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basic organization of behavior
- sensory behaviors: seeing, hearing, touch, smell, taste
- motor behaviors: reflex or voluntary
- emotional behaviors: anger, fear, joy
- visceral functions: temperature, blood pressure, heart rate, sexual drive
- higher cognitive functions: reasoning, learning/memory, consciousness, speech
- personality: mood, temperament
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divisions of the nervous system
- CNS: brain & spinal cord
- PNS: all nerves after they exit the CNS
- ANS: SNS & PSNS
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basic units of nervous system
- neurons: cell body (soma, perikaryon), dendrites (receptive region), axon (effector region)
- glial cells: structural & functional cells
- synapses: connections between neurons
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elements of neuron
- dendrites: receptive & integrative
- cell body: soma
- axon: effector/ sends information
- presynaptic terminal & synapse
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neuron plasma membrane
- double layer of phospholipids
- channels, protein structures, positioned across the membrane
- "selectively" permeable to ions
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shapes of neurons
- unipolar cell: invertebrate neuron
- pseudo-unipolar cell: DRG
- bipolar cell: retinal cells
- multipolar cells: spinal motor neuron, hippocampal pyramidal cell, Purkinje cell of cerebellum, stellate
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functional categories of neurons
- sensory
- motor
- preganglionic autonomic
- postganglionic autonomic
- local interneurons
- projection
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glial cells
- surround neurons
- 50X more numerous than neurons
- serve as supporting elements
- form electrical insulation (Schwann cells & oligodendrocytes)
- remove debris after injury
- buffer ions
- guide neuron growth/ nutritive function
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myelin
- mix of fats, water & protein
- non-conducting
- "white matter"
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microtubules
tubulin structures involved in transport of proteins & for skeletal framework
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neurofilaments
protein structures for transport & maintaining structure
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dendrites
- receptive regions of the neuron (& integration)
- come off multiple locations of the cell body
- extend from cell body to form dendritic trees
- dendritic spines: protrude off of the dendrite & increase surface area; increase receptive area of neuron
- made of cytoskeleton consisting of microtubules, microfilaments, rER & mitochondria
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electrophysiological properties of neurons
- input component
- integrative
- conductile
- presynaptic terminal
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resting membrane potential
- ion distribution differs across neuronal membrane (-70mV)
- extracellular: Na+ and Cl-
- intracellular: K+ and P-
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forces that cause resting potential
- electrostatic force & chemical concentration gradients: produced by membrane bound ion channels which leave more K+ inside, more Na+ outside the cell membrane
- Na/K ATPase pump: pushes Na+ out and K+ into the cell
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why is voltage potential significant?
electrical cellular property than can change quickly (allow quick signaling)
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summary of electrophysiological function of neuron
- neurons are electrically charged (voltage difference between inside & outside of cell)
- neurons receive inputs which summate to produce electrical signals sent to the next neuron in the circuit
- signals are propagated down axon by an electrical impulse (an all or none event)
- electrical signaling is usually in one direction
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synaptic gap junction
- channel connects cytoplasm of two neurons and/or glial cells
- channels on presynaptic cell line up perfectly with channels on postsynaptic cell
- change in ion concentration in one cell flows quickly into next cell
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types of cell signaling
- synaptic gap junctions
- chemical synapse
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chemical synapse
- release of NT
- exocytosis: action potential triggers voltage gated Ca2+ channels; Ca2+ signals synaptic vesicles to fuse with the membrane
- release: as the vesicles fuse, they spill their contents into the synapse
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synaptic potentials
- graded potentials which occur at the synapse; summate at trigger zone (axon hillock)
- occur in respons to presynaptic transmitter release
- proportional to number of ion channels activated
- EPSP: excitatory postsynaptic potential (depolarize the cell; ACh & glutamate); usually mediated by Na+ channels (influx)
- IPSP: inhibitory postsynaptic potential (hyperpolarize the cell; gamma aminobutyric acid & glycine); usually mediated by K+ channels (efflux)
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type I synapse
- excitatory
- asymmetric binding site
- round vesicles
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type II synapse
- inhibitory
- symmetric binding site
- pleomorphic vesicles
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postsynaptic receptors
- postsynaptic proteins which have an affinity for neurotransmitters (ligand binding site)
- usually consist of transmembrane glycoproteins with one/multiple subunits
- binding of ligand to receptor produces a change in protein conformation
- change results in alteration in membrane polarization either directly or indirectly
- ionotropic: direct & fast; ligand and/or voltage gatedmetabatropic: indirect & slow; ligand gated
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grouping of cells in the brain
- nuclei: groups of functionally related cells usually recognized by a cluster of cell bodies in CNS
- layer (lamina): groups of functionally related cells forming layers
- tract (fasciculus): bundle of axons in CNS
- funiculus ("cable"): groups of tracts
- ganglion: group of nerve cell bodies
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monosynaptic reflex arcs
- simplest connection between two neurons
- reflexes are involuntary motor responses to sensory stimuli
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nerve pathways
more complex connections with brainstem; cerebral cortex relay from spinal cord to thalamus to cerebral cortex and back to spinal cord
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functional organization of cell groupings
- topographic localization of function: many areas of cerebral cortex have maps in which the sensory or motor surface is laid out topographically onto the brain
- parallel processing: distinct parallel pathways for many sensory & motor sub-modalities
- input to output processing: information is processed from sensory to unimodal association to multimodal association to motor cortex
- crossed pathways: right side = left brain
- lower motor neurons: spinal motor neuron; directly innervates muscle (alpha motor neuron)
- upper motor neurons: controls activity of LMNs
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regions of the CNS
- spinal cord: receives sensory information from periphery; sends axonal projections from motor neurons to muscle & glands
- brainstem: contains CN nuclei
- basal ganglia: motor related nuclei involved in initiating movement
- thalamus: projection nuclei which send sensory & motor information to cerebral cortex
