Lab 1: External Anatomy of the CNS What spinal cord levels comprise the brachial plexus?

C5-T1 A 22 y/o male presents following a MVA with the CC of left hand numbness. He is told he has carpal tunnel syndrome. He later develops left biceps weakness and atrophy and weakness in his left hand. Where is his lesion? C6- median nerve symptoms @ thumb side of hand. Biceps reflex C5/C6. A 40 y/o F presents for a check-up. Her left hand is held in and abnormal posture- her 4th and 5th digits are partially flexed and there is atrophy between all metacarpals. She also has (on the left), ptosis and miosis. T1- affects the sympathetic from T1 (miosis/ ptosis) and also the interossei in the hand (and other ulnar innervated muscles) What spinal cord levels comprise the lumbosacral plexus? L2-S2 The sacral spinal cord is most closely associated with what vertebrae? T12-L2 How many spinal nerves are there? 31 pairs of spinal nerves (one pair per segment) At what vertebral level does the spinal cord terminate in an adult? What is the clinical significance of that fact? L2; Spinal roots and nerves of the lower segments must traverse longer distances to reach the appropriate vertebral foramen. (Cervical- roots run horizontally, thoracic- roots descend 2-3 segments, lumbar roots descend several segments. This results in the formation of the cauda equine, which is a bundle of dorsal and ventral roots descending from the lumbar and sacral segments of the spinal cord to the appropriate intervertebral foramina. Because the spinal cord ends at L2, lumbar punctures can be done between L4/L5 in an adult (below conus medullaris). What are the signs and symptoms of an injury to the posterior roots at C5-T1? Posterior roots carry sensory information back to the spinal cord (GSA/GVA). For C5-T1, sensation would be lost on part of the shoulder the upper and lower arm and the handall of the areas that send sensory information to the spinal cord from C5-T1. Motor function in these areas would remain normal.

What are the signs and symptoms of an injury to the anterior roots at C5-T1? An injury to the anterior roots would damage the motor efferants to all muscles supplied by levels C5T1. The patient would have problems raising their arm (deltoid), flexing their arm (bicep/brachialis), extending their arm (tricep), flexing and extending their fingers (forearm flexors (C8) and extensors, abducting and adducting their fingers (T1). Their biceps reflex (C5), brachioradialis (C6) and extensor reflexes (C7) would also be absent or diminished. The would NOT have sensory deficits in the area if their posterior roots remained intact. What are the signs and symptoms of injury to spinal nerves at C5-T1? Both sensory and motor deficits in the regions noted above. Sympathtics may also be affected (T1) ptosis and miosis may be present. How do you test the intergrity of the hypoglossal nerve? Ask the patient to stick out his or her tongue. If there is unilateral damage to the nerve, the tongue will deviate to the side of the lesion due to the unopposed action of the opposing genioglossus muscle. Strength can be tested by asking patient to poke tongue into opposite cheek. What clinical signs would indicate damage to CN X? Dysphagia, hoarseness, sagging palate uvula points to opposite side. Viscera innervated by CN X include pharynx, larynx, foregut, and midgut. Weakness or paralysis of pharyngeal muscles (trouble swallowing), and laryngeal muscles (problems speaking), decreased parasympathetic tone (increased HR, digestive issues, increased respiratory rate), sensation in the throat, meninges and a small area of the external auditory meatus, loss of taste from epiglottis (may not be noticed clinically), decreased baro/chemo receptor function in aortic arch (increased BPmay be transient). What muscle is innervated by CN IX? Stylopharyngeus muscle What nerves traverse the jugular foramen? CN IX, X, XI (Glossopharyngeal, Vagus, Spinal Accessory) What muscle actions are controlled by CN XI? SCM and Trapezius What is the function of the abducens nerve? Lateral rectus muscle, Abduction of the eye

