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1. The Skull
 Key facts:
1. The skull is formed of separate bones (6 single and 8 paired). Many of these bones
articulate with one another at serrated edges called sutures.
2. The exterior of the skull is studied in five views, each is called norma :
 From above: Norma verticalis.
 From behind: Norma occipitalis.
 From in front: Norma frontalis.
 From the side: Norma lateralis.
 From below: Norma basalis.
3. The interior of the skull is studied in two items:
 The internal surface of the skull cap.
 Norma basalis interna.

Norma Verticalis:
This view presents:
4 bones:
 The frontal bone.
 The two parietal bones.
 The occipital bone.
3 sutures:
 The coronal suture.
 The sagittal suture.
 The lambdoid suture.
2 meeting points:
 The bregma: is the meeting of the coronal and sagittal sutures. It is the site of
the membrane-filled rhomboidal area called the anterior fontanelle which
exists during fetal life. It usually closes 1.5 - 2 years after birth.
 The lambda: is the meeting of the lambdoid and sagittal sutures. It is the site of
a membrane-filled triangular area, called the posterior fontanelle which exists
during fetal life. It usually closes 3 - 6 months after birth.
2 parietal foramina:
 On each side of the sagittal suture, 3.5 cm anterior to the lambda.

Norma Occipitalis:
This view presents:
Bones: Squamous part of the occipital bone forms the main (middle) part of this view.
Special Features :
 External occipital protuberance.
 External occipital crest.

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 Two superior nucheal lines
 Two inferior nucheal lines.
.

Norma verticalis

Norma occipitalis

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Norma Frontalis:
This view presents:
Bones:
 The frontal bone with its maxillary and zygomatic processes.
 The two nasal bones.
 The zygomatic bone with its maxillary and frontal processes.
 The maxilla with its zygomatic, frontal and alveolar processes.

Special features:
A. The frontal bone presents:
 The superciliary arch is an elevation above the medial ½ of the superior
orbital margin.
 The glabella: Is a median elevation between the two superciliary arches.
 The nasion: Is the meeting point between the frontal bone and the two nasal
bones.
 It is pierced by the supraorbital foramen.
B. The nasal bones: Form the bridge of the nose.
C. Zygomatic bone: Is pierced by zygomatico-facial foramen.
D. The maxillary bone: It is pierced by the infraorbital foramen.

Norma frontalis

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Norma Lateralis:
1. The Temporal Line:
- Starts anteriorly at the zygomatic process of the frontal bone. It arches upwards and
backwards and divides into two lines: the superior and inferior temporal lines.
- The superior line fades away. The inferior temporal line curves down and becomes
prominent, forming the supramastoid crest.
2. The Temporal Fossa: Is bounded by:
- Superiorly: By the superior temporal line.
- Inferiorly: By the zygomatic arch.
- Medially: (floor of the fossa): Presents the H-shaped suture called the pterion formed
by meeting of 4 bones: The frontal, parietal, squamous
temporal and the greater wing of the sphenoid bones
- The pterion lies 3.5 cm behind the z ygomatic process of the frontal bone and about
4 cm above the zygomatic arch. It overlies the intracranial course of the frontal
branch of the middle meningeal A.
3. The Zygomatic Arch (Zygoma):
- It is formed by the temporal process of the zygomatic bone and the zygomatic process
of temporal bone.
4. The Infratemporal Fossa (described in the corresponding fossa).
5. The Pterygo-palatine Fossa (described in the corresponding fossa).
6. The External Auditory Meatus
7. The Mastoid Part of the temporal bone: Posterior to external auditory meatus and its
lower part is pointed and called the mastoid process

Norma lateralis

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Norma Basalis:
A. The Anterior Part of Normal Basalis:
- It includes the alveolar arch and the hard palate which is formed of:
 Anteriorly: By the palatine processes of maxillae.
 Posteriorly: By the horizontal plates of the palatine bones.
Special Features:
 Behind the incisors, it presents the incisive fossa, pierced by incisive foramina.
 Its posterior border has the posterior nasal spine
 Just in front of the posterior border, there is palatine crest.

Norma basalis

B. The Middle Part of Normal Basalis:

-Its median part consists of:
(1) Basilar part of the occipital bone. It bears the pharyngeal tubercle.
-Its lateral part consists of:
(2) Pterygoid process of the sphenoid bone:
- It has medial and lateral pterygoid plates separated by the pterygoid fossa.

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- The medial pterygoid plate divides superiorly to enclose the scaphoid fossa.
(3) The infratemporal surface of the greater wing of sphenoid: It has foramen ovale
and foramen spinosum and spine of sphenoid.
(3) The petrous part of the temporal bone is pierced by the carotid foramen.
(4) The mandibular fossa: It is bounded anteriorly by the articular eminence (tubercle).
(5) The tympanic plate: It is behind the mandibular fossa.
(6) The styloid process.
(7) Stylomastoid foramen.
C. The Posterior Part of Norma Basalis:
- This part consists mainly of the occipital bone and the two mastoid processes of the
two temporal bones.
(1) The Occipital Bone: (Presents 3 parts and 3 foramina)
- It presents the foramen magnum, dividing the occipital bone into three parts:
 Basilar part: In front of F. magnum.
 Lateral condylar part: Lateral to F. magnum.
 Squamous part: Behind the F. magnum.
- On each side, the anterolateral margin of F. magnum is overlapped by the occipital
condyle which is related to three foramina:
 Anterior condylar (hypoglossal) canal in front of the condyle.
 Jugular foramen: anterolateral to the condyle.
 Posterior condylar canal: behind the condyle.
(2) The mastoid process of the temporal bone:
- Its medial side presents the mastoid (or digastric notch).

The Internal Surface of the Skull Cap:

- It includes internal surface of 4 bones: Frontal, parietal bones and the upper part of the
squamous occipital bone. It presents the frontal
crest and sagittal sulcus.

Norma Basalis Interna:

It is divided into anterior, middle and posterior fossae.
A. Anterior Cranial Fossa:
Its floor is formed as follows:
 The anterior part is formed by the orbital plates of the frontal bone
with the cribriform plate of ethmoid in between.
 The posterior part is formed by the lesser wings of the sphenoid
bone with the anterior part of the body of the sphenoid in between.

Special Features:
1. The cribriform plate presents crista galli and foramen caecum.
2. The lesser wing has a medial projection → anterior clinoid process.

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B. The Middle Cranial Fossa:
- Its median part is formed by the body of the sphenoid which has the
following features:
 The optic groove (= sulcus chiasmaticus), between the two optic foramina.
 Sella turcica: Has tuberculum sellae, hypophyseal fossa and
dorsum sellae which projects →posterior clinoid processes.
- Its lateral part is floored by the following bones:
 Greater wing of sphenoid pierced by F. rotundum, ovale and spinosum.
 Anterior surface of the petrous temporal bone.
 Squamous temporal bone.

C. The Posterior Cranial Fossa:

Special Features:
 Foramen magnum.
 Internal auditory meatus.
 Jugular foramen.
 Hypoglossal canal.
 Posterior condylar canal.
 Internal occipital crest.
 Groove for the transverse sinus.
 S-shaped groove for the sigmoid sinus.

Intracranial cavity

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2. The Mandible:
- It has body and two rami.
A. The Body of the Mandible:
It has 2 borders (upper, lower) and 2 surfaces (outer and inner).
(1) The upper border = alveolar border, bears 16 sockets for the permanent teeth.
(2) The lower border = base of the mandible. Near the middle line, it has a digastric fossa.
(3) The outer surface: Has following features:
 Symphysis menti: Is a median faint ridge.
 Mental protuberanc: At the lower end of the symphysis menti.
 Mental foramen.
 Oblique line.
(4) The inner surface: Has the following features:
 The upper and lower genial tubercles.
 Mylohyoid line
 Sublingual fossa: Is above mylohyoid line.
 Submandibular fossa: Is below mylohyoid line.
 Lower part of the mylohyoid groove extends below
the posterior part of the mylohyoid line.

B. The Ramus of the Mandible:

It has 2 surfaces (lateral, medial) and 4 borders (anterior, posterior, upper and lower).
(1) The lateral surface: Is flat and rough.
(2) The medial surface: Has mandibular foramen and lingula and mylohyoid groove.
(3) The anterior border: Is continuous with the oblique line on the lateral surface of the body.
(4) The posterior border: Is related to the parotid gland.
(5) The upper border: It has 2 processes: An anterior (coronoid) process and a posterior
(condyloid) process separated by the
mandibular notch.
(6) The lower border: Joins the posterior border at the angle of the mandible.

Mandible in Relation to Age:

Infants, children Adults Old age
Angle of the mandible 140 degree or more 110 140
Mental foramen Near the lower Midway between the Close to the upper
border upper and lower border.
borders.

Nerves Related to Mandible:

1. Lingual N.: Below the the 3rd molar tooth.
2. Inferior alveolar N.: Enters the mandibular foramen.
3. Mylohyoid N.: Runs in the mylohyoid groove.
4. Mental N.: Escapes through the mental F.
5. Auriculotemporal N.: Runs deep to neck of the mandible.
6. Masseteric N.: Passes laterally through the mandibular notch
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Mandible

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3. The Scalp:
Definition: The soft tissue which covers
the cranial vault of the skull.
(slide 2-10)

Extent: Scalp has the following extent:

(slide 12)
- Anteriorly:
Supraorbital margins
(eyebrows).
- Posteriorly:
External occipital protuberance
and the superior nucheal line.
- On either side:
Superior temporal line. Extent of the scalp

The Scalp has 5 Layers:

(1) Skin (S):
- It is thick, hairy, and adherent to the epicranial aponeurosis (3rd layer).
- Being rich in sebaceous glands, the scalp is a common site for sebaceous cysts and
seborrhea.
(2) Subcutaneous connective tissue (C):
- It is fibrous, dense and connects the skin (layer 1) with the epicranial aponeurosis
(layer 3).
- It is rich in blood vessels and nerves.
(3) Epicranial aponeurosis with Occipitofrontalis muscle (A):
A. Epicranial aponeurosis:
- It is a flat tendon on the cranial vault.
- It is adherent to the first and second layers, so they form a unit moving on the
pericranium (surgical scalp).
- Anteriorly: It receives insertion of the frontal bellies of the occipitofrontalis muscle.
- Posteriorly: It receives insertion of the occipital bellies of the occipitofrontalis
and is attached to the external occipital protuberance and superior
nucheal lines.
- On either side, it is attached to the superior temporal line.