- hypothalamus: endocrine function, emotions, feeding-drinking
- cerebral hemispheres: sensory, motor & association areas (higher cognitive functions)
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basic divisions of brainstem
- medulla oblongata: CN nuclei IX, X, XII and parts of V, VIII; inferior olive, pyramids; important in regulating respiration & cardiac function
- pons: CN nuclei VI, VII, parts of V & VIII; reticular formation, pontine nuclei projecting to cerebellum
- midbrain: CN nuclei III, IV, part of V; mediates visual & auditory reflexes
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internal structuers of the forebrain
- basal ganglia: knots of nuclei within the base of telencephalon (caudate nucleus, putamen, globus pallidus)
- thalamus: relay, association & diffuse nuclei which project to various regions of cortex
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thalamus
- dorsal thalamus: relay nuclei, association nuclei, diffuse projecting nuclei
- epithalamus: habenula, pineal body
- subthalamus
- metathalmus
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hippocampal formation
- hippocampus proper (Ammon's horn)
- dentate gyrus
- fornix (fibers)
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fiber systems: internal structures of the brain
- corpus callosum
- anterior & posterior commissures
- fornix of hippocampus
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cerebral hemispheres
- frontal lobe: motor, prefrontal
- parietal lobe: somatosensory
- occipital lobe: visual
- temporal lobe: auditory, visual
- limbic lobe: emotions, memory
- insular cortex: isle of Reil buried in lateral cortex
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cerebral ventricles
- two lateral ventricles: within the cerebral hemispheres; complex C shaped structures w/ five components
- third ventricle: at midline, adjacent to thalamus & hypothalamus
- fourth ventricle: on dorsal surface of brainstem, below cerebellum; V shaped
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essential functions of the spinal cord
- sensory
- motor
- reflexes
- integration
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functions of the spinal cord: sensory
- receives primary sensory input from receptors in skin, muscle, tendons
- somatosensory - GSA (proprioceptive & exteroceptive)
- viscerosensory - GVA (from thoracic, abdominal & pelvic viscera)
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functions of the spinal cord: motor
- somatic motor (GSE) neurons that project to skeletal muscle
- visceral motor (autonomics) (GVE) neurons that project to smooth, cardiac muscle & glandular epithelium
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functions of the spinal cord: reflexes
forms local segmental reflex arcs (spinal reflexes) that convey sensory input to motor neurons, either directly or through an interneuron
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functions of the spinal cord: integration
integrates information from descending fibers of higher centers, cerebral cortex & brainstem
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spinal cord segment
the portion of the spinal cord that gives rise to a single spinal nerve
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spinal nerve
- arises as dorsal & ventral roots from a single spinal cord segment
- each nerve exits through its own intervertebral foramen
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clinically important dermatomes
- C2 & C3: posterior head and neck
- C4 & T2: adjacent to each other in the upper thorax
- C5: anterior shoulder
- C6: thumb
- C7: index & middle fingers
- C7/8: ring finger
- C8: little finger
- T1: inner forearm
- T2: upper inner arm
- T2/3: axilla
- T4 or T5: nipple
- T10: umbilicus
- L1: anterior upper inner thigh; inguinal ligament
- L2: anterior upper thigh
- L3: knee
- L4: medial malleolus
- L5: dorsum of foot; toes 1-3
- S1: toes 4,5; lateral malleolus
- S3/C1: anus
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spinal nerve #s
- 8 cervical spinal nerves
- 12 thoracic spinal nerves
- 5 lumbar spinal nerves
- 5 sacral spinal nerves
- 1 coccygeal spinal nerves
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spinal cord enlargements
- cervical enlargement: C4 through T1 spinal cord segments; innervation of upper limb (brachial plexus)
- lumbosacral enlargement: L2 through S3 spinal cord segments; innervation of lower limb (lumbar & sacral plexus)
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meninges
- dura mater
- subdural space
- arachnoid mater
- subarachnoid space
- denticulate ligament
- pia mater
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external surface features of the spinal cord
- anterior median fissure: anterior spinal artery
- anterior white commissure
- anterolateral sulcus: ventral roots
- dorsolateral fasciculus: Zone of Lissauer
- posterolateral sulcus: dorsal root entry zone
- posterior intermediate septum
- posteror intermediate sulcus
- posterior median septum
- posterior median sulcus
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arterial supply of spinal cord
- anterior spinal artery: from vertebral arteries; supplies anterior 2/3 of the spinal cord; 75% of the blood supply to the spinal cord is from the ASA
- posterior spinal artery: from posterior inferior cerebellar arteries; supply posterior 1/3 of the spinal cord
- radicular arteries: from segmental vessels; supplies blood to roots as well as cord
- Artery of Adamkiewicz: arteria radicularis magnus; supplies lower 1/3 of cord
- all of these join to form the arterial vasocorona
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vertebral venous plexus
- external vertebral venous plexus
- internal vertebral venous plexus: Batson's plexus; located between the dura mater and the vertebral periosteum in the epidural space
- thin walled, incompetent valves or valveless
- dependent upon pressure differential, venous blood can flow between the vertebral plexuses & skull, neck, thorax, abdomen & pelvis
- pathway for metastasis of prostate cancer OR pelvic infections to the vertebral column & cranial cavity
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organization of white matter
- posterior funiculus: dorsal columns; fasciculus cuneatus & fasciculus gracilis
- lateral funiculus: lateral corticospinal tract
- anterior funiculus: anterolateral system
- intrasegmental fibers & intersegmental tracts
- dorsolateral fasciculus: Lissauer's tract
- fasciculus proprius: propriospinal tract
- anterior white commissure
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regional anatomy of spinal cord
- cervical: large, oval shape; enlarged ventral horn; most white matter
- thoracic: small, round shape; IMLCC (T1-L2)
- lumbar: round; enlarged ventral horn
- sacral: small, round; least amount of white matter
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organization of the gray matter
- nuclear regions in the spinal cord
- named by nuclear groups or by lamina
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Rexed's laminae: spinal cord nuclei
- lamina I: posteromarginal nucleus
- lamina II: substantia gelatinosa
- laminae III + IV: principal sensory nucleus, nucleus proprius
- laminae V + VI: base of posterior horn
- lamina VII: nucleus dorsalis of Clarke (T1-L2); IMLCC (T1-L2/3); sacral parasympathetic cell column (S2-4)
- lamina VIII: motor neurons & interneurons; receive descending information
- lamina IX: lower motor neurons (medial, lateral, anterior & posterior columns)
- lamina X: region around central canal
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organization of motor neurons in lamina IX
- medial motor neurons: axial muscles (proximal)
- lateral motor neurons: extremities (distal)
