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 BASIC ANATOMY AND PHYSIOLOGY OF THE BRAIN AND
THE NERVOUS SYSTEM








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þThe primary functions of the human nervous
system are to monitor, integrate (process) and
respond to information inside and outside the
body.
þThe brain consists of soft, delicate, ÷ ÷

 ÷
 
.
THE BLOOD SUPPLY TO THE BRAIN
The major arteries are :
ANTERIOR CEREBRAL ARTERIES
ANTERIOR COMMUNICATING ARTERY
INTERNAL CAROTID ARTERIES
MIDDLE CEREBRAL ARTERIES
ANTERIOR CHOROIDAL ARTERIES
POSTERIOR COMMUNICATING
ARTERIES
POSTERIOR CEREBRAL ARTERIES
SUPERIOR CEREBELLAR ARTERIES
BASILAR ARTERY
VERTEBRAL ARTERIES

þThe anterior and posterior

cerebral arteries and the O
 
and single  

 

form the    
,
 THE MENINGES
‡The brain is wrapped in O
OO

 
‡The innermost O  O
membrane contains the blood vessels.
‡The brain is nourished and cushioned by cerebrospinal fluid, which is contained between
O O  O
and the
  O
.
‡The outermost ˜

membrane lines the inside of the skull and is comparatively
thick and tough. , it encloses the
  O
˜O  O

Reproduced from [Marieb 1991])

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  in the assessment of patients with serious head injury. It
revolutionized management when it was introduced and remains the investigation of
choice even following the advent of MRI, due both to the ease of monitoring of injured
patients and the better demonstration of fresh bleeding and bony injury.
(andrew@radiology.co.uk). With multi-slice spiral CT scanners short scan times are
possible,e.g. the scan time for a complete unconstrasted brain CT is about 9-10
seconds.

þ The spiral CT scanner has the ability to produce  

 
˜˜


during post processing, with actual scanning taking place in one plane only.

þOnly one dose of radiation is necessary and specialized software packages are used
to manipulate the acquired information as desired to best demonstrate the
patho/physiology.

þSpiral CT can also be used to demonstrate   bleeds and also allows for m


 to demonstrate abnormalities of the blood vessels , for example
aneurysms and arteriovenous malformations.

þ If a CT is indicated, skull x-rays are not necessary and may only cause delay.
 BRAIN HAEMORRHAGES
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 Epidural/ Extradural Haemorrhages (Haematoma)
‡Õ
 or Õ 
 
is caused by TBI, in which a buildup of blood occurs
between the  
and the skull. The dura mater also covers the spine, so epidural
bleeds may also occur in the spinal column. EDH commonly results from acceleration-
deceleration trauma and transverse forces. EDHs are extra-axial bleeds.

‡An EDH occurs when there is a rupture of a blood vessel, usually an artery, but can be a vein.
The affected vessels are often torn by skull fractures. Venous epidural bleeds are usually due
to shearing injury from rotational or linear forces, caused when tissues of different densities
slide over one another.

‡EDH is potentially deadly because the buildup of blood may increase pressure in the
intracranial space (



 

), and compress delicate brain tissue. If the
patient is not treated with prompt surgical intervention, death is likely to follow.

‡The bleeding is usually acute and of high attenuation and there is often significant mass effect
with  

 of the ipsilateral lateral ventricle and 

 of the opposite lateral
ventricle due to obstruction of the 
(interventricular foramen). The basal
cisterns may be effaced.

‡Epidural haematoma is usually found on the same side of the brain that was impacted by the
blow, but on very rare occasions it can be due to a contrecoup injury.
 Ú Ú

Ên CT scans, epidural haemorrhages usually appear biconvex in shape, with a

well defined margin, because their expansion stops at skull's sutures where the
dura mater is tightly attached to the skull. Thus they expand inward toward the
brain rather than along the inside of the skull. The lens like shape of the
haematoma leads the appearance of these bleeds to be called "lentiform".
 Examples

ïig 1.This is the typical appearance and location of an acute ïig 2. This example shows a more unusual, lower location. Note also
extradural haematoma. the gas within the haematoma - this indicates a basal skull fracture or,
Note the high density of the haematoma. Slight midline shift is as in this case, it is post surgical. Note also the dilated lateral ventricle
present on the opposite side.