Trace the course of CN VI from the brainstem to the orbit. The abducens nucleus is in the pons. It exits ventrally at the pontomedullary junction. It travels through the cavernous sinus and exits the skull through the superior orbital fissure to reach the lateral rectus muscle. What neurological deficits would most likely be present in patients with a tumor of the choroid plexus at the pontomedullary junction? CN VII motor function: muscles of facial expression, posterior digastrics. Stylohyoid, stapedius. Patients present with Bells Palsy or complete facial paralysis. Other fx: Loss of: taste on anterior 2/3 tongue (corda tympani), tears (PPG to lacrimal), salivation (submandibular) , secretions into nasal cavity, hyperacusis (if VIII not damaged) VIII- hearing loss How would you test for the integrity of the sensory component of CN V? Tell patient to close eyes. Lightly touch one or both side of each of the three divisions of the trigeminal with a piece of cotton and ask patient if they felt anything and where. Can also be done with a pin. The corneal reflex can also be tested. Ask patient to look away and touch cornea at junction with sclera with a piece of cotton. There should be a blink of the eye being tested as well as the other eye. How would you test the motor component of CN V? Look at masseter muscles for asymmetry or concavity. Ask patient to clench jaws and palpate for asymmetry and tone. When jaw is open observe deviation of the mandibledeviation is to weak side. Ask patient to move jaw side to side against resistance. What neurological deficits would be present in a patient with a cerebellar tumor that compresses the facial colliculus? A tumor here would affect the facial nerve (VII) (facial muscle weakness + above) and the abducens (VI) nerve (lateral rectus weakness-cant abduct eye). What are the boundaries of the posterior cranial fossa? Anteriorly: superior boarder temporal bone and dorsum sellae Posteriorly: lesser part of occipital squama Floor: Condylar/basilar occipital bone, foramen magnum What 7 muscles (skeletal and smooth) are innervated by CN III? Levator palpebrae superior, inferior oblique, medial rectus, superior rectus, inferior rectus, spinchter pupillae, ciliary muscles (accomadation)

How would someone with a complete CN IV palsy present? Vertical diplopia, paralysis of superior oblique muscle, diplopia that worsens when looking down and away from affected side. Many people will develop a head tilt away from the affected side. Foramina of Lushka, Cerebral aquaduct, midline foramina of magendy A pinealoma is most likely to compress what structures? If the tumor occludes the cerebral aquaduct obstructive hydrocephalus with intracranial hypertension may occur Pineal gland- melatonin production Superior colliculus may be compressed- problems with upward gaze and pupil abnormalities Cerebellum- hypotonia and intention tremors Habenula Posterior commisure

What is a central herniation and what structures is it likely to affect? A central herniation is a central downward displacement of the brainstem. These may be caused by any lesion that increases intracranial pressure (hydrocephalus). This may affect the abducens nerve CN VI (lateral rectus palsy). A basilar artery. If this becomes more severe central herniation through the tentorial opening may occur resulting in a bilateral uncal herniation. A tonsillar herniation occurs when the cerebellar tonsils herniated downward. In this case, the medulla may become compressed and respiratory arrest, blood pressure instability, and death may result. What embryological landmark is represented by the lamina terminalis? The lamina terminalis is originally the anterior most portion of the wall of the neural tube. It persists as the median strip of the anterior wall of the prosencephalon, which remains relatively unchanged as the cerebral hemispheres grow out of its (prosencephalons) anterior wall. What structures would be most directly compressed by an uncal herniation? CN III (blown pupil and impaired eye movements), cerebral peduncles (hemiplegia), midbrain reticular formation (coma) End of Lab Qs 1. What gross features can be used to determine the anterior and posterior aspects of the spinal cord? Anterior median fissure/spinal artery Anterior funiculis Posterior median sulcus Posteriolateral sulcus (for dorsal rootlets) Posterior funiculus (posterior-3 sulci)