- anterior motor neurons: extensor muscles
- posterior motor neurons: flexor muscles
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lower motor neurons
- motor neurons located in the ventral horn of the spinal cord [and in brainstem CN motor nuclei] that innervate muscle fibers
- final common pathway
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upper motor neurons
- motor neurons with cell bodies in the motor region of the cerebral cortex or the brainstem
- carry motor information down to the lower motor neuron to influence it's output
- any motor neurons that are not directly responsible for stimulating the target muscle
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spinal cord reflexes
- an involuntary, stereotyped response to a sensory input
- requires an afferent fiber, interneurons and/or motor neurons, and a target tissue usually skeletal muscle
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intrasegmental reflex
- simple reflex; confined to a single spinal cord segment
- involves a receptor structure, an associated afferent neuron in the dorsal root ganglion & an efferent neuron within the CNS
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intersegmental reflex
complex reflex, involving multiple spinal cord segments
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hyperreflexia
reflexes are greatly exaggerated
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hyporeflexia
reflexes are diminished
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areflexia
reflexes are absent
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stretch reflex
- the only reflex that does not involve one or more interneurons
- important for the constant automatic corrections during movements and postures
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deep tendon reflexes
- biceps brachii: C5 musculocutaneous
- brachioradialis: C6 radial
- triceps brachii: C7 radial
- quadriceps femoris: L4 femoral
- gastrocnemius, soleus: S1 tibial
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knee jerk reflex
- monosynaptic myotatic stretch reflex - intersegmental reflex
- tap on patellar tendon stimulate muscle spindles
- quadriceps contracts
- extension of the leg at the knee joint
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reciprocal inhibition
- one group of muscles is excited & the antagonistic group is inhibited
- reflex activity in a given muscle produces similar activity in its ipsilateral synergists and the opposite activity in its ipsilateral antagonists
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autogenic inhibition
- inverse myotatic reflex
- involves Golgi tendon organ - monitors muscle tension
- reflex inhibition of a motor unit in response to excessive tension in the muscle fibers it supplies
- protective mechanism to prevent muscles from exerting more force than the bones & tendons can tolerate
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withdrawal/flexor reflex
- nociceptive reflex
- more complex intersegmental polysynaptic reflex
- initiated by cutaneous receptors
- withdrawal from a painful or nociceptive stimulus
- involves the whole limb & several spinal cord segments & interneurons
- primary afferents bifurcate on entering the spinal cord & their processes extend one or two segments in both a rostral and a caudal direction
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crossed extension reflex
- builds on basic circuits of the flexor reflex
- withdrawal [flexion] in the ipsilateral limb is accompanied by a simultaneous and opposite activity [extension] in the contralateral limb
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spinal cord pathways
- motor (descending) pathways: lateral corticospinal tract & corticobulbar (corticonuclear) fibers
- sensory (ascending) pathways: dorsal column/medial lemniscal pathway; anterolateral system [lateral spinothalamic tract]
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dorsal column - medial lemniscal system function
sensory: vibration, conscious proprioception, two point discrimination (fine touch)
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dorsal column/medial lemniscal system pathway
- 1* dorsal root ganglion: T6 & above - fasciculus cuneatus; T7 & below - fasciculus gracilis
- 2* dorsal column nuclei: give off internal arcuate fibers that cross at lower medulla to form contralateral medial lemniscus
- 3* ventral posterolateral nucleus of thalamus: project up to somatosensory cortex
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spinothalamic tract function
sensory: pain (nociceptive), temperature, crude touch
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spinothalamic tract pathway
- 1* dorsal root ganglion: enters Zone of Lissauer and ascends before synapsing
- 2* dorsal horn laminae 1,2,5: sends neurons across midline at anterior white commissure to form contralateral spinothalamic tract
- 3* ventral posterolateral nucleus of thalamus: projects to somatosensory cortex
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lateral corticospinal tract function
motor: movement of contralateral limbs
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lateral corticospinal tract pathway
- begins in motor cortex (area 4/precentral gyrus)
- travels through crus cerebri of cerebral peduncle & corticospinal fibers --> form pyramids of medulla
- cross at pyramidal decussation fibers terminate on ventral horn cells (Upper Motor Neurons)
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spinal cord lesion 1
- peripheral nerve lesion
- motor & sensory deficits
- peripherally: trauma is most common cause (cervical rib, herniated IV disc)
- peripheral entrapment: carpal tunnel syndrome or pronator teres syndrome
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spinal cord lesion 2
lesion of the dorsal root - sensory deficites only
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spinal cord lesion 3
lesion of the ventral root - motor deficits only
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spinal cord lesion 4
lesion of motor neurons in ventral horn - motor deficits only
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lower motor neuron lesions
- lesions 1 (peripheral nerve), 3 (ventral root), 4 (motor neuron in ventral horn)
- alpha & gamma motor neurons of lamina Ix
- includes axon in spinal or peripheral nerves (ex. brachial plexus lesions, carpal tunnel syndrome)
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upper motor neuron lesion
- descending pathways and cells of origin
- motor cortex lesions (trauma, vascular)
- spinal cord or brainstem lesions that interrupt descending pathways
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lower motor neuron signs
- areflexia: absent deep tendon reflexes
- flaccid paralysis: complete loss of muscle tone & all voluntary and reflex movements
- muscle wasting: wasting & eventual fibrosis & contracture of affected muscles
- fasciculations: visible spontaneous contraction of motor units
- all signs occur IPSILATERAL and in muscles (myotomes) supplied by the affected motor neurons
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upper motor neuron signs
- paresis: difficulty in movement or weakness
- paralysis: loss of movement
- spastic paralysis: spasticity, increased muscle tone, increased resistance to passive stretching of muscles due to loss of descending influences on the LMN
- little wasting of muscles
- hyperreflexia: exaggerated deep tendon reflexes due to loss of inhibitory reflexes on gamma motor neurons
- Babinski sign: abnormal superficial plantar reflex
- all signs occur IPSILATERAL and below the level of the spinal cord lesion
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dorsal column lesion
ipsilateral loss of vibration, position, two point discrimination & deep touch
