Académique Documents
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METC
Primary Areas
Parieto-occipital sulcus
Blood supply
CIRCLE OF WILLIS
Formed by two internal carotid arteries and 2 vertebral arteries at the base of the brain
Language
1- Broca’s Area
– an area of the frontal lobe, usually in the left hemisphere, that directs the muscle movements involved
in speech
2- Wernicke’s Area
– a brain area involved in language comprehension and expression; usually in the left temporal lobe.
Lateralization
Left Hemisphere
Verbal competence
logical
Right Hemisphere
Nonverbal areas
intuitive
Left Hemisphere
Right Hemisphere
The Homunculus
Cerebral Cortex:
Outer layer of neurons (1mm thick)
Modulates consciousness
Distributes neuromodulators
– alertness, attention
Midbrain / Mesencephalon
The cerebral aqueduct is its cavity & connects the 3 rd & 4th ventricles
Roof of midbrain called “tectum” & lies posterior to the cerebral aqueduct
The paired upper bodies serve as visual reflex centers for head & eyeball movements
The Hypothalamus
- Found inferior to the thalamus, forms the floor & part of the lateral walls of 3 rd ventricle
- Contains centers for body temp control, appetite & satiety, & water balance; regulates pituitary
gld & links nervous & endocrine systems; helps control autonomic system;
- It is involved with drives associated with survival such as hunger, thirst, emotion, sex, and
reproduction
Cerebellum
A midline portion, the vermis, separates two lateral lobes, or cerebellar hemispheres.
Because of the location of the fourth ventricle, ventral to the cerebellum, mass lesions or swelling of the
cerebellum can cause obstructive hydrocephalus.
Cerebellum
A. Paleocerebellum- consists of anterior lobe; controls gross movement of head & body
2. controlling equilibrium and muscle tone through connections with the vestibular system
and the spinal cord and its gamma motor neurons.
4. In addition, the cerebellum receives collateral input from the sensory and special sensory
systems.
1. Speaking
2. Walking
3. Tremour
Damage can result in ataxic or uncoordinated movement because of errors in the direction,
range, & rate of movement
Clinical dxtic test; ask pt to place a finger on his / her own nose.
(+) will miss mark & may miss several times before finding the target
Cerebellar Stroke
Dizziness, vomiting
Unsteady so that walking is impossible
1. The spinal cord communicates with the sense organs and muscles below the level of the
head
Bell-Magendie Law- entering dorsal roots carry sensory information and the
exiting ventral roots carry motor information to the muscles and glands
The Spinal
Cord, Spinal Nerves,
and Spinal Reflexes
Spinal Cord
Segmented
1. Cervical
2. Thoracic
3. Lumbar
4. Sacral
Blood Supply
Segmental arteries
Feeder arteries
CSF
Shock absorbing fluid that fills ventricles, cavities within the brain & subarachnoid spaces around
the brain & SC
Most produced by cluster of capillaries known as CHOROID plexuses (projects fr pia matter into
ventricles)
White matter:
Three columns:
Ventral
Dorsal
Lateral
Gray matter:
‘Horns’:
Posterior (dorsal)
Anterior (ventral)
Lateral
Commissures:
White
Pathways are paired (one on each side of the spinal cord or brain)
Spinal Nerves
- capillaries from the perineurium provide oxygen and nutrients ot the axons and Schwann cells
of the nerve
Each spinal nerve forms through fusion of dorsal and ventral nerve roots
- a white ramus and a gray ramus known as rami communicantes (‘communicating branches’)
Rami Communicantes
Carry visceral motor fibers to and from a nearby autonomic ganglion associated with the
sympathetic division of the ANS
Dorsal ramus provides sensory innervation from, and motor innervation to, a specific segment
of the skin and muscles of the neck and back
Ventral ramus supplies the ventrolateral body surface, structures in the body wall, and the limbs
Distribution of sensory fibers within these rami illustrates the segmental division of labor
- each pair of spinal nerves monitors a specific region of the body surface known as a
dermatome
Dermatomal Map
Clinically important -damage to a spinal nerve or dorsal root ganglion produces a loss of
sensation
Pain
Types
Two Modalities:
Sensory Nerves
