIONS complex defects of movement in the absence of weakness

Frontal lobe
Frontal Eye Fields
Brodmann area 8 rostral to the premotor area (area 6) lateral surface of hemisphere conjugate deviation of the eyes to the contralateral side voluntary conjugate movement of the eyes independent of visual stimuli

Frontal lobe
Prefrontal cortex Functions
integrate motivational events with complex sensory stimuli highly responsive to the behavioral importance of sensory inputs inhibitory responses stimuli that require a delay in motor responses

LESIONS
impaired ability to perform tasks requiring alternate responses to stimuli with a delay unilateral ablation of the frontal eye field neglect of stimuli on the contralateral side bilateral lesions
markedly distubed behavior inability to perform complex tasks requiring several steps

Parietal lobe
Primary Somatosensory / Postcentral Gyrus
Brodmann areas 3, 1, and 2
area 3a activated by muscle spindle afferents area 3b, 1 cutaneous afferents area 2 joint receptors

primary (unimodal) somatosensory areas (SI) receives projections from the ventral posterior lateral (VPL) nucleus of the thalamus sensory homunculus LESION
impairment of cortical sensation two-point discrimination, localization of touch, position sense, stereognosis preservation of primary sensory modalities touch, pain, temperature

Parietal lobe
Heschls gyrus
primary auditory area (A1) Brodmann areas 41 and 42 receives projections from the medial geniculate body tonotopic organization low frequencies more rostral and lateral than higher frequencies receives information from both ears, but input from contralateral ear more strongly received unilateral LESIONS
undetectable clinically

complete cortical deafness

bilatetal damage to A1 and adjacent auditory association areas of both cerebra hemispheres

Occipital lobe
Striate Cortex
primary visual cortex (VI) Brodmann area 17 along the banks of the calcarine fissure medially and along the occipital pole laterally receives projections from the lateral geniculate nucleus receives information from the contralateral visual field LESIONS
focal lesions visual field defects complete bilateral damage cortical blindness
intact pupillary reflexes NO useful vision

Antons syndrome lesions of area 17, prestriate cortex in areas 18 and 19

Parietal lobe
Chemical Sensations
olfaction and taste less well understood Brodmann area 43
parietal operculum and adjacent insular cortex gustatory cortical area

olfactory sensation primary olfactory cortex orbitofrontal cortex ability to discriminate among odorants

Parietal lobe
receive sensory inputs directly or indirectly from the thalamus, adjacent sensory areas somatotopic representations secondary somatosensory area (SII)
inner part of the parietal operculum, adjacent to the dorsal insula bilateral representation, but the contralateral side predominates perception of several sensory modalities

secondary auditory area (AII)

immediately surrounding AI

secondary visual area (VII)

contained within Brodmann area 18 adjacent to Brodmann area 17

Auditory Unimodal Association Area

Area 22 of the superior temporal gyrus respond to auditory stimuli - discrimination of auditory frequency, sequence of sound retention of auditory information project to heteromodal association areas, paralimbic and limbic structures of the temporal lobe pure word deafness bilateral lesions of the auditory association areas, or unilateral left-sided lesion disconnecting area 22 from Wernickes area cannot understand or repeat spoken language respond appropriately to environmental sounds - NOT deaf can understand written language - NOT aphasic

Visual Unimodal Association Area

peristriate cortex (area 18, 19), middle and inferior temporal gyri (areas 20, 21, and 37) respond only to visual stimuli - form, motion, color lesions in areas 20, 21, 37 - discrete deficits in naming visual stimuli, affecting some categories of objects

Temporoparietal Heteromodal Association Areas

areas 39 (angular gyrus), 40 (supramarginal gyrus) of the inferior parietal lobule, cortex along superior temporal sulcus, posterior parts of area 7 unilateral lesions (animals) neglect of objects and stimuli in personal and extrapersonal space contralaterally bilateral lesions (animals) impairment of exploring extrapersonal space defects in determining spatial relationships and negotiating relatively simple mazes intact visual, auditory, somatosensory perceptions, but cannot be integrated

Temporoparietal Heteromodal Association Areas

Lesions in Humans
damage to the right cerebral hemisphere
disturbances in the integration of personal and extrapersonal space dressing apraxia constructional apraxia left-sided hemineglect lack of insight about the above deficits

Temporoparietal Heteromodal Association Areas

Lesions in Humans
damage to the left cerebral hemisphere
language disorders, disturged spatial integration Wernickes area
posterior part of the superior temporal gyrus integration of sensory modalities needed to understand written and spoken language lesion Wernickes aphasia

intact Wernickes area + damaged inferior parietal lobule alexia, anomia, constructional apraxia, agraphia, finger agnosia, right-left disorientation