2. What structural features distinguish the a. medulla b. pons c. midbrain? Medulla oblongata Pons Immediately rostral to medulla Anterior aspect is round- walnut/ beer belly Posterior aspect hidden by cerebellum, if removed see floor 4th ventricle Posterior- tegmetum Anterior- basilar pons Abducens exits at junction of medulla and pons CN VI and VIII exit pons near ponto-cerebellar angle Choroid plexus exits from lateral recess of 4th ventrible (CSF) Rostral from CN VI/VIII is middle cerebral peduncle Rostral from peducle CN V exits Begins at level of foramen magnum Anterior median fissure continues from spinal cord On each side of the fissure are the pyramids Pyrimidal decussation- crossover of the pyramidal (corticospinal) tract Lateral to pyramids is a bumpcalled the olive Hypoglossal nerve (CN XII) emerges between the pyramid and olive Groove between olive and pyramid=preolivary fissure Posteriolateral to the olive= postolivary fissure= CN IX and X emerge Posterior aspect- covered by cerebellum, removal exposes floor of 4th ventricle Cerebellar peduncles- where cerebellum attaches Lateral streaks in 4th ventricle= stria medullaris Rhomboid fossa comes to a point- Obex Posterior medial fissure separates R/L Gracile and cuneate fasiculi form posterior columns on each side, capped by gracile (LL) and cuneate tubercles (UL) CN XI travels up from spinal cord and meets with IX and X

Midbrain Transition between brainstem and forebrain Anterior hidden by pons Anterior: cerebral peduncles (substantia nigra/ crus cerebri)carryn info from cortex to brainstem CN III exits between crus cerebri

Posterior: 4 large bumps= tectum (superior and inferior colliculi) o Brachium of inferior colliculus extends toward diencephalon connecting them o Brachium of superior colliculus connects it with lateral geniculate body and optic tract CN IV exits caudal to inferior colliculus Caudal portion of midbrain connected to cerebellum by superior cerebellar peduncles and a thin sheet=anterior medullary velum Ventricles also present in midbrain- anterior to the tectum is the cerebral aquaduct- narrow region/ commonly blocked

3. What cranial nerves emerge from: a. medulla- CN IX, X, XII b. pontomedullary junction- VI b. pontomedullary angle= VII, VIII c. basilar pons- V d. anterior midbrain- CN III e. posterior midbrain- CN IV f. diencephalon- CN II g. telencephalon- CN I With what level of the CNS is the optic tract associated? Optic nerve is an outgrowth of the diencephalon. With what level of the CNS is the olfactory tract associated? Olfactory bulb is a continuation of the telencephalon. What four regions comprise the diencephalon? Thalamus Hypothalamus Epithalamus Subthalamus

Name the lobes of the cerebellum. Vermis 2 lateral hemispheres

Name the lobes of the cerebral cortex. Frontal Parietal Temporal Occipital Insular Limbic

The primary motor cortex is found in what lobe of the fontal cortex? The primary motor cortex is found in the frontal lobe. A tumor in the pontocerebellar angle will most likely affect what cranial nerves? CN VII, CN VIII A tumor in the interpendicular fossa will affect which cranial N? CN III Compression of the tectum by a pineal tumor will most likely affect what cranial N? CN IV (exits posterior midbrain) What structures boarder the third ventricle? Diencephalon boarders third ventricle The pineal gland is part of which brain region? Diencephelon Which cranial nerve exits between the olive and the pyramid? CN XII A stroke involving the postcentral gyrus will affect what modalities? Somatosensory What gyri are associated with the Frontal lobe? Superior gyri Middle gyri Inferior gyri (pars orbitalis-rostral, pars triangularis-apex down, pars opercularis)This gyrus corresponds to Brocas motor speech area (usually left dominant hemisphere).

Case 1: Page 21 What is papilledema and what does it indicate? Papilledema is swelling of the optic disc; it indicates increased intracranial pressure. What cranial nerves are affected? VII paralysis of muscles on the right side of face, absence of corneal reflex (out by CN VII) VIII- tinnitus, loss of hearing What other cranial nerve signs would most likely be present? CN VII: On the right side: Left dry eye, dry nose, decreased salivation, hyperacuesis, decreased taste on anterior 2/3 of tongue What regions of the brain would be compressed by this mass? Medulla, pons, cerebellum