Carry messages from special reporters in the skin, muscles, and other internal and external sense organs
to the spinal cord and then to the brain
Motor Nerves
Carry orders from CNS to muscles, glands to contract and produce chemical messengers
Somatic NS
Autonomic NS
Permits the involuntary functioning of blood vessels, glands, and internal organs such as the bladder,
stomach and heart
Fibers run through the olfactory bulb and terminate in the primary olfactory cortex
Optic nerves pass through the optic canals and converge at the optic chiasm
From there, the optic radiation fibers run to the visual cortex
Functions in raising the eyelid, directing the eyeball, constricting the iris, and controlling lens
shape
Fibers emerge from the dorsal midbrain and enter the orbits via the superior orbital fissures;
innervate the superior oblique muscle
Ophthalmic (V1)
Maxillary (V2)
Mandibular (V3)
Fibers run from the face to the pons via the superior orbital fissure (V 1), the foramen rotundum
(V2), and the foramen ovale (V3)
Conveys sensory impulses from various areas of the face (V1) and (V2), and supplies motor fibers
(V3) for mastication
- In severe cases, nerve is cut; relieves agony but results in loss of sensation on that side of the
face
Primarily a motor nerve innervating the lateral rectus muscle (abducts the eye; thus the name
abducens)
Fibers leave the pons, travel through the internal acoustic meatus, and emerge through the
stylomastoid foramen to the lateral aspect of the face
Facial expression
Sensory function is taste from taste buds of anterior two-thirds of the tongue
• Bell’s palsy: paralysis of facial muscles on affected side and loss of taste sensation
• Tears drip continuously and eye cannot be completely closed (dry eye may occur)
Fibers arise from the hearing and equilibrium apparatus of the inner ear, pass through the
internal acoustic meatus, and enter the brainstem at the pons-medulla border
Fibers emerge from the medulla, leave the skull via the jugular foramen, and run to the throat
Nerve IX is a mixed nerve with motor and sensory functions
Motor – innervates part of the tongue and pharynx, and provides motor fibers to the parotid
salivary gland
Sensory – fibers conduct taste and general sensory impulses from the tongue and pharynx
The only cranial nerve that extends beyond the head and neck
Most motor fibers are parasympathetic fibers to the heart, lungs, and visceral organs
Cranial Nerve X:
Vagus
Formed from a cranial root emerging from the medulla and a spinal root arising from the
superior region of the spinal cord
The spinal root passes upward into the cranium via the foramen magnum
The accessory nerve leaves the cranium via the jugular foramen
Innervates the trapezius and sternocleidomastoid, which move the head and neck
Fibers arise from the medulla and exit the skull via the hypoglossal canal
Innervates both extrinsic and intrinsic muscles of the tongue, which contribute to swallowing
and speech
Each spinal nerve connects to the spinal cord via two medial roots
Each root forms a series of rootlets that attach to the spinal cord
Ventral roots arise from the anterior horn and contain motor (efferent) fibers
Dorsal roots arise from sensory neurons in the dorsal root ganglion and contain sensory
(afferent) fibers
The short spinal nerves branch into three or four mixed, distal rami
Rami communicantes at the base of the ventral rami in the thoracic region – to/from
ANS
Intercostal nerves supply muscles of the ribs, anterolateral thorax, and abdominal wall
Nerve Plexus
Occurs in segments that control skeletal musculature of the neck and limbs
- peripheral distribution of the ventral rami do not directly proceed to their peripheral targets
Ventral rami of adjacent spinal nerves blend their fibers to produce compound nerve trunks
- formed during development when small skeletal muscles fuse to form larger muscles with
compound origins
Cervical plexus
Brachial plexus
Lumbar plexus
Sacral plexus
Cervical Plexus
Consists of cutaneous and muscular branches in the ventral rami of spinal nerves C1-C4, some
C5
The cutaneous branches innervate areas on the head, neck, and chest
Major nerve of this plexus the phrenic nerve provides the entire nerve supply to the diaphragm