Temporoparietal Heteromodal Association Areas

Lesions in Humans
bilateral damage
complex disorders - visual, spatial, language deficits Balint syndrome
inability to gaze toward the peripheral field (with intact EOMs) difficulty in reaching out and touching objects accurately with visual guidance inattention to objects in the peripheral visual field

affective disorders
interruptions with connections between heteromodal association areas and limbic system

The Paralimbic Areas

receive information from the heteromodal association areas, limbic areas memory and learning, drive and affect autonomic regulation in the hypothalamus, reticular formation, dorsal motor nucleus of the vagus, nucleus of the solitary tract olfactory and gustatory information

Agnosia
failure to recognize stimuli when the appropriate sensory systems are functioning adequately visual agnosia
failure to recognize objects visually in the absence of a defect of visual acuity or intellectual impairment; objects identified by other sensibilities bilateral lesions of the visual unimodal association areas

Agnosia
tactile agnosia
inability to recognize objects by touch when tactile and proprioceptive sensibilities are intact lesions of the supramarginal gyrus (area 40) disturbances of body image

auditory agnosia
failure of a patient with intact hearing to recognize what he or she disappears bilateral lesions of the posterior part of the superior temporal convolution (area 22)

Apraxia
loss of ability to carry out correctly certain movements in response to stimuli that normally elicit these movements NO weakness, sensory loss, or disturbance of language comprehension lesions interrupting connections between the site of formulation of the motor act and the motor areas responsible for execution

Apraxia
ideomotor apraxia patient knows what he/she wants to do but is unable to do it can perform many complex acts automatically but unable to do on command lesions of the supramarginal gyrus of the dominant parietal lobe ideational apraxia failure in carrying out sequences of acts, with correct individual movements lesions of the dominant parietal lobe or the corpus callosum kinetic apraxia, gait apraxia - frontal lobe disease

Aphasia
defect in the production or comprehension of vocabulary or syntax lesion in the dominant hemisphere cerebral dominance for language is a plastic phenomenon up to age 7 years

Aphasia
Brocas area
anterior speech region inferior frontal gyrus just rostral to the site of the motor representation of the face Brodmann areas 44, 45, and 47 receives information about incoming speech patterns generates the proper pattern of signals for speech musculature for the production of meaningful speech

BrocasAphasia
lesions of Brocas area synonyms - executive, motor, nonfluent, anterior aphasia slow and effortful language with poorly produced sounds ungrammatical, telegraphic speech good comprehension of spoken and written language *vascular lesions of Brocas area often involve internal capsule associated right hemiplegia

Aphasia
Wernickes area
posterior part of the superior temporal gyrus, extends onto the upper surface of the temporal lobe posterior part of Brodmann area 22 is central to Wernickes area connected to Brocas area by the arcuate fasciculus recognition of speech patterns relayed from the left primary auditory cortex

WernickesAphasia
lesions of Wernickes area synonyms - receptive, sensory, fluent, posterior aphasia more rapid than normal speech preserved grammatic construction inability to find correct words to express thoughts verbal paraphasias literal paraphasias neologisms poor comprehension, poor repetition

Role of the limbic system

Serves as link between cortical sensory association areas, the subcortical autonomic and endocrine centers and the prefrontal association cortex. It mediates the effects of emotion on motor function

Limbic Lobe
Neuroanatomical substrate for drive-related and emotional behavior

Components: 1. Cingulate and parahippocampal gyri 2. Subcallosal gyrus 3. Hippocampal formation 4. Dentate gyrus 5. Amygdala and septal area

Hippocampus

Divided into 4 fields cornu Ammonis (CA) CA1 field (sommers sector) is highly vulnerable to anoxia (temporal lobe epilepsy trigger zone) Plays a role in declarative or associative memory, attention and alertness, behavioral, endocrine and visceral functions

Septal Area

Septum pellucidum and septum verum Septum verum refers to a group of basal nuclei that includes the septal nuclei Plays an important role in emotional behavior, reward, autonomic responses, drinking and feeding, and sexual behavior

The Paralimbic Areas

damage to parahippocampal cortex, hippocampus, amygdala, subcortical limbic structures severe memory disorders damage to the paralimbic areas of the orbitofrontal region, amygdala reduced level of aggressiveness, severe apathy

The Paralimbic Areas

Kluver-Bucy syndrome
lesion of the amygdala in experimental animals excessive sexual activity, often with inappropriate objects loss of aggressiveness compulsive oral exploration of objects *an equivalent syndrome has been observed in humans

Basal Ganglia

Basal Ganglia
Topography: Caudate nucleus Putamen Globus pallidus Substantia nigra Subthalamic nucleus

Basal Ganglia
Originally referred to all masses of gray matter buried within the cerebrum

Caudate, putamen, globus pallidus Regulate somatomotor activity by means of numerous feedback circuits with each other & ultimately with the cerebral cortex Damage of these structures produce extrapyramidal movement syndromes