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B. Occipitofrontalis muscle:
- It has two frontal and two occipital bellies connected by the epicranial aponeurosis.
Frontal bellies Occipital bellies
- Longer, wider, meet in the middle line. - Shorter, narrower, separated by the posterior
extension of the epicranial aponeurosis.
- Has no bony attachment being attached to the - Has bony attachment, each belly arises
subcutaneous tissue in the region of eyebrows. from the superior nucheal line. (lateral ⅔)
- N. supply: Temporal branch of - N. supply: Posterior auricular branch
facial nerve. of facial N.

Actions: It produces transverse wrinkles in the skin of forehead.

(4) Loose areolar tissue: (subaponeurotic space) (L):

- It is the plane of movement for the first three layers of scalp.
- It is the plane of scalping: the fused 3 layers are avulsed here.
- It is the dangerous layer of the scalp; it is traversed by emissary veins which may
spread infections from the second layer of the scalp to the intracranial venous sinuses
 thrombosis.
- Hemorrhage here gravitates down to the upper eyelid causing black eye.

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(5) Pericranium: (= Periosteum of the skull) (P):

Occipitofrontalis muscle and its aponeurosis

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The Scalp has 10 Nerves on Each side:

A. Anterior half of scalp: supplied by 5 nerves (4 sensory and 1 motor) :
 Sensory: By 4 branches from the trigeminal N.
 Motor: From the facial N.
1. Supratrochlear N. (V1)  skin of the forehead.
2. Supraorbital N. (V1)  skin of the forehead up to the vertex of scalp.
3. Zygomaticotemporal (V2)  hairless area of the temple + scalp.
4. Auriculotemporal (V3)  hairy area of the temple + scalp.
5. Temporal branch of facial (motor)  frontal belly of occipitofrontalis muscle.

B. Posterior half of the scalp: (supplied by 5 nerves; 4 sensory and 1 motor):

 Sensory: By 4 branches from the cervical nerves (2 from the ventral rami and
2 from the dorsal rami).
 Motor: From the facial N.
1. Great auricular N. (C2,3) from the cervical plexus  skin over mastoid process.
2. Lesser occipital N. (C2) from the cervical plexus  scalp behind the auricle.
3. Greater occipital N. (C2 dorsal ramus) supplies the occipital scalp up to the vertex.
4. Third occipital N. (C3 dorsal ramus) supplies skin of the lower occipital region.
5. Posterior auricular branch of facial N. (motor)  occipital belly of occipito-frontalis.

Nerves of the scalp

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The Scalp has 5 arteries:
Each side of the scalp is supplied by 5 arteries: - 3 in front and 2 behind the auricle.
A. Anterior 1/2 of scalp is supplied by:
1. Supratrochlear A. (from ophthalmic A.)  skin of the forehead.
2. Supraorbital A. (from ophthalmic A.)  skin of the forehead and scalp up to the
vertex.
3. Superficial temporal A.  skin of temple and side of the scalp.
B. Posterior 1/2 of the scalp is supplied by:
4. Posterior auricular A.  scalp behind the ear.
5. Occipital A.  back of scalp up to the vertex.
 Branches (1) and (2) are derived from ophthalmic A. which is a branch of
ICA.
 Branches (3), (4), and (5) are branches of ECA.

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The Scalp has 5 veins:

The venous return of scalp accompanies that of the face:
- Supratrochlear and supraorbital veins unite at the medial angle of the eye  facial V.
(ant. facial V.). Its upper segment is usually named the angular vein.
- Superficial temporal V. enters the parotid gland to unite within it with the maxillary V.
to form  retromandibular V. (= post. facial V.) which divides into 2 divisions:
anterior and posterior.
- The anterior division of retromandibular vein unites with the anterior facial vein 
common facial V. which joins IJV.
- The posterior division (of retromandibular V.) unites with posterior auricular V. to
form external jugular V. which joins the subclavian vein.
- Occipital vein ends in suboccipital venous plexus in the back of the neck.

Clinical Anatomy:
-Infections in the scalp may spread to intracranial venous sinuses through 2 emissary veins:
1. Parietal emissary vein to superior saggital venous sinus  thrombosis of that sinus.
2. Mastoid emissary vein to sigmoid venous sinus  thrombosis of that sinus.

Lymphatic Drainage of the Scalp:

- Anterior ½  preauricular (parotid) lymph nodes.
- Posterior ½  occipital lymph nodes and mastoid lymph nodes.

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4. The Face
Extent of the Face:
 Superiorly: The hair line.
 Inferiorly: The lower borders of chin and the mandible.
 On each side: Auricle.
 The forehead is common to the face and scalp.

Superficial Fascia: Contains:

 Facial muscles
 Vessels and nerves
 Small amount of fat specially developed in cheeks of infants.

Deep Fascia: Is absent in most of the face (to allow facial expressions).

Muscles of the Face:

 Key facts 
1. Muscles of the face have the following common features.
 They arise from bones or subcutaneous tissue
 They are innervated by the facial N.
2. Modiolus of the face:
- It is a dense, compact, mobile fibromuscular mass, lying 1.25 cm from the angle of
the mouth. It provides attachment for many muscles of the face.

1) Orbicularis Oculi: .
It has 3 parts:
● Orbital part: Its fibers arise from the medial palpebral ligament (M.P.L) and adjacent
bony processes. The fibers form complete loops around the orbital
opening and return to the M.P.L without lateral bony attachment.
● Palpebral part: Arises from the M.P.L and adjacent bones and runs laterally in the
eyelids and insert laterally in the lateral palpebral raphe.
● Lacrimal part: Arises from the posterior lacrimal crest and is attached to the lacrimal
sac.
Actions:
- Orbital part: closes to the eye tightly to protect the eye as in exposure to strong
light.
- Palpebral part: closes the eye gently as in sleep and in blinking reflex to spread
tears over the avascular cornea preventing its dryness.
- Lacrimal part: widens the lacrimal sac to increase flow of tears.

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2) Orbicularis Oris : .
- Formed of circular muscle loops inside the lips, around the mouth which are attached
laterally to the modiolus.
- Actions: Orbicularis oris is used in speech and whistling.

3) Buccinator :
-It is the muscle of the cheek and lips.
Attachments:
 The upper fibers arise from the maxilla opposite the molar teeth. These fibers pass
straight to the upper lip.
 The lower fibers arise from the mandible opposite the molar teeth. These fibers pass
straight to the lower lip.
 The middle fibers: arise from the pterygomandibular raphe and decussate at the
modiolus before passing to the lips.
Actions:
 It compresses the cheek against the teeth, so it prevents accumulation of food in the
vestibule of mouth.
 It expels air as in blowing the mouth (buccinator = trumpeter).
 Paralysis of the muscle leads to accumulation of food in the vestibule of the mouth.

N.B: Pterygomandibular raphe is a fibrous band which extends from the tip of the pterygoid
hamulus to the posterior end of the mylohyoid line of the mandible

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Orbicularis oculi muscle

Buccinator muscle

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Sensory Nerve Supply of the Face:

-The skin of the face is divided into 3 main zones meeting at lateral angles of the eye and
mouth. These zones (upper, middle, lower) are supplied by V1, V2, V3 divisions of the
trigeminal. The area over the mandibular angle is supplied by cervical plexus.
Nerve Distribution
A. Ophthalmic division:
(gives 5 branches):
1- supratrochlear N. - Skin of the forehead up to the hair line.
2- Supraorbital N. - Skin of the forehead and skin of the scalp up to
its vertex.
3- Palpebral N. - Skin of the upper eyelid.
4- Infratrochlear N. - Skin of the upper eyelid and skin over the
nasal bone.
5- External nasal N. - Skin over middle of the nose down to its tip.
B. Maxillary Division:
(gives 3 branches)
6- Zygomaticofacial N. - Skin over the zygomatic bone.
7- Zygomaticotemporal N. - Non hairy area of the temple.
8- Infraorbital N. (Gives 3 a. Palbebral branch  lower eyelid.
branches in the face) b. Nasal branch  side and ala of the nose.
c. Superior labial branch  upper lip.
C. Mandibular division (gives 3
branches):
9- Auriculotemporal N. - Hairy area of the temple.
10- Buccal N. - Skin of the cheek, below the zygomatic arch.
11- Mental N. - Skin of the chin, lower lip.
D. Cervical plexus:
12- Great auricular N. (C2, 3) - Skin over the angle of the mandible

Facial nerve

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Motor Nerve Supply of the Face:

 All muscles of the face are supplied by the facial N. (7th cranial).
 The 5 branches of the facial N. appear in the face beneath the anterior border of the
parotid gland.
 These branches are temporal, zygomatic, buccal, marginal mandibular, and cervical.
The detailed distribution of these branches would be discussed with the facial N.

Sensory nerves of the face

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Arterial Blood Supply of the Face:

The face is mainly supplied by the facial A., a branch of ECA.

The Facial Artery:

 It enters the face by crossing round the base of the mandible at the antero-inferior
angle of the masseter muscle.
 It runs upwards ½ inch lateral to the angle of the mouth. Then, close to the side of the
nose up to the medial angle of the eye (here, it is named angular A.)

Branches in the Face:

1. Inferior labial  lower lip.
2. Superior labial  upper lip.
3. Lateral nasal  ala and dorsum of the nose.
4. Terminal angular  lacrimal sac.
5. Unnamed muscular branches  adjacent muscles.

N.B.: Each branch anastomoses with the contralateral one.