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ïig 1 ïig 2
 fig 4
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‡Fig. 3 Right frontal acute EDH with an air bubble, and midline shift.
‡Fig. 4 shows a 3 D CT image demonstrating skull fractures.
On March 18, 2009, actress Natasha Richardson died as a result of an
epidural hematoma sustained two days earlier while skiing in Mont-
Tremblant, Québec, Canada. Like many patients, she had a lucid
interval where she did not exhibit any symptoms until approximately
an hour after her fall when she complained of a headache. By the
time she reached medical care, the hematoma had already caused
significant damage.

Extracts taken from:

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‡As with an Õ an acute  is associated with high mortality and morbidity

rates and is therefore treated as an emergency. Differentiating the two is
therefore not so important in the acute situation. SDH presents in a similar
fashion to the Õ , and can have equally severe consequences due to mass
effect, requiring urgent surgery.

‡An 
 is a rapidly clotting blood collection below the inner layer of the
 but external to the brain and  
 membrane,(extra-axial) often
from ruptured veins crossing this potential space.

‡Two further stages, 

and  
 , may develop with untreated
acute  . Each type has distinctly different clinical, pathological, and
imaging characteristics.
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‡ The blood is again of high attenuation, but may spread more widely in the
subdural space, with a 


 appearance and a more




margin on CT.
 EXAMPLES Oï SUBDURAL HAEMATOMAS

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oChronic SDHS are probably due to trauma. Symptoms are

vague and often develop slowly with a gradual depression or
fluctuation of consciousness.

oWhile acute SDH have increased attenuation, this

decreases with time, becoming  ÷  after a week or so,
and  ÷  thereafter, therefore chronic subdurals are
often hypodense crescentic collections, often with mass
effect.

Ú oExpansion due to osmosis may tear veins further leading to

recurrent bleeds; hyperdense red blood cells from fresh
bleeding may layer posteriorly, and complex septated
collections may develop.

oIsodense collections may be better demonstrated after

intravenous contrast as the density will then be less than that
of the brain. However this is rarely a problem since the
introduction of Multi-slice CT scanners
 This haematoma is not so old and is
almost isodense. It is probably about
one to two weeks old. This could be
missed on older scanners with poorer
quality images, but this is rarely a
problem now.

Note the crescentic low density

collection typical of a chronic
subdural haematoma, with
associated midline shift.

Chronic(hypodense)subdural

This is the same case, higher up.

Note the dilated opposite lateral
ventricle.
Midline shift often distorts the ïoramen
of Munro of the opposite side causing
obstruction.
 Ú m  ÕÚÚ Õ 
extracts from Ë 
‡A potentially life-threatening condition where blood leaks out of blood vessels over
the surface of the brain. The classic symptom of subarachnoid hemorrhage is a
³thunderclap headache´.

‡The bleeding occurs in the arteries that run underneath the  
 membrane,
thereby damaging the brain tissue. The reduction of blood supply can also cause
further brain damage, leading to disruption or loss of brain function and possibly
death.

‡ SAH,S are classified into two general categories:


  - brain injury that might be sustained in an accident or a fall.
M ÷÷
 -occur with little or no warning and frequently arise
because of ruptured aneurysms or blood vessel abnormalities.

‡Spontaneous SAH are often due to an 

 which bursts. 

!


 ( ), which are abnormal interfaces between arteries and veins,
may also rupture and release blood into the subarachnoid space. Both conditions are
associated with weak spots in the walls of blood vesselsĺaccounts for 60% of all
spontaneous SAH.
‡The immediate danger due to SAH, is ischemia. Ischemia refers to tissue damage
caused by restricted or blocked blood flow. The areas of the brain that do not
receive adequate blood and oxygen can suffer irreparable injury, leading to
permanent brain damage or Õ  . Anyone surviving the initial hemorrhage is
susceptible to a number of complications in the following hours, days, and weeks.