Basal Ganglia Terminology

Caudate nucleus Putamen
LENTIFORM NUCLEUS

STRIATUM

CORPUS STRIATUM

Globus pallidus
Substantia Nigra Subthalamus

Corpus Striatum
Situated lateral to the thalamus Divided by a band of nerve fibers, the internal capsule, into the caudate nucleus and the lentiform nucleus

Corpus striatum
Caudate Nucleus A large C-shaped mass of gray matter closely related to the lateral ventricle and lies lateral to the thalamus Divided into a head, a body, and a tail

Corpus striatum
Lentiform Nucleus A wedge-shaped mass of gray matter whose broad convex base is directed laterally and its blade medially Related medially to the internal capsule separating it from the caudate nucleus and the thalamus

Corpus striatum
Lentiform Nucleus Related laterally to a thin sheet of white matter, the external capsule, separating it from a thin sheet of gray matter, the claustrum A vertical plate of white matter divides the nucleus into the putamen and the globus pallidus

Claustrum

A thin sheet of gray matter separated from the lateral surface of the lentiform nucleus by the external capsule Lateral to it is the subcortical white matter of the insula Of unknown function

Claustrum

Connections of the corpus striatum and globus pallidus

The caudate nucleus and the putamen form the main sites for receiving input to the basal nuclei Receive no direct input from or output to the spinal cord

Afferent & Efferent Connections of the Basal Ganglia

Connections of the Corpus Striatum

Afferent Fibers A. Corticostriate fibers Each part of the cerebral cortex projects to a specific part of the caudate-putamen complex Most of the projections are from the cortex of the same side Largest input is from the sensory-motor cortex Glutamate is the neurotransmitter of the corticostriate fibers

Connections of the Corpus Striatum

Afferent Fibers

B. Nigrostriate fibers Neurons in the substantia nigra send axons to the caudate nucleus and the putamen and liberate dopamine at their terminals as the neurotransmitter C. Striatopallidal fibers These fibers pass from the caudate nucleus and putamen to the globus pallidus; neurotransmitter GABA

Connections of the Corpus Striatum

Efferent Fibers Pallidofugal fibers divided into groups: 1. ansa lenticularis pass to the thalamic nuclei 2. fasciculus lenticularis pass to the subthalamus 3. pallidotegmental fibers terminate in the caudal tegmentum of the midbrain 4. pallidosubthalamic fibers pass to the subthalamic nuclei

Efferent Connections of the Globus Pallidus

Clinical Notes
Disorders of the basal nuclei are of two general types: Hyperkinetic disorders with excessive and abnormal movements such as seen with chorea, athetosis, and ballism Hypokinetic disorders with lack or slowness of movement

HUNTINGTONS CHOREA Clinical Feature

- Predominantly autosomal dominant inherited chronic fatal disease (Gene: chromosome 4) - Insidious onset: Usually 40-50 - Choreic movements in onset - Frequently associated with emotional disturbances - Ultimately, grotesque gait and severe dysarthria, progressive dementia ensues.

Principal Pathologic Lesion:

Corpus Striatum (esp. caudate nucleus) and Cerebral Cortex

Clinical Notes

Chorea exhibits involuntary, quick, jerky, irregular movements that are nonrepetitive Huntingtons Disease autosomal dominant single gene defect on chromosome 4 adult onset choreiform movements and progressive dementia degeneration of the GABA-secreting, substance Psecreting and acetylcholine-secreting neurons of the striatonigral inhibiting pathway resulting in the dopasecreting neurons of the substantia nigra becoming overactive so that the nigrostriatal pathway inhibits the caudate nucleus and the putamen

SYDENHAMS CHOREA

Clinical Feature
- Complication of Rheumatic Fever - Fine, disorganized , and random movements of extremities, face and tongue - Accompanied by Muscular Hypotonia - Typical exaggeration of associated movements during voluntary activity - Usually recovers spontaneously Principal Pathologic Lesion: Corpus Striatum in 1 to 4 months

Clinical Notes

Chorea Sydenhams Chorea childhood onset rapid, irregular, involuntary movements of the limbs, face, and trunk associated with rheumatic fever transient

HEMIBALLISM

Clinical Feature
- Usually results from CVA (Cerebrovascular Accident) involving subthalamic nucleus - sudden onset - Violent, writhing, involuntary movements of wide excursion confined to one half of the body - The movements are continuous and often exhausting but cease during sleep - Sometimes fatal due to exhaustion - Could be controlled by phenothiazines and stereotactic Nucleus surgery

Lesion: Subthalamic

Clinical Notes

Hemiballismus a form of involuntary movement confined to one side of the body usually involves proximal extremity musculature and the limb suddenly flies about out of control in all directions lesion in the opposite subthalamic nucleus