Facial artery

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Venous Drainage and its Clinical Anatomy :
- Veins of the face drain with those of scalp :
- Veins of face are connected to the cavernous sinus through 2 routes:
 Direct route: A communication is present between facial vein and superior
ophthalmic vein which drains to cavernous sinus.
 Indirect route: Facial vein is connected to pterygoid venous plexus by deep facial
vein. The pterygoid venous plexus in turn is connected to cavernous sinus by
emissary veins.
- Dangerous area of the face: → It is the  which includes nose and upper lip. Infections
in this triangular area will lead to cavernous sinus
thrombosis.

Veins of the face and scalp

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Lymph Drainage of the Face:

 The area of the face lateral to the facial vessels→ parotid lymph nodes.
 The area medial to the facial vessels→ submandibular lymph nodes except the central
parts of the lower lip and the chin, which drain to the submental lymph nodes.

Lymph drainage of face and scalp

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5. Skin, Fasciae & Superficial Veins of the Neck:

1. Subdivisions of the side of the neck:

- The side of the neck is divided by the obliquely set sternocleidomastoid muscle into
posterior and anterior triangles.

2. Main topics in the superficial dissection of the neck:

 Skin and fasciae of the neck.
 Posterior triangle (and sternomastoid).
 Anterior triangle.

Superficial Fascia contains:

1. A subcutaneous muscle called the platysma.
2. The superficial venous system of the neck.

Platysma:
- Origin: From the fascia covering pectoralis major and deltoid muscles.
- Insertion: → lower border of the mandible, lower lip and modiolus.
- N. Supply: cervical branch of the facial N.
- Actions:
 It draws down the lower lip and angle of the mouth.
 It is associated with the expression of horror and surprise.

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Superficial Veins of the Neck:
1) Anterior Jugular Vein:
 Starts in the submental triangle from a submental venous plexus and descends
downwards (in the superficial fascia) 1 cm from the midline.
 About 1 inch above the sternum, it pierces investing fascia and turns laterally deep to
sternomastoid, to join the external jugular V.
 It is connected to the opposite one by the jugular arch which lies anterior to the
trachea.

2) External Jugular Vein:

 It is formed by union of the posterior division of the posterior facial V. and the
posterior auricular V.
 It descends superficial to sternomastoid to reach the lower part of the posterior
triangle, 1 inch above the clavicle; it pierces the investing fascia to join the
subclavian V.
 Tributaries: anterior jugular, transverse cervical and suprascapular veins.

Superficial veins of the neck

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6. Posterior Triangle of the Neck

Boundaries of the Posterior Triangle :
1. Anteriorly: the posterior border of the sternocleidomastoid muscle.
2. Posteriorly: the anterior border of the trapezius muscle.
3. Base: the intermediate 1/3 of the clavicle.
4. Apex:meeting of sternomastoid and trapezius muscles.
5. Roof: skin, superficial fascia and the investing layer of the deep cervical fascia.
6. Floor: scalenus medius, levator scapulae, splenius capitis and a small part of semispinalis
capitis, all are covered by the prevertebral fascia.

Boundaries of the posterior triangle

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Nerves in posterior triangle

Contents of the Posterior Triangle :

A. Nerves:
1) The spinal accessory N. (C1 - C5 spinal segments):
 It appears above the midpoint of the posterior border of sternomastoid.
 It descends posteroinferiorly embedded in the fascial roof of the triangle to end
in the deep surface of trapezius.
 It is the only motor nerve supply to sternomastoid and trapezius muscles.

2) The Four Cutaneous Branches of the Cervical Plexus:

- All arise from the cervical plexus.
- All appear at the middle of the posterior border of sternomastoid.
- All pierce the investing fascia of the roof to reach skin.
- These 4 nerves are:
-Lesser occipital N. (C2): Ascends on the posterior border of sternomastoid, to
supply upper 1/3 of medial surface of the auricle and
scalp behind the auricle.
-Great auricular N. (C2, 3): It crosses sternomastoid towards the parotid gland. Its
branches supply:
 Skin over angle of the mandible.
 Lower ⅓ of the lateral surface and lower ⅔ of
the medial surface of the auricle.
 Scalp over the mastoid process.
-Transverse cervical N. (C2, 3): → skin overlying the anterior triangle.
-Supraclavicular nerves (C3, C4): → skin on front of the chest down to the level
of sternal angle and over the upper 1/2 of the
deltoid muscle.
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3) The First and Second Stages of the Brachial Plexus:
- Roots and trunks in lower part of the posterior triangle, between scalenus anterior
and scalenus medius. (It is the neurovascular plane of the neck).

B. Arteries in the Posterior Triangle:

1) Part of Occipital A.: crosses the apex of the triangle.
2) The 3rd part of the Subclavian A
3) Transverse Cervical A.:
4) Suprascapular A.:
- Both arteries arise from the thyrocervical trunk of the first part of the subclavian A.
- Both pass laterally→ posterior triangle.
- Both share in the anastomosis around the scapula

C. Veins in the Posterior Triangle:

1) Subclavian V.:
- It is the continuation of the axillary V. begins at the lateral border of the first rib
and ends at the medial border of scalenus anterior where it joins IJV. to form the
brachiocephalic vein
- Tributaries: external jugular vein.

2) Lower part of the external jugular vein which pierces the investing fascia to join
the subclavian V. Within the triangle, EJV. receives 3 tributaries:
 Transverse cervical V.
 Suprascapular V.
 Anterior jugular V.

3) Transverse cervical V.  EJV.

4) Suprascapular V.  EJV.

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D. Muscles in the Posterior Triangle:
- Inferior belly of omohyoid muscle.
- It divides the posterior triangle into a large occipital triangle above it and a smaller
supraclavicular below it.\

E. Lymph Nodes:
1) Occipital lymph nodes: near apex of the posterior triangle.
2) Supraclavicular lymph nodes: near the base of the triangle.

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Sternocleidomastoid:
Origin: by 2 heads:
 Sternal head: from the anterior surface of the manubrium sterni.
 Clavicular head: medial 1/3 of the clavicle. (upper surface)

Insertion: into the lateral surface of the mastoid process and the lateral 1/2 of the
superior nucheal line.

Nerve Supply:
 Motor: spinal accessory N.
 Sensory: proprioceptive: C2, 3 nerves.

Actions:
 Acting alone: it tilts the head to its own side and rotates it, so that, the face is turned to
the opposite side (shaving position).
 Acting together: the two muscles flex the neck.

ClinicalAnatomy: Spasm of the muscle (due to cold, myositis) leads to a condition called
torticollis.

Torticollis

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7. Anterior Triangle of the Neck

Boundaries:
- Anteriorly: middle line of the neck.
- Posteriorly: anterior border of sternomastoid.
- Base: is directed superiorly and is formed by the lower border of the mandible and a
line extends from the mandibular angle to the mastoid process.
- Apex: is directed inferiorly and is represented by the suprasternal notch.
- Roof: (Also it is the roof of the subdivisions of the anterior )
 Skin.
 Superficial fascia and investing cervical fascia.

Subdivisions of the Anterior Triangle:

By means of the digastric and the superior belly of omohyoid muscles; the anterior triangle
is subdivided into 3 triangles (muscular, carotid, digastric) and half submental triangle.

Subdivisions of the anterior triangle

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The Carotid Triangle:
Boundaries:
- Posterior: upper part of sternomastoid.
- Anteroinferior: superior belly of the omohyoid muscle.
- Anterosuperior: posterior belly of the digastric muscle.

Subdivisions of the anterior triangle

Contents:
A. Arteries:
1. Upper part of CCA
2. Internal carotid A. (ICA).
3. External carotid A. (ECA) with 5 of its branches, 3 from the anterior and 1 from
the medial and 1 from the posterior aspect of the artery.
 Superior thyroid artery →thyroid gland.
 Lingual A.: disappears deep to the
hyoglossus muscle.
 Facial A.: ascends to the digastric triangle.
 Ascending pharyngeal A.: runs close to
wall of the pharynx.
 Occipital A.: runs p steriorly along the
lower border of the posterior belly of the
digastric muscle.

B. Veins:
-Internal jugular V. Descends lateral to ICA or
CCA and receives 5 tributaries:
 Superior thyroid V.

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 Lingual vein.
 Common facial vein.
 Pharyngeal veins.
 Middle thyroid vein.
C. Nerves:
1. Hypoglossal N.: appears at the lower border of the posterior belly of digastric. In
the carotid triangle, it gives 2 branches both contain fibers from the ventral ramus
of C1 nerve which joins the hypoglossal N., near the skull base:
 Upper root of ansa cervicalis (see below).
 Nerve to the thyrohyoid muscle.
2. Spinal accessory N. crosses the upper angle of the carotid triangle.
3. Vagus N.: descends vertically downwards behind and in between ICA (or CCA)
and IJV. (All are enclosed in the carotid sheath).
4. Sympathetic chain: posterior to and outside the carotid sheath.
5. Ansa cervicalis: (C1, 2, 3)
 It is a loop of nerves. embedded in the front of the carotid sheath.
 Formation: it is formed by 2 roots: superior root is derived from hypoglossal N.
and contains fibers from C1 ventral ramus and inferior contains fibers from C2,
C3 ventral rami coming from cervical plexus.
 Distribution: the ansa supplies 3 of the infrahyoid muscles: sternohyoid,
sternothyroid and omohyoid.

D. Deep cervical lymph nodes: lie close to the I. J. V

Ansa cervicalis

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Digastric Triangle:
Boundaries:
- Anteroinferior: anterior belly of digastric.
- Posteroinferior: posterior belly of the digastric + stylohyoid.
- Above: the base of the mandible and a line drawn from mandibular angle to the
mastoid process.
- Floor: formed by hyoglossus muscle covered partially by the mylohyoid muscle

Contents:
A. Contents of the anterior (submandibular) part of the digastric triangle:
- Two glands:
 Submandibular salivary gland.
 Submandibular lymph nodes
- Two arteries:
 Facial A.: is posterolateral to the submandibular gland.
 Submental A.: is a branch of the facial A.
- Two veins:
 Common facial V.
 Submental V.: ends in the facial V.
- Two nerves:
 Hypoglossal N.: disappears between mylohyoid and hyoglossus muscles.
 Mylohyoid N. (from the mandibular N.) supplies mylohyoid and anterior
belly of the digastric muscle.