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corticospinal tract lesion
ipsilateral paralysis, paresis, spasticity, hyper-reflexia/clonus, Babinski sign (**UMN symptoms)
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spinothalamic tract lesion
contralateral loss of pain & thermal sense
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spinal motor neuron lesions
ipsilateral paralysis, paresis, hypotonia, hyporeflexia to areflexia, fibrillations, muscle atrophy (LMN symptoms)
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autonomic neuron lesions
ipsilateral miosis, ptosis, anhidrosis, enopthalamus; urinary & bowel incontinence
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spinal cord transsection
- results in loss of all sensation & voluntary movement inferior to the lesion
- trauma commonly associated with C spine fracture
- deficits depend on the level of transsection
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high cervical spinal cord transsection
- consists of respiratory insufficiency
- quadriplegia: paralysis of all four limbs (bilateral paralysis)
- spinal shock: period of areflexia of upper & lower extremity following trauma to spinal cord
- autonomic symptoms
- spasticity below level of lesion
- hyperreflexia: exaggerated DTR below level of lesion (lateral corticospinal tract)
- bilateral anesthesia, loss of pain & temperature (spinothalamic tract)
- loss of proprioception (dorsal column system)
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low cervical spinal cord transsection
spares respiratory muscles (C3,4,5 keep the diaphragm alive)
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high thoracic spinal cord transsection
paraplegia: paralysis of lower body including both lower extremities
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Brown-Sequard Syndrome
- spinal cord hemisection
- ipsilateral dorsal column signs: loss of the following sensations at & below the level of the hemisection; vibration; conscious proprioception (position sense); two point discriminitive touch
- ipsilateral corticospinal tract signs: lateral corticospinal tract injury; muscle paralysis, spasticity, clonus, hyperreflexia, Babinski sign
- contralateral spinothalamic tract signs: loss of pain & temperature in the contralateral half of the body beginning one or two segments below the hemissection
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syringomyelia
- lesiosn around central canal
- occurs commonly in ages 25-40; males more than females
- cyst or cavity (syrinx) forms within spinal cord
- lesions in & around the central canal encroach initially on fibers conveying pain & temperature in the anterior white commissure
- causes segmental & bilateral loss of pain & temperature sensations in corresponding dermatomes
- usually affects cervical spinal cord segments
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early syringomyelia lesion
crossing spinothalamic fibers involved
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late syringomyelia lesion
crossing spinothalamic fibers & motor neurons involved
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symptoms of syringomyelia
- loss of pain & temperature in the upper limbs on back of both arms & shoulders
- paresis of hands
- weakness & wasting in hands & arms
- fasciculations - visible spontaneous contractions of muscle units
- eventual paralysis of limbs
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anterior spinal artery syndrome
- anterior cord syndrome: occlusion of the anterior spinal artery (supplies anterior 2/3 of the spinal cord)
- characterized by abrupt onset of symptoms & signs; damage is related to vascular insufficiency
- syndrome is manifested by complete motor paralysis (corticospinal function) & sensory anesthesia (spinothalamic functions)
- posterior columns are spared
- deep pressure & proprioception are only retained sensibility of trunk & lower extremities
- flaccid paralysis below level of the lesion - LMN spinal shock
- patient demonstrates greater motor loss in legs than arms
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general function of the brainstem
- conduit functions: ascendign & descending fiber systems
- cranial nerve functions: motor & sensory cranial nerve nuclei
- integrative function: nuclei control respiration, cardiac function, consciousness, pain, balance, equilibrium
- cranial reflexes: mediates cranial reflexes (jaw jerk reflex, corneal reflex, accomodation reflex, vestibulo-ocular reflexes)
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divisions of the brainstems
- medulla, pons & midbrain
- each division has roof, tegmentum & basilar parts
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functional components of cranial nerves
GSE, GSA, GVE, GVA, SVE, SSA, SVA
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GSE
- general somatic efferent
- multipolar neuronal cell bodies in the motor nuclei of cranial nerves
- synapse directly on striated muscle via motor end plates
- CN: III, IV, VI, XI and XII
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GSA
- general somatic afferent
- found in several cranial nerves, but primarily CN V
- supplies skin & mucous membranes of head & neck
- CN: V, VII, IX, and X
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GVE
- general visceral efferent (parasympathetic)
- primary preganglionic neurons for the parasympathetic nervous system are multipolar neurons in parasympathetic nuclei associated with CN III, VII, IX and X
- sympathetic fibers innervating the head & neck originate from secondary postganglionic neurons located in the superior cervical ganglion
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GVA
- general visceral afferent
- pain & sensibility of viscera
- CN: VII, IX & X
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SVE
- special visceral efferent (branchiomotor)
- supply striated muscles embryologically derived from pharyngeal arches
- CN V: supplies muscles derived from 1st pharyngeal arch; muscles of mastication, tensor tympani, tensor veli palatini, anterior belly of the digastric, mylohyoid
- CN VII: supplies muscles derived from 2nd pharyngeal arch; muscles of facial expression, posterior belly of digastric, stapedius, stylohyoid
- CN IX: supplies muscle derived from 3rd pharyngeal arch; stylopharyngeus m
- CN X: supplies muscles derived from the 4th & 6th pharyngeal arches; pharyngeal, palatal & laryngeal musculature
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SSA
- special somatic afferent (special senses with physical stimulus)
- CN II: responds to light stimuli
- CN VIII: responds to sound stimuli
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SVA
- special visceral afferent (taste & smell)
- CN I: responds to chemical stimuli that mediate the sense of smell
- CN VII, IX, X: responds to chemical stimuli that mediate the sense of taste
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trigeminal pathways
- somatosensory information from face - mediate touch, pain, and temperature
- dorsal trigemino-thalamic tract
- ventral (anterior) trigeminothalamic tract
- from spinal trigeminal nucleus & principal (chief) sensory nucleus of CN V
- to ventral posterior medial nucleus (VPM) of thalamus
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corticobulbar (corticonuclear) projections
- trigeminal motor nucleus: CN V; bilateral
- facial motor nucleus: CN VII; contralateral, bilateral to upper face
- nucleus ambiguus: CN IX, CN X; bilateral, contralateral to CN X to soft palate & uvula
- accessory nucleus: CN XI; ipsilateral
- hypoglossal nucleus: CN XII; bilateral but predominantly contralateral
- corticoreticular & corticopontine fibers
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lesion of corticonuclear fibers before the facial nucleus