Parkinsons Disease
Disease of mesostriatal dopaminergic system

PD

Muhammad Ali in Alanta Olympic

normal

Clinical Notes

Parkinsons Disease neuronal degeneration in the substantia nigra, and to a lesser extent, in the globus pallidus, putamen, and caudate nucleus results in a reduction in the release of the neurotransmitter dopamine within the corpus striatum leading to hypersensitivity of the dopamine receptors in the postsynaptic neurons in the striatum

Parkinsons Disease - Paralysis Agitans

Substantia Nigra, Pars Compacta (SNc) DOPAminergic Neuron

Clinical Feature (1) Slowness of Movement

- Difficulty in Initiation and Cessation of Movement

Parkinsons Disease Paralysis Agitans

Clinical Feature (2)

Resting Tremor Parkinsonian Posture Rigidity-Cogwheel Rigidity

Clinical Notes

Parkinsons Disease tremor rigidity bradykinesia postural disturbances no loss of muscle power

Clinical Notes

Athetosis slow, sinuous, writhing movements commonly involving distal segments of the limbs degeneration of the globus pallidus

THALAMUS
Group of Nuclei that form the lateral boundary of the 3rd ventricle

Boundaries of the Thalamus

Anterior:

Interventricular Foramen

Posterior:
Lateral: Superior:

Posterior Commissure
Internal capsule Part of the floor of the lateral

ventricle

Parieto-occipital sulcus Corpus callosum

Thalamus
Anterior commisure Hypothalamus Optic nerve Infundibulum Mammillary body Posterior commisure

Thalamic Functions

Processes all sensory information (except olfactory) Regulates execution of motor programs Controls level of cortical excitability Influences motivational & emotional responses
Functions as gate or filter: switchboard -- what input is allowed through for processing Integration of motor and sensory input to the cortex

Topographical Subdivisions of the Thalamus

Subdivided by a fiber tract: Internal lamina (Yshaped) separates 6
Groups: 1. Lateral: Dorsal & ventral tier 2. Medial 3. Anterior 4. Intralaminar 5. Midline 6. Reticular

Relay & Association Nuclei

Anterior: Anterior Nuclei Lateral Ventral: VA, VL, VP (VPM, VPL) Dorsal: pulvinar, LD, LP Medial: Dorsomedial nucleus Lateral (visual) & medial (auditory) geniculate nucleus

Diffuse Projection Nuclei

Intralaminar: Centromedian nucleus (ARAS input) Reticular: lies like a mantle covering the lateral part of the thalamus, separated by the external medullary lamina (not shown in schematic)
No projections to the cortex, only thalamic nucleus with inhibitory output to other thalamic nuclei

Midline nuclei : dorsal half of the wall of the 3rd ventricle

Thalamic Nuclei
Type
Relay

Nucleus
Lateral geniculate Medial geniculate VPL VPM VL / VA Anterior

Major input
Optic tract Inferior brachium Medial lemniscus, spinothalamic tract Trigeminothalamic tract Cerebellum, basal ganglia

Major output
Visual cortex Auditory cortex Somatosensory cortex Somatosensory cortex Motor / premotor cortex

Mammillothalamic tract Cingulate gyrus

Thalamic Nuclei
Type
Association

Nucleus
Pulvinar Lateral posterior (LP) Lateral dorsal (LD) Dorso-medial (DM)

Major input
Retina, superior colliculus Superior colliculus Few Amygdala, septal area, olfactory cortex

Major output
Parieto occipital temporal cortex Parietal association cortex Cingulate gyrus Pre-frontal cortex

Projection

Intralaminar

Reticular formation, BG, Widespread cortical cerebellum, sensory areas pathways Thalamus Thalamus

Reticular

Thalamocortical & Corticothalamic Projections

DM, Pulvinar, LP, MD AN

VA, VL

MGB

LGB

VPL, VPM

Meninges
The brain and the spinal cord are surrounded by three distinct connective tissue membranes or (meninges)

1. thick dura mater externally

Subarachnoid granulation

2. delicate arachnoid

3. thin pia mater

Dura + arachnoid = Pachymeninges

* Pia + arachnoid = Leptomeninges (meaning thin & delicate)

Dura Mater - Outer periosteal layer - rich in blood vessels and nerves and adherent to the cranium - Inner meningeal layer closely attached to underlying arachnoid At certain sites, these layers are separated and form large venous sinuses

Projections of the dura mater

Falx cerebri sickle shaped double layer of the dura matter, lying n between the cerebral hemisphere Falx cerebelli small sickle shaped projection between the cerebellar hemispheres Tentorium cerebelli crescentic fold that supports the occipital lobes and covers the cerebellum, divides the cranial cavity in supratentorial and infratentorial compartments Diaphragma sellae circular fold wc covers the sella turcica separating the pituitary gland fr the hypothalamus