Cervical Plexus
Brachial Plexus
Formed by C5-C8 and T1 (C4 and T2 may also contribute to this plexus)
Ulnar – supplies the flexor carpi ulnaris and part of the flexor digitorum profundus
Flow chart summarizing relationships within the brachial plexus - dashed lines to the posterior
cord merely indicate that the posterior division lie posterior to the anterior divisions
Lumbar Plexus
Arises from (T12) L1-L4 and innervates the thigh, abdominal wall, and psoas muscle
Sacral Plexus
Arises from L4-S4 and serves the buttock, lower limb, pelvic structures, and the perineum
The major nerve is the sciatic, the longest and thickest nerve of the body
The sciatic is actually composed of two nerves: the tibial and the common fibular (peroneal)
nerves
Cervical – C1-C4
Phrenic nerve
Brachial – C5 – T1 (roots/trunks/divisions/cords)
Lumbar – L1-L4
Femoral, obturator
Sacral – L4-S4
1. Divergence:
2. Convergence:
3. Serial processing:
Parallel processing:
5. Reverberation:
Reflex activity
Sensory neuron
Motor neuron
Effector
Spinal Reflexes
monosynaptic reflexes
polysynaptic reflexes
Monosynaptic Reflexes
Muscle Spindles
Postural Reflexes
Postural reflexes:
stretch reflexes
maintain normal upright posture
Polysynaptic Reflexes
Withdrawal Reflexes
Reciprocal Inhibition
Crossed Extensor
Reflexes
processing centers in brain can facilitate or inhibit reflex motor patterns based in spinal
cord
Automatic reflexes:
Superficial reflexes
Involves functional upper motor pathways as well as cord level reflex arcs
Spinal Reflexes
Spinal Reflexes
Spinal Reflexes
Spinal Reflexes
Spinal Reflexes
Cross sectioning of the spinal cord at any level results in total motor and sensory loss in regions
inferior to the cut
NEUROLOGICAL EXAM
MENTAL STATUS
CRANIAL NERVES
MOTOR EXAM
STRENGTH
GAIT
CEREBELLAR
REFLEXES
SENSATION
MENTAL STATUS
Level of Consciousness
Agitated
Lethargic
Arousable with
Voice
Gentle stimulation
Painful/vigorous stimulation
Comatose
LANGUAGE
FLUENCY
NAMING
REPETITION
READING
WRITING
COMPREHENSION
MEMORY
IMMEDIATE
REMOTE
HISTORICAL EVENTS
PERSONAL EVENTS
ORIENTATION
PERSON
PLACE
TIME
CALCULATION
ABSTRACTION
SIMILARITIES/DIFFERENCES
JUDGEMENT
PERSONALITY/BEHAVIOR
CRANIAL NERVES
I - OLFACTORY
II - OPTIC
VISUAL ACUITY
VISUAL FIELDS
FUNDOSCOPIC EXAM
PUPILLARY RESPONSE
EYE MOVEMENTS
9 CARDINAL POSITIONS
V - TRIGEMINAL
CRANIAL NERVES
VII - FACIAL
VIII - VESTIBULAR
ACUITY
RINNE, WEBER
CRANIAL NERVES
GAG
XI - SPINAL ACCESSORY
STERNOCLEIDOMASTOID M.
TRAPEZIUS MUSCLE
XII - HYPOGLOSSAL
TONGUE STRENGTH
MOTOR EXAMINATION
STRENGTH
STRENGTH
GRADED 0 - 5
0 - NO MOVEMENT
1 - FLICKER
5 - NORMAL STRENGTH
STRENGTH EXAM
SUBTLE WEAKNESS
Pronator drift
Orbiting
Gait evaluation
High steppage
Waddling
Hemiparetic
Shuffling
Turns en bloc
MUSCLE OBSERVATION
ATROPHY
FASCIULATIONS
ABNORMAL MOVEMENTS
TREMOR
REST
INTENTION
CHOREA
ATHETOSIS
ABNORMAL POSTURES
CEREBELLAR FUNCTION
HEEL TO SHIN
GAIT
TANDEM
Romberg Sign
Stand with feet together - assure patient stable - have them close eyes
Measures
Cerebellar function
Proprioception
Vestibular system
REFLEXES
GRADED 0 - 5
0 - ABSENT
2 - NORMAL
3 - ENHANCED
4 - UNSUSTAINED CLONUS
5 - SUSTAINED CLONUS
MSR / DTR
BICEPS
BRACHIORADIALIS
TRICEPS
KNEE
ANKLE
OTHER REFLEXES
BABINSKI
present or absent
HOFMAN’S
JAW JERK
GRASP
SNOUT
SUCK
PALMOMENTAL
TONE
COGWHEELING
CLASP KNIFE
SENSORY EXAM
SENSORY EXAM
VIBRATION
PIN PRICK
TEMPERATURE
GRAPHESTHESIA
STEREOGNOSIS
BAROSTHESIA
TEXTURES
or infections
Glasgow scoring
Posturing
Decorticate
Decerebrate
Progressive
Stimulation
Eye opening
Verbal response
Motor response
Supraorbital pressure
Sternal rub
Glasgow score
Score range
Extubated: 3 – 15
Intubated: 3 – 11T
Clinical presentation
Normal: GCS = 15
Comatose: GCS ≤ 8
Dead: GCS = 3
Moderate: GCS 9 – 12
Severe: GCS ≤ 8
Example report
GCS 9 = E2 V4 M3 at 07:35
Prognosis
Prognosis variability
Injury
Type and location, depth, duration of coma, presence of low blood pressure, oxygen
levels
Current findings
the brain
The patient’s eyes, initially closed, opened to the sound of his name.
Eye opening
3
When asked where he was, the patient said “my shoes to change.”
Verbal response
3
The patient moved all of his fingers and toes when prompted.
Motor response
6
Score
GCS 12 = E3 V3 M6 at 16:34
Moderate