- contralateral lower facial paralysis
- sparing of contralateral upper face because of bilateral corticonuclear projections
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lesions of facial motor nucleus or facial nerve
Bell's Palsy: ipsilateral facial paralysis (upper and lower face)
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lesions of corticonuclear fiber before nucleus ambiguus & hypoglossal nucleus
- uvula deviates to the side of the lesion
- tongue deviates to the side opposite the lesion
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CN nuclei in the medulla
- Hypoglossal Nucleus: CN XII - GSE
- Dorsal Motor Nucleus: CN X - GVE
- Inferior Salivatory Nucleus: CN IX - GVE
- Nucleus Ambiguus: CN IX, X - SVE
- Solitary Nucleus: CN VII, IX, X - SVA, GVA
- Spinal Trigeminal Nucleus: CN V, VII, IX, X - GSA
- Cochlear & Vestibular Nuclei: CN VIII - SSA
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CN nuclei in the pons
- Abducens Nucleus: CN VI - GSE
- Facial motor nucleus: CN VII - SVE
- Superior Salivatory Nucleus: CN VII - GVE
- Trigeminal Motor Nucleus: CN V - SVE
- Principal (Chief) Sensory Nucleus of CN V: CN V - GSA
- Spinal Trigeminal Nucleus: CN V, VII, IX, X - GSA
- Vestibular Nuclei: CN VIII - SSA
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CN nuclei in the midbrain
- Oculomotor Nucleus: CN III - GSE
- Edinger-Westphal Nucleus: CN III - GVE
- Trochlear Nucleus: CN IV - GSE
- Mesencephalic Nucleus of CN V: CN V - GSA
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lateral medullary syndrome
- AKA PICA syndrome; Wallenberg Syndrome
- lesion of posterior inferior cerebellar artery
- anterolateral system fibers damaged: contralateral loss of pain & thermal sense on body
- spinal trigeminal tract & nucleus damaged: ipsilateral loss of pain & thermal sense on face
- nucleus ambiguus, roots of CN IX & X damaged: dysphagia, soft palate paralysis, hoarseness, diminished gag reflex
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medial medullary syndrome
- infereior alternating hemiplagia
- lesion of anterior spinal artery
- pyramid (corticospinal fibers) damaged: contralateral hemiplegia of arm & leg
- medial lemniscus damaged: contralateral loss of position sense, vibratory sense & discriminatory touch
- hypoglossal nerve in medulla or hypoglossal nucleus damaged: deviation of tongue to ipsilateral side; muscle atrophy and fasciculations
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medial pontine syndrome
- middle alternating hemiplagia
- lesion of paramedian branches of basilar artery
- corticospinal fibers in basilar pons damaged: contralateral hemiplagia of arm & leg
- medial lemniscus damaged: contralateral loss or decrease of position & vibratory sense & discriminitive touch (arm & leg)
- abducens nerve fibers or nucleus damaged: ipsilateral lateral rectus muscle paralysis
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lateral pontine syndrome
- lesion of long circumferential branches of the basilar artery
- facial motor nucleus (caudal levels) damaged: ipsilateral paralysis of facial muscles
- trigeminal motor nucleus damaged: ipsilateral paralysis of masticatory muscles
- spinal trigeminal tract & nucleus damaged: ipsilateral loss of pain & thermal sense from face
- anterolateral system damaged: contralateral loss of pain & thermal sense from body
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medial midbrain syndrome
- superior alternating hemiplagia, Weber syndrome
- lesion of paramedian branches of P1 segement of posterior cerebral artery
- CN III damaged: ipsilateral paralysis of eye movement ("down & out")
- corticospinal fibers in cerebral peduncle (crus cerebri) damaged: contralateral hemiplegia of arm & leg
- red nucleus spared: no contralateral ataxia
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midbrain syndromes
- clue: CN III palsy or vertical gaze problem
- Claude's syndrome: central midbrain region (tegmentum, red nucleus, CN III)
- Benedikt's syndrome: lesion of tegmentum, red nucleus, CN III & cerebral peduncle
- Weber's syndrome
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6 subsets of the neuro exam
- mental status
- cranial nerves
- motor
- coordination
- sensory
- gait
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screening neuro exam
- screening of each of the subsets (mental status, CNs, motor, coordination, sensory & gait)
- allows one to check entire neuroaxis (cortex, subcortical white matter, basal ganglia/thalamus, brainstem, cerebellum, spinal cord, peripheral nerves, NMJ & muscles)
- expand evaluation of a given subset to answer questions generated from the history OR confirm/refute expected or unexpected findings on exam
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the complete neuro exam
- is NEVER done given the amount of time & effort it would take
- LONG & REDUNDANT
- take advantage of this to confirm/refute abnormal findings
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components of mental status
- level of alertness
- degree of orientation
- concentration
- memory
- language
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mental status: level of alertness
- subjective view of examiner
- definition of consciousness
- terminology for depressed level of consciousness
- coma
- delerium
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mental status: degree of orientation
- to what? name, place date
- A and O x 4: alert and oriented to person, place, time, etc.
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mental status: concentration
- requires a patient to remain on task during a sustained mental activity
- serial 7s or 3s, WORLD backwards, etc
- try to quantify degree of impairment
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mental status: memory
- immediate recall: a task of concentration
- short-term memory: 3/3 objects after 5 minutes; function of hippocampus & connection to cortex
- long-term memory: last thing to go
-
mental status: language
- confined to dominant hemisphere
- aphasia: have difficulty with spoken language AND reading, writing, sign language & gestures (localization of problem area)
- dysarthria: intact language with a motor speech production problem (does not localize to language areas)
- receptive language: command following; function of Wernike's area
- expressive language: fluency & word finding; function of Broca's area
- repetition: screens for receptive, expressive & conductive aphasias
-
indications of mental status problem
- Gerstmann's Syndrome: difficulty with calculations, R-L confusion, finger agnosia & agraphia (deficiency in writing); dominant parietal lobe lesion
- Hemineglect: non-dominant parietal lobe lesion
-
CN I test
- olfactory nerve
- distinguis coffee from cinnamon
- smelling salts irritate nasal mucosa & test V2 trigeminal sense
- disorders of smell result from closed head injuries; loss of tate will also occur
-
CN II test
- optic nerve
- tests acuity, field, pupil & fundus
- visual acuity: cover one eye, read line on chart, switch
- visual field: direct confrontational testing of peripheral vision
- pupillary light reflex: afferent portion through CN II, efferent through CN III (papillary constrictor mm)
- fundoscopic exam: looks at nerve
-
APD
- afferent pupillary defect
- intact consentual pupillary light reflex but neither pupil constricts when light is shined on affected eye
-
PERLA
pupils equal, reactive to light and accomodation
-
CN III test
- oculomotor nerve
- responsible for most extra-ocular eye muscles (all except lateral rectus & superior oblique)
- Edinger Westphal nucleus: in tegmentum of midbrain; efferent limb of pupillary light reflex
- lesion: lateral strabismus ("down & out"), blown pupil & ptosis
-
CN IV test
- trochlear nerve
- innervates superior oblique m.