Projections of the dura mater

Blood Supply for the Dura

Middle Meningeal Artery branch of maxillary artery

Anterior Meningeal Artery from the ophthalmic artery

Posterior Meningeal Artery from the occipital and vertebral artery

Innervation supratentorial dura branch of trigeminal nerve infratentorial dura branch of upper cervical spinal nerve and the vagus nerve

In the regions adjacent to the superior sagittal sinus, the pia-arachnoid gives rise to arachnoid granulations which protrude through the meningeal layer of the dura into the superior sagittal sinus

Arachnoid granulations and villi are the major site of fluid transfer from the subarachnoid space to the venous system -In the upright position, venous P < CSF hydrostatic P -When the venous system exceeds CSF P, the valves close and blood cannot enter the CSF - functions as passive, pressure dependent, one way flow valves

Meninges & Spaces

At the base of the brain and around the brainstem, the pia and arachnoid often are widely separated, creating subarachnoid cisterns Cisterna magna cerebellomedullary
Pontine cisterns Interpeduncular cisterns Chiasmatic cisterns Superior cisterns Lumbar cistern from the conus medullaris to about the 2nd sacral vertebra; contains the filum terminale and nerve roots of cauda equina
Superior sagittal sinus

The motor system plans, coordinates, and executes movements.

CEREBRAL MOTOR CORTEX

THALAMUS
CONTROL CIRCUITS

CEREBELLUM

BASAL GANGLIA
DIRECT ACTIVATION PATHWAYS

BRAIN STEM
INDIRECT ACTIVATION PATHWAYS

SPINAL CORD

FINAL COMMON PATHWAY

Motor System

Direct Activation Pathways

Corticospinal tract Corticobulbar tract

Indirect Activation Pathways

Reticulospinal, vestibulospinal, rubrospinal, tectospinal tracts

Control Circuits
Cerebellum & Basal ganglia

Final Common Pathway

Motor unit

The motor systems are organized into 3 control levels

The motor areas of the cerebral cortex The descending systems of the brainstem The spinal cord

The motor systems generate 3 types of movement

1. Reflex
simplest & least affected by voluntary control.

2. Rhythmic motor patterns

combined features of voluntary & reflex acts.

3. Voluntary movements
most complex. Purposeful, goaldirected & learned.

CORTICOSPINAL & CORTICOBULBAR TRACTS

Direct Activation Pathways

Corticospinal & Corticobulbar tracts

Function: To initiate & control skilled voluntary activity, under conscious control.

Glutamate is the neurotransmitter

MCA ACA -

MOTOR SYSTEM Descending pathway

BRAIN BRAINSTEM Neuromuscular junction SPINAL CORD Synapse MUSCLE

Motor areas of the cerebral cortex

The region of electrically excitable cortex from which isolated movements can be evoked by stimuli of minimal intensity.

Primary motor cortex (area 4) Premotor area - lateral premotor cortex (area 6a) Supplementary motor area - medial premotor cortex (area 6b) Primary somatosensory cortex (areas 3,1,2) Superior parietal lobule (areas 5,7) Anterior cingulate motor area Frontal eye fields (area 8) Brocas area (area 44)

Motor areas of the cerebral cortex

Fibers of the corticospinal & corticobulbar tracts:

55% originate from the frontal lobe (areas 4 & 6)

35% originate from areas 3,1,2 & postcentral gyrus of the parietal lobe. 10% originate from the other areas. Only 5% of all the fibers originate from the giant pyramidal cells(Betzs cells) in the primary motor cortex (area 4).

Direct activation pathways

Corticobulbar tracts those that end on brainstem nuclei.

Control the cranial motor nerve nuclei.

Corticospinal tracts those that travel to the spinal cord & end on anterior horn cells (alpha motor neurons).
Control the motor neurons innervating the trunk & limb muscles.

Corticobulbar fibers

These fibers leave the pyramidal pathway at several levels in the brainstem, some crossing the midline & some remaining uncrossed. These fibers synapse in the motor centers & nuclei of the cranial nerves: Oculomotor, trochlear, abducens Trigeminal Facial Glossopharyngeal Vagus Spinal Accessory Hypoglossal

Somatotopic representation of the corticospinal & corticobulbar tracts

CORTICOBULBAR

CORTICOSPINAL ARM TRUNK LEG

Descending fibers of the pyramidal system pass through the posterior limb of the internal capsule.