‡The most common complications are 




 

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, can lead to further bleeding from damaged blood
vessels; a complication associated with a 70% fatality rate.

‡ ,, is a principal cause of secondary ischemia. As the blood vessels

become narrower, blood flow in the brain becomes increasingly restricted.
Approximately one third of spontaneous subarachnoid hemorrhages and 30-60% of
traumatic bleeds are followed by vasospasm.

‡ 
 due to restricted circulation of cerebrospinal fluid, follows
approximately 15% of subarachnoid hemorrhages. Because cerebrospinal fluid
cannot drain properly, pressure accumulates on the brain, possibly prompting further
ischemic complications.
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‡ m  be caused by brain trauma, or it can occur spontaneously.

‡A m is an


 
; that is, it occurs within the brain tissue rather than
outside of it.

‡ Intracerebral bleeds are the second most common cause of stroke. High blood pressure
raises the risk of spontaneous intracerebral hemorrhage.

‡ 
  bleeds due to trauma are usually due to



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can also be due to 


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‡The risk of death from an intraparenchymal bleed in traumatic brain injury is especially high
when the injury occurs in the 

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 are
almost always fatal, because they cause damage to the vagus nerve, which plays an
important role in 

 and breathing. This kind of haemorrhage can also occur
in the 
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 lobes when due to
head injury, and sometimes in the 


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. HAEMORRHAGIC CONTUSIONS
‡These occur due to stretching and shearing injuries, often
due to impaction of the brain against the skull on the side
opposite to the injury.
‡Thus they may be seen directly opposite the impact
site, subcutaneous haematoma, fracture, or
extradural haematoma (contre coup injury).

There is a focal area of haemorrhagic contusion in the right

frontal lobe, with surrounding low density due to infarction
or oedema. This is a frequent location for a contre-coup
injury following a blow to the back of the head.
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‡Multiple contusions may be present throughout the cerebral
hemispheres.
‡They are often very small and visible at the grey/white matter
interface.
‡They are due to a shearing injury with rupture of small
intracerebral vessels, and in a comatose patient with no other
obvious cause they imply a severe diffuse brain injury with a poor
prognosis.
‡Larger haemorrhages may occur in severe trauma, and they may
not be apparent on a scan performed immediately after the injury,
only becoming prominent after a day or two. MRI is more sensitive
to diffuse brain injury, particularly in the absence of haemorrhage.

Ú Ú Ú

This image demonstrates a small petechial

haemorrhage in a typical location at the grey-white
matter interface (arrow).
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CT ANGIÊGRAPHY ÊF THE VESSELS ÊF THE BRAIN
SHÊWING ANEURYSMS
RECÊNSTRUCTED BY RADIÊLÊGIST DR S MURPHY
SÊME ACTIVITIES TÊ STAY AWAY FRÊM
 REïERENCES
1. Ben Pansky,Ph.D.,M.D.1975. ͞ Review of gross Anatomy.͟
2. Retrieved from "http://en.wikipedia.org/wiki/Cerebral_hemorrhage"
3. University of Vermont College of Medicine. "Neuropathology: Trauma to
the CNS." Accessed through web archive. Retrieved on February 6, 2007.
4. Brain injury victims can seem OK, symptoms delayed, Associated Press, March
19, 2009 http://www.biomedcentral.com/1471-2377/7/1
l
MedlinePlus - Intracerebral hemorrhage Update Date: 7/14/2006. Updated by:
J.A. Lee, M.D.
'
Downie A. 2001. "Tutorial: CT in Head Trauma". Retrieved on ïebruary 6, 2007.
7. Wagner AL. 2006. "Subdural Hematoma." Emedicine.com. Retrieved on
ïebruary 6, 2007.
8. Shepherd S. 2004. "Head Trauma." Emedicine.com. Retrieved on ïebruary 6,
2007
9. http://www.neurologyindia.com/article.asp?issn=0028.http://en.wikipedia.org/
wiki/Epidural_hematoma, Categories: Neurotrauma | Neurology.
 We've made great medical progress in the last
generation. What used to be merely an itch is
now an allergy.
 

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