- lesion: extorted eye (patient cannot depress or intort adducted eye; leads to head tilt)
-
CN VI test
- abducens nerve
- innervates lateral rectus m.
- lesion: adducted eye (cannot abduct)
-
EOMI without nystagmus
extraocular movement intact without involuntary movements of the eye
-
CN V test
- trigeminal nerve
- opthalmic (V1): primary sensation; afferent input for the corneal blink reflex
- maxillary (V2): primary sensation
- mandibular (V3): sensory & motor component (muscles of mastication)
- test by light touch, cold, pin prick, position & vibration sense, movement of jaw
-
CN VII test
- facial nerve: motor innervation to facial muscles; efferent output to corneal blink reflex
- UMN deficit: affects contralateral corticobulbar tracts resulting in weakness of the lower part of the face only
- LMN deficit: affects the upper & lower facial muscles ipsilateral to the site of injury
- test by smiling & wrinkling forehead
-
CN VIII test
- vestibulocochlear nerve
- hearing & balance: patients will complain of tinnitis, hearing loss &/or vertigo
- Weber test: tuning fork on vertex of skull, conductive hearing loss detected in loudest ear; sensory neural hearing loss detected in ear opposite of loudest sound
- Renne Test: air conduction should be louder than bone conduction
- Doll's eye maneuver: in comatose patients, when head is moved quickly to one side, eyes should lag but follow
- cold calorics: cold water in right ear; eyes should drift to right side
-
CN IX test
- glossopharyngeal nerve
- afferent component of gag reflex - not usually tested
- check for palate elevation when patient says AHHH
-
CN X test
- vagus nerve
- efferent component of gag reflex - not usually tested
- parasympathetic innervation from neck to midtransverse colon
- check for palate elevation when patient says AHHH
-
CN XI test
- spinal accessory nerve
- check sternocleidomastoid & trapezius strength
-
CN XII test
- hypoglossal nerve
- have patient stick out their tongue - look for deviation, atrophy & fasciculations
- UMN lesion: contralateral deviation of tongue
- LMN lesion: ipsilateral deviation of tongue; hemi-atrophy & fasciculations
-
motor examination
- strength
- tone
- DTRs
- plantar responses
- involuntary movements
-
medical research council scale
- measure of strength
- 5/5: full strength
- 4/5: weakness with resistance
- 3/5: can overcome gravity only
- 2/5: can move limb without gravity
- 1/5: can activate muscle without moving limb
- 0/5: cannot activate muscle
-
upper motor neuron weakness pattern
- decrease strength
- spasticity - increased tone
- brisk DTRs
- upgoing toes on plantar response
- no atrophy/fasciculations
- cause: corticospinal tract lesion, stroke
- symptomes: strong flexors in upper limb, strong extensors in lower limb, Babinski sign
-
lower motor neuron weakness pattern
- decreased strength
- hypotonia - decreased tone
- diminished or absent DTRs
- downgoing toes on plantar response
- +/- atrophy/fasciculations
- causes: ALS (anterior horn cell degeneration)
-
peripheral neuropathy weakness pattern
symptoms: distal weakness (hands/feet), spared proximal weakness (shoudler/hip girdle)
-
myopathic weakness pattern
- symptoms: proximal weakness (shoulder/hip girdle), spared distal weakness (hands/feet)
- causes: Duchenne's Muscular Dystrophy
-
tone
- resistance appreciated when moving a limb passively
- central hypotonia: Down's syndrome
- peripheral hypotonia: myopathy, neuropathy
- spasticity: limb must be moved at a certain direction/velocity to produce tone (corticospinal tract)
- rigidity: no direction/velocity component, tone is constant (basal ganglia, Parkinson's Disease)
- dystonia: discoordination of agonist & antagonistic muscles (basal ganglia)
-
DTRs
- deep tendon reflexes
- 0/4: absent
- 1-2/4: normal range
- 3/4: pathologically brisk
- 4/4: clonus ("flapping reflex")
-
hyperkinetic movements
- chorea: rapid, quick movements all over body
- athetosis: distal writhing
- tics: repetitive contractions localized to a group of muscles or vocalizations (Tourette Syndrome)
- myoclonus: shock like contraction of a group of muscles
-
bradykinetic movements
- parkinsonism: tetrad of bradykinesia, rigidity, postural instability & resting tremor
- dystonia: keeping limbs in fixed/twisted uncomfortable position
-
parkinsonism
- bradykinesia: slow movements, decreased facial expressioins
- rigidity: form of increased tone
- postural instability: falls easily
- resting tremor: relieved with voluntary movement
-
sensory examination
- primary sensory modalities: light touch, pain/temperature sensation, vibration/position sensation
- cortical sensory modalities: stereognosis, graphesthesia, two point discrimination, double simultaneous extinction
-
primary sensory modalities
- light touch (multiple pathways)
- pain/temperature sensation (spinothalamic tract)
- vibration/position sense (posterior columns)
- reflect input from sensory receptors, sensory nerves, spinal cord, brainstem, through to the level of the thalamus
-
cortical sensory modalities
- stereognosis: test by placing coin into contralateral hand & ID by touch
- graphesthesia: ID letter "drawn" on hand
- two point discrimination: ability to sense one or both points of stimulation
- double simultaneous extinction: can identify stimuli individually on R & L side, but only one side when stimulated bilaterally
- reflects processing by the somatosensory cortex (post-central gyrus)
-
pain & temperature sensation
- small unmyelinated fibers provide pain & temperature input
- travels through DRG
- Lissauer's tract up/down a few segments
- synapse in lamina II (substantia gelatinosa)
- 2* neurons cross midline at anterior white commissure
- travel up lateral spinothalamic tract
- synapse on VPL nucleus of thalamus
-
vibration/position sense vibration
- large myelinated fibers bring sensory information concerning vibration & joint position sense
- fasciculus gracilis (legs) & fasciculus cuneatus (arms)
- synapse on ipsilateral dorsal column nuclei
- 2* neurons corss at medial lemniscus
- synapse on VPL nucleus of thalamus
-
coordination
- tests cerebellum inputs/outputs
- hemisphere dysfunction
- midline dysfunction
-
hemisphere dysfunction
- ipsilateral hemiataxia
- dysmetria on finger-nose-finger testing
- irregularly irregular tapping rhythm
- dysdiadochokinesis
- impaired check
- hypotonia
- impaired heel-knee-shin
- falls to side of lesion