Somatotopic representation of the corticospinal & corticobulbar tracts The corticospinal & corticobulbar fibers occupy the middle 2/3 of the cerebral peduncle, with the corticobulbar fibers being more medial. 90% of the fibers decussate & 10% remain uncrossed.
LATERAL CORTICOSPINAL TRACT in the lateral funiculus (crossed fibers) VENTRAL CORTICOSPINAL TRACT in the anterior funiculus (uncrossed fibers)
S T L

MIDBRAIN

SPINAL CORD

CORTICOBULBAR TRACT
MOTOR CORTEX INTERNAL CAPSULE

CEREBRAL PEDUNCLE

BULBAR MUSCLES

CORTICOSPINAL TRACT
MOTOR CORTEX INTERNAL CAPSULE

CEREBRAL PEDUNCLE

PYRAMIDAL DECUSSATION ANTERIOR HORN OF THE SPINAL CORD

80-90% of the fibers cross to the opposite side.

ARM MUSCLES

CORTICOSPINAL TRACT
MOTOR CORTEX INTERNAL CAPSULE

CEREBRAL PEDUNCLE

PYRAMIDAL DECUSSATION

80-90% of the fibers cross to the opposite side.

LATERAL FUNICULUS OF THE SPINAL CORD

ANTERIOR HORN OF THE SPINAL CORD

LEG MUSCLES

DIRECT ACTIVATION PATHWAYS Corticospinal and Corticobulbar tracts

BULBAR MUSCLES

ARM MUSCLES
LEG MUSCLES

CORTICOSPINAL & CORTICOBULBAR TRACTS

FACE

ARM

LEG

The Facial Nerve

The Facial Nerve

CORTICOBULBAR TRACT

FACIAL NERVE NUCLEUS

FACIAL NERVE

The Facial Nerve

CORTICOBULBAR TRACT

FACIAL NERVE NUCLEUS

FACIAL NERVE

The lower half of the face is innervated only by the contralateral motor cortex.

The Facial Nerve

CORTICOBULBAR TRACT

FACIAL NERVE NUCLEUS

The upper half of the face receives innervation from both cerebral hemispheres.

FACIAL NERVE

(bilateral innervation)

Central facial palsy

- Supranuclear lesions in the cerebral cortex or corticobulbar tract (upper motor neuron)

- Paralysis of the lower half of the face contralateral to the lesion.

Peripheral facial palsy

- Lesion in the facial nerve nucleus or lesion of the facial nerve (lower motor neuron)

- Paralysis of the entire half of the face ipsilateral to the lesion.

Generalities regarding the corticospinal & corticobulbar tracts

Muscle groups of the two sides of the body that habitually act in unison tend to have bilateral cortical innervation.

Greater innervation from the contralateral hemisphere.

Muscle groups that act alone in isolated, delicate, and especially in learned movements tend to have a unilateral innervation from the opposite hemisphere.

FINAL COMMON PATHWAY

MOTOR CORTEX

CEREBELLUM

BASAL GANGLIA

THALAMUS

SUPERIOR COLLICULUS VESTIBULAR NUCLEI RETICULAR FORMATION RED NUCLEUS

Final Common pathway

ALPHA MOTOR NEURON IN THE SPINAL CORD or MOTOR NUCLEI IN THE BRAINSTEM

DIRECT ACTIVATION PATHWAYS Corticospinal and Corticobulbar tracts

FINAL COMMON PATHWAY BULBAR MUSCLES

ARM MUSCLES
LEG MUSCLES

CONTROL CIRCUITS

CONTROL CIRCUITS
BASAL GANGLIA Concerned with selective activation & inhibition of specific motor programs necessary for automatic performance of learned movements & postural adaptations. CEREBELLUM Involved in the control of the execution of motor acts, including maintenance of balance & posture, planning & execution of coordinated limb movements, adjustment of motor performance, & learning of new motor tasks.

Basal Ganglia Control Circuit

CEREBRAL CORTEX

BASAL GANGLIA

THALAMUS

Basal Ganglia Control Circuit

Functions:

Enable the automatic performance of learned motor acts & postural adjustments. Selectively reinforce the desired motor act by broadly inhibiting competing motor mechanisms that would interfere with the desired movement.

Basal Ganglia Control Circuit

Functions:

The basal ganglia receive inputs from all cortical areas & project principally to areas of frontal cortex that are concerned with motor planning.

Anatomy of the Basal Ganglia

CAUDATE
STRIATUM

PUTAMEN
LENTIFORM NUCLEUS

GLOBUS PALLIDUS

INTERNAL CAPSULE

THALAMUS

Anatomy of the Basal Ganglia

SUPPLEMENTARY MOTOR CORTEX PRIMARY MOTOR CORTEX

CAUDATE

PUTAMEN GLOBUS PALLIDUS (Internal & external segments) THALAMUS

SUBTHALAMIC NUCLEUS

SUBSTANTIA NIGRA

Neurotransmitters of basal ganglia neurons Putamen GABA Globus pallidus GABA Subthalamic nucleus Glutamate Substantia nigra Pars compacta Dopamine Pars reticulata anatomically & functionally a continuation of the globus pallidus.