B. Contents of the posterior (retromandibular) part of the digastric triangle:

 Lower part of the parotid gland.
 External carotid A.
 The upper part of the carotid sheath with its contents.

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Boundaries of the digastric triangle

Contents of the digastric triangle

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Submental triangle

Submental Triangle:
Boundaries:
-Base: hyoid bone.
-Apex: is the chin.
-On either side: the anterior belly of the digastric.
-Floor: is the mylohyoid muscle.

Contents:
 Submental lymph nodes: drain the tip of the tongue, lower incisors, floor of the mouth,
central parts of the lower lip and chin.
 Submental artery and vein.
 Submental small veins which unite (on either side) to form the anterior jugular vein.

Muscular Triangle:
A Superficial layer:
1- The sternohyoid muscle:
Attachments:
- Arises from the posterior surface of the manubrium sterni and clavicle (medial end)
→ body of the hyoid bone.

2- The omohyoid muscle:

Attachments:
- The muscle has superior and inferior bellies joined by an intermediate tendon.
- The superior belly: from the hyoid bone
- The inferior belly: from the upper border of the scapula.
- The intermediate tendon is attached to the medial end of the clavicle by a fibrous
band.

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B- Deep layer:
3- The sternothyroid muscle:
Attachments: Arises from the manubrium sterni and first costal cartilage→
oblique line of thyroid cartilage.
4- The thyrohyoid muscle:
Attachments: from the oblique line of the thyroid cartilage→ hyoid bone.

Nerve Supply: All are supplied by ansa cervicalis except thyrohyoid which is
supplied by the nerve to thyrohyoid (C1) which is carried to it by
the hypoglossal N.
Actions:
 In the second stage of deglutition, thyrohyoid assists in elevation of the larynx
to close the laryngeal inlet.
 When the second stage is over, all the infrahyoid muscles depress the larynx
down to open the laryngeal inlet.

Infrahyoid muscles

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8. Cranial Cavity
Dura Mater:
Definition: It is the outermost and the thickest meningeal layer.
The dura has 2 layers:
1- The outer (periosteal) layer: It is the periosteum which lines the inside of the skull
and is named endocranium.
2- The inner meningeal layer: It is the dura mater proper and forms four dural folds.

Meninges

The four Dural Folds:

All are formed by the inner meningeal layer.
(1) Falx Cerebri:
Definition: It is a crescenteric fold of dura which lies between the two cerebral
hemispheres.

Description: It has 2 ends, 2 borders, 2 surfaces.

 Anterior end is attached to the crista galli.
 Posterior end is blended with the tentorium cerebelli.
 Upper border: is convex and is attached to the internal
surface of the skull.
 Lower border: is concave and free.
 The two surfaces (right, left) are in contact with the cerebral hemispheres.
- Venous sinuses related to it: the superior and inferior sagittal and straight venous sinuses.

(2) Tentorium Cerebelli:

Definition: It is a tent shaped fold of dura which forms a roof over the posterior
cranial fossa, dividing the cranial cavity into supratentorial and
infratentorial compartments.
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Description: It has 2 margins, 2 surfaces.
 Inner (free) margin is concave and bounds the tentorial notch
occupied by the midbrain and is attached anteriorly to the anterior
clinoid process.
 Outer (attached) margin is convex and is attached on either side to
the lips of the transverse sulcus, superior border of the petrous
temporal bone and the posterior clinoid process. This attached
border encloses the transverse and the superior petrosal venous
sinuses.
 Superior surface: it gives attachment for falx cerebri.
 Inferior surface: it gives attachment for falx cerebelli.

Special Features:
 At the apex of the petrous bone, the attached margin is crossed by
the free margin of the tentorium. The triangular area so formed is
pierced by oculomotor and trochlear nerves.
 Five venous sinuses are enclosed in the tentorium: Rt. and Lt.
transverse, Rt. and Lt. superior petrosal sinuses as well as the
(single) straight sinus.

(3) Falx Cerebelli:

Definition: It is the small cresenteric dural fold which lies between the 2 cerebellar
hemispheres.

Description: It has base, apex and 2 margins.

 Base: is attached to the inferior surface of the tentorium cerebelli.
 Apex: fuses with the sides of foramen magnum.
 Posterior margin: is attached to the internal occipital crest.
 Anterior margin: is concave and free.

(4) Diaphragma Sellae:

Definition: It is a small, circular horizontal dural fold which forms a roof for the sella
turcica and covers the pituitary gland.

Attachment:
 It is stretched between the four clinoid processes.
 It has a central opening which transmits the infundibulum.

-The anterior and posterior intercavernous sinuses run in the anterior and posterior
borders of the diaphragma sellae respectively

Functions of the Dural Folds:

1. They support and protect the different parts of the brain against sudden
momentary movements.
2. They cover important structures like the pituitary gland.

Nerve supply of the dura:

- Supratentorial dura is supplied by trigeminal nerve.
- Infratentorial dura is supplied by 9th, 10th cranial nerves + C1, C2, C3 nerves

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Dural folds

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Tentorium cerebellei

Diaphragma sellae

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Dural Venous Sinuses: :

 Key facts:
1. They are wide venous channels which lie between the outer periosteal and
meningeal layers of the dura except the inferior saggital and straight sinuses which
lie within dural folds.
2. They are lined by endothelium supported by the 2 dural layers and have no muscle
tissue in their wall. Also, they have no valves.
3. They communicate with the veins outside the skull by the valveless emissary veins.
4. They drain bones of the skull, meninges, C.S.F., and brain into the I.J.V.

Classification:
The venous sinuses are classified into 2 main groups
Unpaired group Paired group
- Superior saggital sinus. - Sphenoparietal.
- Inferior saggital sinus. - Cavernous.
- Straight sinus. - Superior petrosal.
- Occipital - Inferior petrosal.
- Basilar plexus. - Transverse.
- Intercavernous (circular). - Sigmoid.

A. The Unpaired Venous Sinuses:

1. The Superior sagittal sinus:
-Site, Course: It begins near the crista galli and runs backwards in the superior
border of the falx cerebri and near the internal occipital protuberance, it
deviates (usually) to the right to become the right transverse sinus.

-Tributaries: The sinus is triangular in cross and receives:

 Superior cerebral veins: They cross the subdural space to join the sinus.
Rupture of these veins  subdural hemorrhage
with compression of the brain.
 Arachnoid granulations which filter C.S.F. into the venous circulation
 On either side it communicates with 3 lateral extensions called lateral
venous lacunae which receive meningeal veins and some arachnoid
granulations.

N.B.: Arachnoid granulations are protrusions of the cerebral arachnoid through

the dura which come in contact with the endothelium of most venous
sinuses especially the superior sagittal sinus. In children, they are small
and called arachnoid villi.

2. Inferior sagittal sinus:(slide 44)

-It lies the lower (free) border of falx cerebri. It joins the great cerebral vein to
form the straight sinus.

3. Straight sinus: (slide 44)

-It lies at the junction between falx cerebri and the tentorium cerebelli.
-It deviates usually to the left to become the left transverse sinus.

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4. Occipital sinus: (slide 45)
-It lies in the attached border of falx cerebelli.
-Above, it divides to join the beginning of the 2 transverse sinuses and below, it
divides to join the end of the 2 sigmoid sinuses.

5. Basilar venous Plexus:

It lies on the basilar part of occipital bone: (slide 46)
- It connects the 2 inferior petrosal venous sinuses.
- It receives veins from the pons and medulla (vital centers).Thrombosis in
the plexus is fatal.
6. Inter-cavernous sinuses: (slide 46)
They connect the 2 cavernous sinuses and include:
 Anterior and posterior groups: in the anterior and posterior borders of the
diaphragma sellae.
 Inferior group: runs in the floor of hypophyseal fossa.

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The Paired Venous Sinuses:
(1) The Sphenoparietal Sinuses:
- Each runs close to the posterior border of the lesser wing of sphenoid.
- It ends in the cavernous sinus.

(2) The Cavernous Sinuses:

Site: It lies between the 2 layers of the dura on the side of the body of the sphenoid bone.

Dimensions: 2, 1 cm for length and width.

Relations:
1. Anteriorly: It reaches the medial end of the superior orbital fissure.
2. Posteriorly: It reaches the apex of the petrous temporal bone.
3. Medial wall: Is related to:
 Pituitary gland + diaphragma sellae.
 Body of the sphenoid containing the spheroidal air sinuses.
4. Lateral wall: Temporal lobe of the brain.
5. Roof: Is pierced by 3 structures: I.C.A. (leaves the sinus) and the oculomotor
and trochlear nerves (enter the sinus to run in its lateral wall).
6. Floor: Body of sphenoid.
7. Structures traverse the cavernous sinus:
 Its interior of is traversed by the 3rd part of the I.C.A. and the abducent N.
 Its lateral wall is traversed (from above downwards) by the oculomotor, trochlear
nerves and the ophthalmic and maxillary divisions of the trigeminal N.

Paired dural venous sinuses

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Connections of the cavernous sinus

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Tributaries and Connections of the Cavernous Sinus:
1. Anteriorly: It receives:
 Superior ophthalmic V.: It connects the cavernous sinus to the
facial vein.
 A tributary from the inferior ophthalmic vein.
 Central vein of the retina.
 Sphenoparietal venous sinus.

2. Posteriorly: The sinus is drained by:

 Superior petrosal sinus: drains blood  transverse sinus.
 Inferior petrosal sinus: drains blood  I.J.V.

3. Laterally: Middle meningeal V.

4. Medially: Is connected to the opposite cavernous sinus by the intercavernous

sinuses.

5. Superiorly: superficial middle cerebral V.

6. Inferiorly: Is connected to the pterygoid venous plexus by 3 emissary veins

passing through the emissary sphenoidal foramen, foramen ovale
and foramen lacerum.

Clinical Anatomy:
Infections in dangerous area of the face leads to cavernous sinus
thrombosis (see the face).

(3) Superior Petrosal Sinus:

- It runs in the attached border of the tentorium cerebelli along the superior border
of petrous temporal bone.
- It drains blood from the cavernous sinus the transverse sinus.