- variable directions of nystagmus
-
midline dysfunction
- lesion to Vermis of cerebellum
- truncal ataxia
- titubation
- ataxic speech
- gait ataxia (acute or chronic)
-
gait
- normal: requires multiple levels of the neuroaxis to be intact (vision, strength, balance/coordination, joint position)
- observe arm swing, base of gait, heel strike, time spent on each leg, posture of trunk, toe walking, heel walking, tandem walking
-
classical patterns of abnormal gait
- parkinsonism gait: shuffling, magnetic gait
- hemiparetic gait: circumduction of leg with flexion & adduction of arm
- spastic diplegia gait: "knock kneed"
- acute ataxia gait: drunken gait
- chronic ataxia gait: wide base
- waddling gait: hip girdle weakness (Gower's sign)
- high stepping gait: due to foot drop (LMN) or loss of proprioception of feet
-
subdivisions of the diencephalon
- dorsal thalamus: relay, association & diffuse projecting nuclei to cortex
- hypothalamus: controls endocrine function and autonomic behaviors
- ventral/ subthalamus: subthalamic nucleus and zona incerta (an extension of midbrain reticular formation)
- epithalamus: pineal body, habenular nucleus, stria medullaris- receives fibers from the globus pallidus & limbic system; enables basal ganglia & limbic system to modulate the reticular system in brainstem; helps control circadian rhythms
-
anatomic divisions of thalamus
- anterior division
- medial division
- lateral division - dorsal & ventral tiers
-
nuclei in divisions of thalamus
- anterior division: anterior nuclei
- medial division: dorsomedial nucleus
- lateral division - dorsal tier: laterodorsal & lateroposterior nuclei
- lateral division - ventral tier: ventral anterior, ventolateral, ventral posterolateral, & ventral posteromedial nuclei
- metathalamus: lateral & medial geniculate nuclei
- lamiar tracts: intralaminar nuclei
- surrounding the thalamus: reticular nucleus
- pulvinar nucleus: posterior thalamus
-
thalamic nuclei functional groups
- specific (or relay) nuclei
- association nuclei
- non-specific nuclei
-
specific (or relay) nuclei
- mostly comprise the ventral tier and the geniculate bodies (nuclei & inputs)
- the result is a somatosensory thalamus that is the first place to bring the whole body map together
-
specific (or relay) nuclei & inputs
- ventral anterior nucleus: from globus pallidus and sustantia nigra
- ventrolateral nucleus: from cerebellus & globus pallidus
- ventral posterolateral nucleus: somatosensory from body to primary somatosensory cortex
- ventral posteromedial: somatosensory from head to primary somatosensory
- lateral geniculate nucleus: from retina to primary visual cortex
- medial geniculate nucleus: from auditory pathway to primary auditory cortex
- lateral dorsal nucleus: from hippocampus to cingulate cortex
-
thalamic peduncles
- extensive thalamocortical efferents that merge and become part of the internal capsule
- 4: anterior, inferior, posterior, superior
-
association nuclei
- reciprocally connected to the association areas of the cortex
- dorsomedial nucleus: inputs from olfactory & limbic systems; reciprocal connections with entire prefrontal cortex
- lateral posterior & pulvinar nuclei: receive afferents from parietal, occipital & temporal lobes; each has reciprocal efferents back to the same lobes
-
nonspecific nuclei
- reciprocally connected to the association areas of the cortex
- intralaminar/ centromedian/ parafascicular: afferents from the basal ganglia & limbic system; efferents to the cerebral cortex, basal ganglia & limbic system
- reticular nucleus: afferents from the dorsal thalamus and cortex; efferents from the dorsal thalamus; almost exclusively GABA neurons inhibiting/modulating specific (or relay) nuclei
- enables increased detection of novel or deviant stimuli, enabling attention
-
basic functions of the hypothalamus
- blood pressure & electrolyte composition: thirst, salt appetite, drinking, vasomotor tone
- energy metabolism: hunger, feeding, digestion, regulates GH & TSH
- reproductive behavior: sexual & parental; autonomic control of reproductive organs, endocrine regulation of gonads
- body temperature: thermoregulation behavior, metabolic rate
- defense behavior: regulates stress response (fight or flight)
- sleep wake cycle: circadian clock via suprachiasmatic nucleus
-
integration of inputs in thalamus
- contextual information: cerebral cortex, amygdala, hippocampal formation
- sensory inputs: visceral & somatic sensory pathways, chemosensory & humoral signals
- hypothalamus - compares input to biological set points
- effect: visceral motor, somatic motor, neuroendocrine, behavioral responses
-
subdivisions of the hypothalamus
- chiasmatic zone: lies above the optic chiasm, includes nuclei related to anterior pituitary
- tuberal zone: several nuclei in this zone are related to feeding & drinking behaviors; others to pituitary function
- mammillary zone: includes mammillary bodies which are involved in memory
- medial-lateral zones: hypothalamic areas involved in food & water intake; lateral zone contains medial forebrain bundle
-
divisions of hypothalamic nuclei
- rostral: preoptic, supraoptic, paraventricular, & suprachiasmatic nuclei
- middle: ventromedial hypothalamic & lateral hypothalamic nuclei
- caudal: mammillary nuclei
-
hypothalamic nuclei function
- rostral nuclei: magnocellular neurons produce vasopressin (antiduretic - neural control of BP & water balance), oxytocin (uterine control) & GnRH (gonal control) project to pituitary
- stimulation of ventromedial hypothalamic nucleus: refusal to eat
- stimulation of lateral hypothalamic nucleus: increase food/water intake (destruction --> refusal to eat)
- damage to mammillary nuclei: impaired ability to learn specific location within a cognitive map
-
afferents & efferents to hypothalamus
- fornix: from the hippocampus to the mammillary bodies; related to emotional components of behavior & memory
- medial forebrain bundle: brainstem inputs related to states of consciousness & autonomic afferents (bidirectional)
- mammillothalamic tract: ascending pathway that projects from mammillary bodies to anterior nucleus of thalamus (which projects to cingulate cortex
-
blood supply of thalamus
- posterior cerebral artery
- thalamogeniculate arterial branches
- thalamoperforator arterial branches
-
contents of cerebral hemispheres
- neocortex: thin layer of cell bodies covering the cerebrum