MECHANISM OF BASAL GANGLIA FUNCTION

The striatum is the receptive component of the basal ganglia. Receives inputs from the cerebral cortex, substantia nigra.
The putamen is the primary striatal component of the circuit involved with controlling motor function.

+ _ + +

MECHANISM OF BASAL GANGLIA FUNCTION

The internal segment of the globus pallidus is the output structure of the basal ganglia. It projects to the thalamus that relay to the premotor, supplementary motor areas, & frontal lobe.

+ _ + +

The output of the basal ganglia affects both the corticospinal & the brainstem motor pathways. The basal ganglia exerts a continuous(tonic) inhibitory effect on the motor thalamocortical circuits. Acts as a continuous brake on motor programs.

MECHANISM OF BASAL GANGLIA FUNCTION

The subthalamic nucleus has reciprocal connections with the globus pallidus. The substantia nigra is reciprocally connected with the striatum.

+ _ + +

Dopaminergic input from the substantia nigra to the striatum modulates the balance between the direct & indirect striatopallidal pathways. Dopamine exerts a global excitatory effect on the direct striatopallidal pathway. .

Cerebellar Control Circuit

CEREBRAL CORTEX

CEREBELLUM

THALAMUS

Cerebellar Control Circuit

Functions:

Control of posture, balance, & eye movements necessary to maintain equilibrium. Adjustment of ongoing execution of movement. Initiation, timing, & planning of coordinated limb movements. Learning new motor tasks.

Cerebellar Control Circuit

Functions:

Improves the accuracy of movement by comparing descending motor commands with information about the resulting motor action.

Cerebellar Control Circuit

Functions: Acts as a comparator between the motor commands & their actual execution.
- An error detection system. It corrects an error by sending signals to motor areas of the brainstem & cerebral cortex.

Corticospinal tract
MOTOR CORTEX

INTERNAL CAPSULE

CEREBRAL PEDUNCLE

Muscle

Corticospinal tract
-A lesion in the motor cortex causes paralysis of the extremities contralateral to the lesion.

Left hemiparesis

Cerebellums influence on the corticospinal tract

MOTOR CORTEX

INTERNAL CAPSULE

THALAMUS

CEREBRAL PEDUNCLE

RED NUCLEUS

Double decussation

2
Muscle

Dentato-thalamo-cortical tract

Cerebellums influence on the corticospinal tract

- A cerebellar lesion causes ataxia ipsilateral to the lesion.

Double decussation
Left-sided ataxia

Dentato-thalamo-cortical tract

INDIRECT ACTIVATION PATHWAYS

Indirect pathways

Originate in the red nucleus, superior colliculus, vestibular nuclei, & reticular formation. These areas receive inputs from the cerebellum. Involved in the maintenance of equilibrium, posture, muscle tone, & coordination.

CREBRAL MOTOR CORTEX

THALAMUS
CONTROL CIRCUITS

CEREBELLUM

BASAL GANGLIA
DIRECT ACTIVATION PATHWAYS

BRAIN STEM
INDIRECT ACTIVATION PATHWAYS

SPINAL CORD

FINAL COMMON PATHWAY

SUPERIOR COLLICULUS

The red nucleus controls flexor muscles of the contralateral upper limb. The superior colliculus controls neck muscles in coordination with head movement.

RED NUCLEUS

PONTINE RETICULAR FORMATION

LATERAL VESTIBULAR NUCLEUS

The lateral vestibular nucleus & nuclei in the paramedian pontine & medullary reticular formation control postural reflexes & balance between extensor & flexor tone in the limbs.

MEDULLARY RETICULAR FORMATION

All these nuclei(except the vestibular nucleus) receive inputs from the motor areas of the cortex & the cerebellum.

Lateral Pathways

Rubrospinal tract Concerned with goal-directed movements. Terminate in the dorsolateral part of the spinal gray matter. For control of the upper limb

RUBROSPINAL TRACT

Controls the distal muscles especially of the arms & hands.

RED NUCLEUS

-Reaches as far as the cervical spinal

cord, where it innervates predominantly alpha motor neurons that innervate flexors of the upper limb.

Motor axon to flexors of the upper extremities

Medial pathways

Vestibulospinal, reticulospinal, & tectospinal pathways. Terminate in the ventromedial part of the spinal gray matter. Influences motor neurons that innervate axial & proximal muscles. Control posture, synergistic whole limb movements(particularly extensor), & orienting movements of the head & body.

VESTIBULOSPINAL TRACT

For the reflex control of balance & posture.