(4) Inferior Petrosal Sinus:

- It runs in the lower border of the petrous temporal bone.
- It drains blood from the cavernous sinus and passes through the jugular foramen to
join I.J.V.

(5) The Transverse Sinuses:

- Each runs in the attached margin of tentorium cerebelli.
- The right sinus is continuous with the superior sagittal sinus, the left with the
straight sinus.
- Each terminates by becoming the sigmoid sinus.

(6) The Sigmoid Sinuses:

- This S-shaped sinus is the direct continuation of the transverse sinus
- It passes through the jugular foramen where it continues as the I.J.V.

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Middle meningeal artery

Emissary Veins :
- These valveless veins connect the intracranial venous sinuses with veins outside the
skull through cranial foramina.
- Physiological significance: by transmitting the blood in either direction, they maintain
a constant intracranial pressure.
- Surgical significance: they may transmit extracranial infections to the sinuses with
development of thrombosis in the affected venous sinus.
- Examples:
(1) The superior sagittal sinus is connected:
 With the nasal cavity through the foramen caecum.
 With the veins of the scalp through parietal emissary foramen.
(2) The cavernous sinus is connected: -
 With the veins of the face through ophthalmic veins.
 With the pterygoid venous plexus through sphenoidal emissary foramen,
foramen ovale and foramen lacerum.
(3) The sigmoid sinus: is connected:
 With the posterior auricular through the mastoid foramen.

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The Arteries in the Cranial Cavity :

Middle meningeal A.
Definition: Arises from first part of the maxillary A. outside the skull.
Course and Relations:
1. It enters the skull through the foramen spinosum, runs between the 2 layers of
the dura close to the endocranium the middle cranial fossa. Two cm above the
midpoint of the zygomatic arch, it divides into frontal and parietal branches.
2. The frontal branch crosses the greater wing of the sphenoid, then close to the
pterion,here, it is related medially to the motor area of the cerebral cortex.
Then, runs upwards and backwards to a midpoint between the nasion and
inion (inion is the summit of the external occipital protuberance).
3. The parietal branch runs backwards on the squamous temporal bone towards
the lambda.,

Distribution: Supplies the skull bones and dura mater.

- Surface marking:
- Pterion (site of trephining) is about 1.5 inches above the zygomatic arch and 1.5
inches behind the frontozygomatic suture.
- Frontal branch is represented by a line joining the pterion to a point midway
between nasion and inion.

Clinical Anatomy:
- Head injuries may cause rupture of the frontal branch of the middle meningeal
artery extradural hemorrhage which presses on the motor area  contralateral
hemiplegia.

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Exradural hemorrhage

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9. Preauricular Region:
The Facial Nerve:
Definition: It is the seventh cranial N., It is famous as a motor nerve, but it has also
parasympathetic and sensory functions.

Nuclei and Types of Fibers of the Facial N.:

The nerve carries four types of fibers (2 efferent, 2 afferent) arising from 4 (groups) of nuclei
(2 motor, 2 sensory lie in the lower part of the pons).

Fibers Nuclei Distribution

[Link] motor [Link] nucleus innervates -muscles of the scalp, face, buccinator,
( branchiomotor) muscles of the second posterior belly of digastric,
arch stylohyoid, platysma, stapedius
[Link] 2a. Special lacrimatory - to the lacrimal gland
parasympathetic nucleus
2b. Uncertain nucleus -to nasal, palatine, nasopharyngeal,
2c. superior [Link] -submandibular and sublingual glands
3. Afferent 3. Nucleus solitarius  from the anterior 2/3 of the tongue
(gustatory) taste (except vallate papillae); soft palate.
4. Afferent 4. Spinal nucleus of the  from the concha of the external ear.
(somatic) Trigeminal nerve
cutaneous

Central connections of the motor nucleus:

 Its upper part (which project to muscles of the forehead and around the eyes)
receives bilateral cortico-nuclear fibers.
 Its lower part (which project to the muscles of the lower part of the face) receives
only contralateral cortico-nuclear fibers.

Exit from the brain:

- The facial N. emerges at lower border of the pons as 2 roots: motor root and nervus
intermedius (root).
1. The motor root is formed by the axons of the motor nucleus. After winding round the
abducent nucleus, it appears at the lower border of the pons at the cerebello-pontine angle.
2. The nervus intermedius is formed by all the sensory and parasympathetic nerve fibers.

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Central nuclei of the facial nerve

Course of the Facial N.:

A. Intrapetrous part of the facial N.
 The 2 roots of the facial N. run through the internal acoustic meatus (with the
vestibule-cochlear nerve) to run in the bony facial canal.
 In the facial canal, the nerve runs in 3 directions:laterally; posteriorly, then
downwards to exit from the skull at the stylomastoid foramen.
 At the junction of the lateral and posterior parts of the nerve, the geniculate
(sensory) ganglion of the facial verve is present.
B. Extracranial Part of the Facial N.: (slide 10,12)
 The nerve enters the posteromedial surface of the parotid gland and divides into
5 terminal branches piercing the anteromedial surface of the gland to reach the
face.

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Central connection of the facial nerve nuclei

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Intrapetrous part of the facial nerve

Branches of the Facial N.:

- The facial N. gives 3 branches within the petrous bone, 3 branches after exit from the
stylomastoid foramen and 5 terminal branches within the parotid gland.

Within petrous bone Below stylomastoid F. Within the parotid gland

 Greater petrosal N.  Posterior auricular N.  Temporal, zygomatic
 N. to stapedius  Digastric N.  buccal, marginal mandibular
 Chorda tympani  Stylohyoid N.  cervical
3 3 5

A. Branches of the facial nerve within the petrous bone:

1. Greater petrosal N.:
 This nerve contains mainly preganglionic parasympathetic fibers with some
sensory taste afferents from the soft palate.
 It arises at the geniculate ganglion, passes through a hiatus in the petrous bone
to reach the middle cranial fossa, towards foramen lacerum. Its
parasympathetic fibers relay in the pterygopalatine ganglion. (See the
pterygopalatine fossa).

2. Nerve to stapedius: →stapedius muscle of the middle ear.

3. Chorda tympani:
 This nerve contains preganglionic parasympathetic fibers to submandibular and
sublingual glands and sensory taste afferents from the anterior 2/3 of the
tongue

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 It arises from the vertical part of the facial N., 6 mm above the stylomastoid
foramen, and runs anteriorly across the tympanic membrane and escapes
through the petrotympanic fissure to reach the infratemporal fossa where it
joins the lingual N. Its parasympathetic fibers relay in the submandibular
ganglion (see the submandibular region)

Branches of the facial nerve

Course of chorda tympani nerve

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B. Branches of the facial N. after exit from the Stylomastoid Foramen:
1. Posterior auricular N.→ occipital belly of the occipitofrontalis muscle.
2. Digastric N.  posterior belly of the digastric muscle.
3. Stylohyoid N.  the stylohyoid muscle.
C. Branches within the Parotid Gland:
1. Temporal branches:  frontal belly of occipitofrontalis + orbicularis oculi.
2. Zygomatic branches:  orbicularis oculi.
3. Buccal branches: upper and lower  buccinator and elevators of the upper lip.
4. Marginal mandibular branch:  muscles of the lower lip.
5. Cervical N.: comes from the lower end of the parotid gland  platysma.

 Key facts:
1-All the sensory and parasympathetic nerve fibers leave the facial N. within the petrous
bone, so that at the stylomastoid foramen, the facial N. is a purely motor nerve.

2-Along its course, the facial nerve has two parasympathetic ganglia; pterygopalatine and
submandibular ganglia and one sensory which is the geniculate ganglion.

Clinical Anatomy:
1) Supranuclear lesions:
-It is an upper motor neuron lesion (U. M. N. L).
-Only the lower half of the contralateral side of the face is paralyzed.

2) Nuclear and infranuclear lesions:

-It is a lower motor neuron lesion L. M. N. L)
-All muscles of the ipsilateral half of the face are affected.
-If the lesion of the nerve is proximal to the geniculate ganglion, all functions of the
facial N. are lost. In addition to the paralysis of facial muscles, there is:
 Loss of taste sensation in the anterior ⅔ of the tongue and oral surface of
the soft palate in the affected side.
 Hyperacusis (sounds are abnormally loud) due to paralysis of stapedius.
 Impaired secretion of the submandibular, sublingual and lacrimal glands.
-Lesion (oedema) of the facial N. at the stylomastoid foramen is called Bell’s palsy. There
is only motor loss of the ipsilateral side of the face.

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Branches of the facial nerve in the face

Right sided facial nerve palsy

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[Link], Infratemporal&Pterygopalatine
FOSSAE:
TEMPORAL FOSSA:
Definition: It is the area on the side of the head between the superior temporal line
and the zygomatic arch.

Boundaries:
1. Superiorly: superior temporal line.
2. Inferiorly: zygomatic arch.
3. Anteriorly: frontal process of zygomatic bon
4. Floor: presents the pterion which is H-shaped suture between 4 adjacent bones
(frontal, parietal, squamous temporal and greater wing of sphenoid).

Contents: The main content is the temporalis muscle covered by temporal fascia.

Temporal Fascia: Attachments:

- Superior: to superior temporal line.
- Inferior: to superior border of the zygomatic arch.

Temporalis muscle: It is the first muscle of mastication.

- Origin: From floor of whole temporal fossa and deep surface of temporal fascia.
- Insertion: coronoid process of the mandible.
- N. Supply: mandibular N. (anterior division).
- Actions:
- Its anterior vertical fibers elevate the mandible to close the mouth.
- Its posterior horizontal fibers retract the protruded mandible (they are the only
retractor of the mandible).

INFRATEMPORAL FOSSA:
Definition: it is the postmaxillary space which lies below the base of the skull
between lateral pterygoid plate medially and (the ramus of the mandible
covered by the masseter muscle) laterally.

Boundaries:
1. Medial: lateral pterygoid plate.
2. Lateral: ramus of the mandible (covered by the masseter muscle).
3. Anterior wall: posterior surface of the maxilla.