- subcortical nuclei: basal ganglia, hippocampus & amygdala (and all fiber tracts between them)
-
dorsal & ventral telencephalon
- dorsal: cerebral cortex & hippocampus
- ventral: basal ganglia
-
lobes of the telencephalon
- frontal
- parietal
- occipital
- temporal
- limbic (cingulate gyrus)
-
frontal lobe
- rostral to the central sulcus
- contains primary motor, premotor (including Broca's area for speech production)
- critical to planning response to stimuli
- attention
- much executive function
-
parietal lobe
- caudal to the central sulcus
- contains primary & secondary somatosensory; multimodal association areas; part of Wernicke's area
- critical to mediating endogenous (self generated) attention
-
occipital lobe
- posterior lobe bounded by the parieto-occipital sulcus & preoccipital notch
- contains much of the visual processing in the cortex (some multimodal processing too)
-
temporal lobe
- inferior to the lateral fissure
- largely consists of Heschl's gyrus (auditory), part of Wernicke's area (association for speech processing) & multimodal sensory processing (including recognizing audio & visual stimuli)
-
limbic lobe
- part of the cortex on the medial aspect of cerebral hemispheres
- forms rim (limbus) around the corpus callosum & diencephalon
- largely consists of cingulate gyrus, parahippocampal gyrus, olfactory bulb & cortex
- cortical control of emotional expression
-
cortical cellular organization: layers
- the number & size of the layers (created by cell bodies at different depths) varies for different types of cortex
- archicortex: hippocampus; 3-4 layers
- paleocortex: pyriform cortex; 3 layers
- neocortex: motor & visual cortex: 6 layers
-
functional cortical layers
- supragranular: layers above layer IV; densely packed; pyramidal neurons; cortico-cortical connections
- internal granular: layer IV; densely packed stellate cells; receives input from thalamus
- infragranular: layers below layer IV; develops first; primary descending projections (efferent mechanisms); layers V & VI - pyramidal neurons the thalamus, brainstem & spinal cord
-
cortical fiber systems
- commissural fiber systems: corpus callosum; cortico-cortical connections
- projection fiber systems: internal capsule
- association fiber systems: within a lobe (NOT across)
-
regions of cytoarchitecture
Brodmann's areas: regional difference in cell morphology (different cell type suggests different functions)
-
important Brodmann's areas
- visual: areas 17,18,19 (occipital, temporal lobes)
- auditory: areas 41,42 (superior temporal lobe; parts of Heschel's gyrus)
- somatosensory: areas 1,2,3,5-7 (postcentral gyrus, parietal lobe)
- motor: areas 4,6,8 (precentral gyrus, frontal)
- frontal association cortex: areas 9,10
- Broca's speech area: areas 44,45 (frontal)
- Wernicke's speech areas: areas 22,39,40 (parietal & temporal lobes)
-
principles of cortical functional organization
- areas of primary sensory input: subcortical or non-cortico-cortical source
- peripheral organization: sensitivity & output is maintains in areas of cortex
- cortical magnification: more complex processing requires relatively more cortical (and subcortical) space than the relative amount of body area occupied by the sensory receptors
- columns: the primary sensory cortices (& subcortical stations) are organized into repeating patterns of neurons with similar functional properties
- association areas: multisensory integration (LOTS of cortico-cortical)
- areas of primary motor output: neurons that go directly to other brain regions
- premotor: neurons coordinating sequences of motor output
-
primary sensory cortices
- primary visual cortex: area 17 (occipital lobe)
- primary auditory cortex: areas 41,42 (superior temporal lobe)
- primary somatosensory cortex: areas 1,2,3 (postcentral gyrus of parietal lobe)
- primary olfactory cortex: medial temporal lobe (pyriform cortex near first nerve entrance)
- primary gustatory cortex: located in part in the insula of the frontal lobe
-
peripheral organization of the cortex
- "sensorotopic" mapping
- the organization of stimulus processing in the sensory receptor cells is maintained in areas of the cortex
-
primary motor cortices
- primary motor cortex: rostral of central sulcus; contains neurons that go directly to other brain regions outside the cortex
- premotor cortex: neurons activate prior to the initiation, coordination & timing of movements (connection to LMNs)
-
association cortices
- parieto-temporal association cortex (non dominant hemisphere): mediates spatial relationships, attention, object recognition
- prefrontal association cortex: planning, judgement, intellect
- parieto-frontal association cortex: dominant hemisphere; mediates language comprehension (Wernicke's area) and expression (Broca area); initiates attention instructions
-
Neglect syndrome
- common brain lesion that results in striking attentional deficits
- arises from strokes, tumors, or traumatic injury to right inferior parietal lobe
-
nuclei of basal ganglia
- caudate nucleus
- putamen
- globus pallidus
- substantia nigra
- subthalamic nucleus
- do NOT project to local circuit or LMNs: influence movement by regulating activity of UMNs
-
neostriatum
caudate + putamen
-
paleostriatum
globus pallidus
-
corpus striatum
neostriatum (caudate + putamen) & paleostriatum (globus pallidus)
-
lenticular nucleus
putamen + globus pallidus
-
blood supply to telencephalon
- anterior cerebral artery: frontal lobe back to parietal
- middle cerebral artery: parietal lobe
- posterior cerebral artery: occipital lobe, some parietal & temporal lobe
-
damage to primary sensory areas
results in deficits in stimulus detection & discrimination
-
damage to primary motor areas
results in deficits of paralysis
-
damage to parietal association cortex
- inattention or contralateral neglect
- defect or affect (humorless, lack of concern, lack of speech prosody)
-
damage to temporal association cortex
- deficits in recognizing stimulus
- agnosia - detection or no recognition
- face blindness
-
cortical functions of left hemisphere
- speech
- writing
- lexical & syntactic language
- analysis of right visual field
- mathematical skills
-
cortical functions of right hemisphere
- rudimentary speech
- spatial abilities
- prosodic aspects of language
- analysis of left visual field
- music & artistic skills
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