LATERAL VESTIBULAR NUCLEUS

-Terminates on interneurons that activate motor neurons innervating extensor muscles in the trunk & ipsilateral limb. -For postural adjustments in response to gravity & to changes in the position & acceleration of the head. -For mediating cerebellar control of posture. The ascending component of the MLF coordinates activity of the vestibular & oculomotor nuclei. Motor axon to leg muscles Motor axon to arm muscles

Corticoreticular axons are distributed bilaterally but predominantly crossed.

RETICULOSPINAL TRACT
MEDULLARY RETICULOSPINAL TRACT -Exerts predominantly inhibitory effect on segmental reflexes via inhibitory interneurons. Dorsolateral excitatory reticular formation PONTINE RETICULOSPINAL TRACT -Facilitates extensor & inhibits flexor motor neurons.

Ventromedial inhibitory reticular formation

For maintenance of posture.

Motor axon to arm muscles

Motor axon to arm muscles

Motor axon to leg muscles

Motor axon to leg muscles

Reticulospinal Pathways

The corticoreticulospinal pathway is important in making the adjustments needed to execute cortically directed movements by inhibiting potentially interfering segmental reflexes.

TECTOSPINAL TRACT

SUPERIOR COLLICULUS

For coordination of head & eye movements.

-The tectospinal tract & the medial vestibulospinal tract descend to reach only the cervical cord level & participate in the control of neck muscles & the coordination of movements of the head & eyes in response to various stimuli. -These tracts constitute the descending component of the medial longitudinal fasciculus.

Motor axon to neck muscles

A. Localizes painful stimuli B. Decorticate posturing C. Decerebrate posturing D. Spinal reflex posturing

Suprasegmental control of the axial & proximal limb musculature (antigravity postural mechanisms)

Reticulospinal tract Vestibulospinal tract Rubrospinal tract Corticospinal tract

Extrapyramidal system Cerebellum Basal ganglia Thalamus

Paralysis
Loss of voluntary movement due to interruption of one of the motor pathways at any point from the cerebrum to the muscle fiber.

Paresis lesser degree of paralysis.

Localization of lesions causing paralysis

Upper motor neuron

Corticospinal tract Corticorubrospinal tract Corticoreticulospinal tract Corticovestibulospinal tract Corticotectospinal tract

All these tracts are pathways through which the cortex influences the spinal motor neurons.

UMN vs LMN paralysis

UPPER MOTOR NEURON OR SUPRANUCLEAR PARALYSIS Muscles are affected in groups, never individual muscles. Slight atrophy due to disuse. Spasticity with hyperactivity of the tendon reflexes & extensor plantar response (Babinski sign). Absent fascicular twitches Normal EMG-NCV LOWER MOTOR NEURON OR NUCLEAR-INFRANUCLEAR PARALYSIS Individual muscles may be affected. Pronounced atrophy (up to 70% of total bulk). Flaccidity & hypotonia of the affected muscles with loss of tendon reflexes. Plantar reflex, if present is of normal flexor type. Fasciculations may be present. Abnormal EMG(fibrillations, fasciculations, positive sharp waves). Abnormal NCV (denervation potentials).

CORTICOSPINAL & CORTICOBULBAR TRACTS

FACE

ARM

LEG

Lesion in the brain

(Lacunar infarct)

FACE - Unaffected

ARM Spastic paralysis

LEG - unaffected

Lesion in the brain

(MCA infarct)

FACE Central weakness

ARM Spastic paralysis

LEG Spastic paralysis but not as weak as the arm DIFFERENTIAL WEAKNESS OF THE ARM & LEG

Lesion in the brain

(ACA infarct)

FACE Central weakness(mild)

ARM Spastic paralysis(mild)

LEG Spastic paralysis but weaker than the arm DIFFERENTIAL WEAKNESS OF THE ARM & LEG

Lesion in the brain

(Internal capsule)

FACE Central weakness

ARM Spastic paralysis

LEG Spastic paralysis DENSE HEMIPLEGIA OF THE ARM & LEG. The degree of weakness is the same in the arm & leg.

Lesion in the brainstem

FACE Peripheral weakness

FACE Unaffected

ARM Spastic paralysis CROSSED SIGNS LEG Spastic paralysis

Lesion in the upper cervical spinal cord

FACE Unaffected

ARM Spastic paralysis

LEG Spastic paralysis

Lesion in the cervical spinal cord (C5 C7)

FACE Unaffected

ARM Flaccid paralysis

LEG Spastic paralysis

Lesion in the cervical roots or brachial plexus

FACE Unaffected

ARM Flaccid paralysis

LEG Unaffected

Lesion in the thoracic spinal cord

FACE Unaffected

ARM - Unaffected

LEG Spastic paralysis

Lesion in the lumbar spinal cord

FACE Unaffected

ARM - Unaffected

LEG Flaccid paralysis

Lesion in the lumbar roots or plexus

FACE Unaffected

ARM - Unaffected

LEG Flaccid paralysis

Thank you !