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Lateral and medial pterygoid muscles

Temporalis muscle

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Masseter muscle

Masseter Muscle:
- It is the second muscle of mastication.
- Origin: from zygomatic arch.
- Insertion: outer surface of the mandibular ramus.
- N. Supply: mandibular N. (Anterior division).
- Action: elevation of mandible to close the mouth, so of value in biting and chewing.

Contents of the Infratemporal Fossa:

1. The contents are divided into superficial and deep contents
2-The superficial contents are seen after removal of the mandibular ramus. They include
the lateral pterygoid muscle and all the structures seen while that muscle is intact.

2. The deep contents are seen only after removal of the lateral pterygoid muscle.

Superficial Contents of the Infratemporal Fossa:

Lateral Pterygoid Muscle:
- It is the third muscle of mastication.
- Origin: by 2 heads: upper and lower:
 The upper head from greater wing of sphenoid.
 The lower head: from the lateral pterygoid plate. (the lateral surface)
- Insertion: 2 insertions:
 Neck of the mandible.
 Capsule and the articular disc of the temperomandibular joint (T.M.J.).

N. supply: mandibular N. (anterior division).

Actions:
 It is the main opener of the mouth.
 Both lateral and medial pterygoid muscles (acting together) protrude the
mandible.

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Medial Pterygoid Muscle:

- It is the fourth muscle of mastication.
- Origin: it arises by 2 heads: superficial and deep which embrace the lower head of
the lateral pterygoid.
 The superficial head: from the maxillary tuberosity.
 The deep head: from medial surface of the lateral pterygoid plate.
- Insertion: medial surface of the mandibular ramus.
- N. supply: From the trunk of the mandibular N.
- Actions:
 With masseter, elevate and close the mandible.
 M and L. pterygoids of both sides acting together protrude the mandible.
 M and L. pterygoids of one side acting together in alternation with those of the
opposite side produce side to side grinding movement of the mandible.

Mandibular Nerve:
 Key facts:
1. It is the third division (V3) of the trigeminal N.
2. It is a mixed nerve, formed by the union of sensory and motor roots; both pass
through and unite in the foramen ovale and descends deep to lateral pterygoid muscle
3. The nerve trunk divides into a small anterior division (mainly motor) and a large
posterior division (mainly sensory).

Branches of the mandibular nerve

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Branches and Distribution:

From the trunk From the anterior division From the posterior division
 N. spinosus.  Nerves to L. pterygoid.  Auriculotemporal N.
 N. to the M. pterygoid.  Masseteric N.  Lingual N.
 Deep temporal nerves.  Inferior alveolar N., gives
 Buccal N. (sensory) mylohyoid N.

Branches of the trigeminal nerve

A. Branches from the Trunk:

1. Nervus spinosus (sensory)→foramen spinosum to supply the dura.
2. Nerve to the medial pterygoid muscle (motor to 3 muscles): it supplies M. pterygoid and
gives a small branch which passes through the otic ganglion without synapse to supply
tensor palati and tensor tympani muscles.

B. Branches from the Anterior Division: (3 motor + 1 sensory)

1. Nerves to lateral pterygoid.
2. Masseteric nerve: traverses the mandibular notch→ masseter.
3. Deep temporal nerves (two): ascends deep to zygomatic arch→ temporalis.
4. Buccal N. (sensory): appears between the 2 heads of L. pterygoid and supplies skin and
mucous membrane of the cheek over and inside buccinator muscle, respectively.

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C. Branches from the Posterior Division:

(1) Auriculotemporal N. (sensory).
- It passes backwards deep to the neck of the mandible and appears at the upper end
of the parotid gland.
- Distribution:
 Articular branches to T.M.J.
 Cutaneous branches: supplies upper 2/3 of the external surface of the
auricle, external auditory meatus, tympanic membrane (outer surface), hairy
area of the temple.
 Sensory branches to the parenchyma of the parotid gland.
 It carries and conducts postganglionic parasympathetic secretomotor nerve
fibers from the otic ganglion to the parotid gland.

(2) Lingual Nerve (sensory):

- Deep to L. pterygoid, the nerve is joined by the chorda tympani (branch of the
facial N.).
- It appears below the L. pterygoid. It enters the floor of the mouth in contact with
the mandible below and medial to the root of the third molar tooth, being covered
only by the mucous membrane of the gum (dangerous site).
- It crosses hyoglossus muscle on which, the nerve suspends the submandibular
parasympathetic ganglion and hooks round the submandibular duct, crossing it
from lateral to medial side
- Distribution:
 Two communicating branches to the submandibular ganglion.
 Sensory branches to the anterior 2/3 of the tongue, mucosa of the floor of
the mouth.

(3) Inferior Alveolar N. (mixed

- It appears below the L. pterygoid muscle, posterior to the lingual nerve.
-The nerve gives a mylohyoid branch and then enters the mandibular foramen,
supplying the teeth and gums and come through the mental foramen as mental
nerve which supplies the skin of the chin and the lower lip.
- Mylohyoid N.:(motor), It runs in the mylohyoid groove of the mandible→ digastric
triangle mylohyoid and the anterior belly of digastric muscle.

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Distribution of the mandibular nerve

N.B: The sensory root of V3 supplies the lower zone of the face and its motor root supplies 8
muscles:
• 4 muscles of mastication
• 2 tensor muscles: tensor palati and tensor tympani.
• 2 adjacent muscles: mylohyoid and anterior belly of the digastric.

The Maxillary Artery:

 Key facts:
1. It is one of the two terminal branches of the E.C.A., begins behind the neck of the
mandible within the parotid gland and ends in the pterygopalatine fossa by dividing
into terminal branches.
2. It has 3 parts: the first and second parts are superficial contents in the infratemporal
fossa, the third part is a content in the pterygopalatine fossa.
3. It is the artery of the middle and lower zones of the face.

Course of the Maxillary Artery: is divided into 3 parts:

 First (mandibular) part passes deep to the neck of the
mandible.
 Second (pterygoid) part runs on the lower head of L.
pterygoid muscle.
 Third (pterygopalatine) part: the artery passes between the
2 heads of the L. pterygoid and enters pterygo-palatine
fossa.

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A. Branches from the first part:
Name Foramen or Fissure Distribution
1. Deep auricular A.  Squamotympanic fissure  Ext. Auditory meatus.
2. Anterior tympanic A.  Squamo-tympanic fissure  Tympanic cavity.
3. Middle meningeal A.  Foramen spinosum  Bones + dura of the
cranium
[Link] meningeal  Foramen ovale  Bones +dura

5. Inferior alveolar A.  Mandibular foramen  Lower teeth and gum, its

mental branch  chin,
also gives mylohyoid A.

B. Branches of the second part: 4 branches to the 4 muscles of mastication and buccal
branch to the buccinator muscle.
C. Branches from the third part:
Name Foramen Distribution
1. Posterior superior  Pierces back of maxilla.  Upper molars.
alveolar A.
2. Infraorbital A.  Infraorbital fissure,  Gives middle superior
groove, canal and alveolar. A (to the upper
foramen. premolars) and anterior
superior alveolar. A (to
upper canine and
incisors) and supplies
part of the face.
3. Greater palatine A.  Greater palatine canal,  Hard palate and soft
foramen. palate.
4. Sphenopalatine A.  Sphenopalatine foramen.  Nasal cavity.
5. Pharyngeal A.  Palatovaginal canal.  Nasopharynx
6. A. of the pterygoid  Pterygoid canal.  Auditory tube, tympanic
canal cavity.

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Maxillary artery

Maxillary artery

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Pterygoid Venous Plexus:
- Site: On and around the lateral pterygoid muscle.
- Tributaries: correspond to those of the maxillary A.
- Drainage: by the maxillary vein which passes posteriorly deep to the mandibular neck and
ends within the parotid gland by uniting with the superficial temporal V. to form posterior
facial V.
- Communications:
 With the anterior facial V. by the deep facial V.
 With the cavernous sinus by 3 emissary veins passing through sphenoidal emissary
foramen, F. ovale and F. lacerum

Pterygoid venous plexus

Deep Contents of the Infratemporal Fossa :

(1) Trunk of the mandibular N. (described).
(2) Middle and accessory meningeal arteries (described).
(3) Otic ganglion: ((slide 79-81)
Definition: It is a collateral parasympathetic ganglion, it is connected
anatomically to the mandibular N., but functionally connected
with the glossopharyngeal N.
Roots: (only the parasympathetic root relays in the ganglion)
 Parasympathetic root: is the lesser petrosal N. of the
glossopharyngeal. The fibers begin in the inferior salivatory
nucleus in the upper part of the medulla  glossopharyngeal N. 
tympanic N.  middle ear  lesser
 Petrosal N.  middle cranial fossa  foramen ovale  relay in
the otic ganglion  postganglionic fibers join auriculotemporal N.
 parotid gland.
 Sympathetic root: from a plexus around the middle meningeal A.
 Motor root: is a branch from the N. to medial pterygoid, traverses
the ganglion without relay to supply tensor palati and tensor
tympani.

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Distribution: Postganglionic parasympathetic secretomotor and
postganglionic sympathetic vasomotor fibers join the
auriculotemporal [Link] supply the parotid gland.

Otic ganglion

(4) Tensor Palate: will be described with the palate.

(5) Chorda tympani: It is a branch of the facial N. It joins the lingual N and its
parasympathetic fibers relay in the submandibular ganglion in
the submandibular region.

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PTERYGOPALATINE FOSSA:
Definition: It is the pyramidal space which lies below the apex of the orbit.
Boundaries:
 Anterior: Is the posterior wall of the maxilla.
 Posterior: Pterygoid process of the sphenoid bone.
 Medial: Perpendicular plate of the palatine bone, separating the fossa from the
nasal cavity.
Contents of the Fossa: Maxillary. N, maxillary.A, sphenopalatine ganglion
The Maxillary Nerve:
Definition: Is the second division (V2) of the trigeminal N. It is a purely sensory
nerve. It is the nerve of the middle zone of the face
Course:
-The nerve arises from the trigeminal ganglion and runs in the lateral wall of
the cavernous sinus below the ophthalmic N.
-Then passes through the foramen rotundum to reach the pterygopalatine fossa
where it suspends pterygopalatine ganglion.
-Now, the nerve (is named infraorbital N.) enters infraorbital fissure, groove,
canal and foramen to reach the face
Branches of the Maxillary N.
There are four sets of branches: two from the maxillary N. and two from its
continuation, the infraorbital N.

Maxillary N. Infraorbital N.
In cranial cavity In pterygopalatine In floor of orbit In the face
fossa
 Meningeal N.  Two ganglionic  Middle  Palpepbral
branches to the superior  Nasal
pterygopalatine alveolar N.  Superior labial
ganglion.  Anterior
 Zygomatic N. superior
 Posterior alveolar N.
superior alveolar
N.
1 3 2 3

1. Meningeal branch: arises in the middle cranial fossa  dura.

2. Two ganglionic branches: →pterygopalatine ganglion (see below).
3. Zygomatic N.: enters the orbit via the infraorbital fissure and runs in the
lateral wall of the orbit and divides into 2 branches:
 Zygomaticofacial: →skin over the prominence of the cheek.
 Zygomaticotemporal: →the non-hairy of the [Link] conducts
postganglionic parasympathetic fibers to the lacrimal gland (see below).

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4. Post. superior alveolar N: → upper molar teeth.

Maxillary nerve

5. Middle superior alveolar N.: →upper premolars.

6. Anterior superior alveolar N.: →incisor and canine teeth.
7. Palpebral branch  lower eyelid.
8. Nasal branch to skin of the side and ala of the nose.
9. Superior labial branch  upper lip.

Pterygopalatine (Sphenopalatine) Ganglion:

Definition: It is a collateral parasympathetic ganglion which lies in the upper part
of the pterygopalatine fossa. It is connected anatomically to the
maxillary N., but functionally with the greater petrosal N. of the facial
nerve.
Roots:
1- Parasympathetic root: is the greater petrosal branch (of the facial nerve)
which reaches the ganglion in the N. of the pterygoid canal which is formed
by union of the greater petrosal and deep petrosal nerves. The fibers of the
greater petrosal are the only ones to relay in the pterygopalatine ganglion.
The greater petrosal N. contains also afferent taste fibers from the soft
palate.
2- Sympathetic root: is the deep petrosal N. which reaches the ganglion also in
the N. of the pterygoid canal. It contains postganglionic sympathetic
vasomotor nerve fibers derived from carotid plexus around I.C.A.
3- Sensory: from the maxillary N. These sensory fibers pass in the ganglion
without relay to accompany most branches of the ganglion.
Branches and Distribution:
1. Orbital branches:→inferior orbital fissure →periosteum of the orbit.
2. Branches to the lacrimal gland: they are postganglionic parasympathetic
secretomotor fibers which join the maxillary N.  its zygomatic branch 

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its zygomaticotemporal N. which in the orbit gives these parasympathetic
fibers to the lacrimal N.  to lacrimal gland.
3. Nasal branches: →sphenopalatine foramen→ lateral nasal wall and nasal
septum.
4. Palatine branches: Includes:
 Greater palatine nerves: →greater palatine canal→
hard palate.
 Lesser palatine nerves: →lesser palatine canal→ soft
palate.
5. Pharyngeal N.: →palatovaginal canal→nasopharynx.

Pterygopalatine ganglion

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11 The Submandibular Region (Suprahyoid region)

1. The submandibular region (suprahyoid region) is the anatomical area which lies
between the body of mandible and the hyoid bone. It corresponds to the Rt. and Lt.
digastric and the submental triangles. Here, their deeper structures are studied.

2. This region will be studied under the following items:

 The 4 suprahyoid muscles.
 The submandibular gland. (See G.I.T)
 Structures in the floor of the mouth deep to the mylohyoid muscle.

The 4 Suprahyoid Muscles:

They include digastric, stylohyoid, mylohyoid and geniohyoid. The latter muscle is deep
to the mylohyoid muscle.

(1) The Digastric Muscle: It has 2 bellies:

-Anterior belly: from the digastric fossa of the mandible.
-Posterior belly: from the digastric notch of the mastoid process
-Insertion: the 2 bellies are united by an intermediate tendon which is held by
fibrous loop to the junction of the body and greater horn of the hyoid
bone.

(2) Stylohyoid Muscle:

- Arises from the styloid process.
- Near its insertion; its tendon divides to surround the intermediate tendon of
digastric and is inserted into the hyoid bone at the junction of the body and
greater horn.

(3) The Mylohyoid Muscle:

-Origin: from the mylohyoid line of the mandible.
-Insertion: the muscles meet at the mylohyoid raphe which extends from the
symphysis menti to the body of the hyoid. Both muscles form the diaphragma
oris which forms the floor of the mouth.

(4) The Geniohyoid Muscle:

-This muscle is superior (deep) to the mylohyoid muscle.
-Arises from the inferior genial tubercle of the mandible→ hyoid bone.

Nerve supply of suprahyoid muscles in relation to embryology :

 Mylohyoid and anterior belly of digastric by mylohyoid branch of the mandibular N.
 The stylohyoid and posterior belly of digastric by facial N.
 Geniohyoid: by C1 ventral ramus through the hypoglossal N.

Actions of suprahyoid muscles:

 In the first stage of deglutition, they raise the floor of the mouth and this in turn
improve the function of the tongue
 If the hyoid is fixed by infrahyoid muscles, they produce depression of the
mandible.

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The Submandibular Ganglion :
Definition: It is a collateral parasympathetic ganglion which is anatomically connected to
the lingual N., but functionally with the chorda tympani branch of the facial N.
Site: It lies on the upper part of hyoglossus muscle suspended from the lingual N.
Roots:
1- Parasympathetic root: is chorda tympani which join the lingual N. The whole
pathway is superior salivatory nucleus  nervus intermedius  facial N. 
chorda tympani joins the lingual N.  relays in the ganglion.
2- Sympathetic root: from the plexus around the facial A.
3- Sensory root: from the lingual N.
Distribution:
- Postganglionic parasympathetic, sympathetic and sensory fibers supply the
submandibular and sublingual glands.

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Summary of the Parasympathetic Ganglia:

The ganglion and Nucleus and its Pathways Distribution
its site site (Fig. 52)
(1) Ciliary ganglion - Edinger-Westphal  oculomotor nerve - Ciliary muscle.
- lies in the orbit nucleus in the  its inferior division - Constrictor pupillae
lateral to the upper part of  N. to inferior of the eyeball.
optic N. midbrain. oblique relays in the
- Connected to ganglion  short
nasociliary N. ciliary nerves.
(2) Pterygopalatine - Special lacrimatory Facial N. (Nervus - Lacrimal gland.
ganglion nucleus + part of intermedius)  - Nasal, palatine and
- In pterygo- Superior salivatory greater petrosal N. nasopharyngeal
palatine fossa. nucleus. (join deep petrosal glands.
- Connected to - Both lie in the N.)  N. of the
maxillary N. lower part of the pterygoid canal, relay
pons. in the ganglion.
(3) Submandibular - Superior salivatory Facial N. (Nervus - Submandibular and
ganglion. nucleus. intermedius)  sublingual glands.
- In the floor of - In the lower part of chorda tympani (joins
mouth on the pons. lingual N.) and relays
hyoglossus. in the ganglion.
- Connected to
lingual N.
(4) Otic ganglion - Inferior salivatory Glossopharyngeal N. - The parotid gland.
- In the nucleus.  tympanic N. 
infratemporal - In the medulla tympanic cavity and
fossa, deep to oblongata. plexus  lesser
lateral pterygoid. petrosal N. pass
- Connected to N. through F. ovale to
to M. pterygoid relay in the ganglion
of mandibular  postganglionic join
N. auriculotemporal N.

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12. Arteries of the Head and Neck:

Arteries of the head and neck includes
 Subclavian arteries.
 Carotid system: C.C.A., E.C.A., I.C.A.

Subclavian Artery :
 Key facts:
1. On the right side, the subclavian A. arises from the brachiocephalic trunk, on the
left side, from the aortic arch and on either side, it enters the neck behind the
sternoclavicular joint.
2. On each side, the artery arches laterally behind the scalenus anterior muscle and
ends at outer border of the first rib by becoming the axillary A. Scalenus anterior
divides the artery into 3 parts; the first part is medial, second part is behind, and the
third part is lateral to the muscle.

Main arteries of the head and neck

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Branches of the Subclavian A. :

First part Second part Third part

1- Vertebral A. -Costocervical trunk; - No branches
2-Thyrocervical trunk; divides into :
divides into :  superior intercostal A.
 inferior thyroid A.  deep cervical .A
 Suprascapular A.
transeverse cervical A.
3- Internal thoracic A.

Branches of the first part of the subclavian artery

A-Branches from the first part of the subclavian A.:

(1) The Vertebral A.
Definition: It arises in the root of the neck from the first part of the subclavian
A. and ends in the cranial cavity at the lower border of pons by
uniting with the opposite one to form the basilar artery.

Course and Relations: It is described in 4 parts:

1. The First Part:
It ascends in vertebral triangle which is bounded by the longus colli
muscle (medially) and scalenus anterior muscle (laterally) and reaches
the foramen transversium of the 6th cervical vertebra. It has no branches

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2. The Second Part of the Vertebral A.:
-It ascends in the foramina transversia of the upper six cervical vertebrae.
-Branches: it gives spinal branches to the cervical part of the spinal cord.

3. The Third Part:

-Is seen in the suboccipital triangle above the posterior arch of atlas.
-Then the artery passes medially to enter the cranial cavity.
-Branches: muscular to the adjacent muscles.

4. The Fourth Part:

-It ascends in the foramen magnum and pierces the cranial dura and
arachnoid to run in the subarachnoid space and ends at the lower border
of the pons.
-Branches of the fourth part: (see Neuroanatomy)
 Anterior spinal A.
 Posterior spinal A.
 Posterior inferior cerebellar A.
 Medullary branches
 Meningeal branches.

(2) Thyrocervical Trunk:

Origin: From the first part of the subclavian A. at the medial margin of the
scalenus anterior muscle. It divides into inferior thyroid, suprascapular
and transeverse cervical arteries.

1. Inferior thyroid A.:

-It ascends upwards up 6th cervical vertebra, curves medially, then
descends to reach the posterior surface of the thyroid lobe.

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-Near the thyroid gland, the recurrent laryngeal N. runs between the
branches of the inferior thyroid A.
- It is the visceral artery of the neck

Branches:
-Two branches to the thyroid gland and the posterior one supplies
parathyroid glands.
-Four tubal branches: to larynx, trachea, pharynx and esophagus.
-The branch to the larynx is named inferior laryngeal A. →lower ½ of
larynx
2. The suprascapular A.: shares in the anastomosis around the scapula
3. Transverse cervical A.: mentioned in the posterior triangle.

(3) The Internal Thoracic A.: It descends into the thorax.

B. Branches from the Second Part of the Subclavian A.:

The Costocervical Trunk:
-It arises behind the scalenus anterior and divides at the neck of the first rib into:
1. The deep cervical A.: it passes backwards→ the back muscles.
2. The superior intercostal A.: mentioned in the thoracic wall.

Inferior thyroid artery

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The Carotid System:

The Common Carotid A. (C.C.A.) :
Origin and Termination:
-The Rt. C.C.A. arises from the brachiocephalic trunk behind the Rt.
sternoclavicular joint.
-The Lt. C.C.A. arises from the arch of the aorta and ascends to enter the neck
behind the Lt. sternoclavicular joint.
-From the joint, each artery ascends to the upper border of the thyroid cartilage, at
the level of the disc between the 3rd and 4th cervical vertebrae, where it divides
into I.C.A. and E.C.A. (its only branches).
External Carotid A.:
Definition: It is one of the terminal branches of C.C.A., begins opposite the upper
border of the thyroid cartilage level with the disc between the 3rd and 4th
cervical vertebrae and ends within the parotid gland behind the
mandibular neck by dividing into the superficial temporal and maxillary
arteries.
Branches of E.C.A.: It gives 4 groups of branches:

3 anterior 2 posteriors 1 medial 2 terminals

- Superior thyroid - Occipital A. - Ascending - Superficial
A. - Posterior pharyngeal A. temporal A.
- Lingual A. auricular A. - Maxillary A.
- Facial A.

Branches of E.C.A

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(1) The Superior Thyroid A. :
-It descends downwards and medially (in company with external laryngeal N.)
towards the apex of the thyroid lobe.
-Branches:
A. Two branches to the thyroid gland:
B. Two laryngeal Arteries:
* Superior laryngeal A.: pierces the thyrohyoid membrane upper 1/2 of the
larynx.
* Cricothyroid A.

(2) Lingual A.:

-Course: Is divided into 3 parts:
* First part: in the carotid triangle: it forms a loop which is crossed by
the hypoglossal N.
* The second part: is deep to hyoglossus muscle.
* The third part: runs in the inferior of the tongue and here is named
the deep artery of the tongue.

-Branches:
* The second part: gives two dorsal lingual arteries→ posterior part of the tongue.
* The third part: gives sublingual A. to the sublingual gland, then it continues
as the deep lingual A. which runs deep to the mucous membrane of the
inferior surface of the tongue supplying it.

Lingual artery

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(3) The Facial Artery:

* From its origin in carotid triangle,it ascends to the digastric triangle where it
runs close to the posterolateral aspect of the submandibular gland and
descends down to the base of the mandible.
* In the face: the artery runs close to the anteroinferior angle of masseter,
ascends towards the angle of the mouth, then up to medial angle of the eye
where it ends as the angular A.

Branches of the Facial A. :

The facial A. gives 5 branches in the neck and 5 branches in the face:
A. Branches in the Neck:
1. Ascending palatine A.: → soft palate.
2. Tonsillar A.: it pierces the superior pharyngeal constrictor to supply
the tonsil (its main blood supply).
3. Glandular branches to the submandibular gland.
4. Submental A.: it runs to the submental triangle, supplying muscles and
skin.
5. Muscular branches to adjacent muscles.

B. In the Face:
It gives inferior labial, superior labial, lateral nasal, angular and muscular
branches.

(4) Occipital A.:

Course: Runs in the carotid triangle along the lower border of the posterior belly
of the digastric muscle.

Branches: Occipital branches to the posterior part of the scalp.

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(5) Posterior Auricular A. :

Course: It runs along the upper border of the posterior belly of the digastric
muscle.

Branches:
 Stylomastoid A.: enters the stylomastoid foramen to supply the facial N.
 Branches to the posterior part of the scalp.

(6) Ascending Pharyngeal A. :

It ascends vertically close to the pharyngeal wall up to the base of the skull→
pharyngeal constrictors.

(7) The Superficial Temporal A. :

-It is the smaller of the two terminal branches of E.C.A.
-It begins within the parotid gland behind the mandibular neck.
-It comes from the upper end of the gland and divides 2 inches above the
zygomatic arch into frontal and parietal branches supplying the temple

(8) The Maxillary A. (Described)

Facial artery

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The Internal Carotid Artery (I.C.A.) :

Definition: It is one of the two terminal branches of C.C.A. It begins opposite the
upper border of the thyroid cartilage level with the disc between the 3rd
and 4th cervical vertebrae. It ends in the cranial cavity below the anterior
perforated substance by dividing into anterior and middle cerebral
arteries.

Course: The artery has 4 parts: cervical, petrous, cavernous and cerebral parts.

A. The Cervical Part: It ascends in the carotid triangle up to enter the

carotid canal o the skull.

B. The Petrous Part: The artery runs horizontally in the carotid canal and
pierces the posterior wall of the foramen lacerum
to enter the cavernous sinus

C. The Cavernous Part: I.C.A. runs within the sinus with the abducent N.
and pierces the dural roof of the sinus.

D. The Cerebral Part: The artery curves backwards (in the subarachnoid
space) to the anterior perforated substance of the
brain where it divides into anterior and middle
cerebral arteries.
Branches of I.C.A.: The cervical part has no branches, other parts give the following
branches:

From the petrous From the cavernous From the cerebral part
part part
As  tympanic - Hypophyseal As - Ophthalmic A.
cavity. - Anterior cerebral A.
- Middle cerebral A.
- Posterior communicating.
- Anterior choroidal (see
neuroanatomy)

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I.C.A

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13. Veins of the Neck:

This item includes:
 Subclavian veins
 Internal jugular veins
 Brachiocephalic veins

The Subclavian Veins :

- Each is the direct continuation of the axillary vein, begins at the outer border of the first
rib and ends at the medial border of scalenus anterior muscle by joining I.J.V. to form
the brachiocephalic vein.
-Tributaries: external jugular vein.

Major veins in the head and neck

Internal Jugular Vein (I.J.V.) :

Each is the direct continuation of the sigmoid sinus, begins in the posterior compartment
of the jugular foramen. It ends posterior to the medial end of the clavicle by joining the
subclavian V. to form the brachiocephalic vein.

Course: It descends vertically in the neck, lateral to I.C.A. and C.C.A., enclosed with
them and the vagus N. in the carotid sheath.

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Tributaries:
 Inferior petrosal sinus.
 Pharyngeal veins: drains the pharyngeal venous plexus.
 Common facial V.
 Lingual V.
 Superior thyroid V.
 Middle thyroid V.

I.J.V and its tributaries

Brachiocephalic Veins:
-Each is formed behind the medial end of the clavicle by union of the subclavian V. and
I.J.V.
-The left vein crosses the median plane to join the right vein to form superior vena cava
behind the lower border of the right first costal cartilage.

Tributaries: Each receives:

 The vertebral vein: arises in suboccipital venous plexus in the suboccipital triangle,
and escapes from the 7th cervical foramina transversium.
 Inferior thyroid vein.
 Internal thoracic V.
 First posterior intercostal V.
 The right brachiocephalic vein receives the right lymph duct while the left vein
receives the thoracic duct and the left superior intercostal vein.

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14. Nerves Of the Head & Neck:

This item includes:
* The lower 4 cranial nerves.
* The cervical plexus.
* The sympathetic chains.

The Lower 4 Cranial Nerves :

The Glossopharyngeal Nerve:
Nuclei and Types of Fibers:
It has 4 types of fibers, 2 afferent and 2 efferent connected to 4 nuclei (2
sensory and 2 motor), all lie in the medulla oblongata (see the neuroanatomy

Fibers Nuclei Distribution

1. Somatic afferents (pain, T) Spinal nucleus of * From tympanic cavity,
the trigeminal N. auditory tube, fauces, tonsils,
posterior ⅓ of the tongue.
2. Taste afferents Nucleus solitarius * From posterior 1/3 of the
tongue.
3. Efferent parasympathetic Inferior salivatory  parotid gland.
nucleus.
4. Efferent branchiomotor Upper part of  stylopharyngeus muscle.
nucleus ambiguus.

Extracranial Course:
- The nerve leaves the skull via the anteromedial part of the jugular foramen
- In the neck, the glossopharyngeal N. has the following course :
* It descends between I.J.V. and I.C.A.
* Then, between E.C.A. and I.C.A.
* Then between the superior and middle constrictors of the pharynx.
* It passes deep to hyoglossus muscle and ends by giving tonsillar and lingual
branch

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Glossopharyngeal nerve

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Branches and Distribution:
1. Meningeal branch to the cranial dura.
2. Tympanic N. (of Jacobson):
 It contains somatic sensory and parasympathetic fibers.
 It enters the tympanic cavity where it gives its sensory fibers to the
tympanic plexus which supplies tympanic cavity and auditory tube
 The remaining parasympathetic fibers form the lesser petrosal nerve 
its hiatus  middle cranial fossa  foramen ovale, → relays in the otic
ganglion  parotid gland.
3. Pharyngeal branches (sensory) pass to the pharyngeal plexus (see below).
Through the plexus, it provides sensory fibers to the pharyngeal mucosa.
4. Carotid branch  carotid sinus and body.
5. Muscular branch: →stylopharyngeus muscle.
6. Lingual branches: transmit general and taste sensations from the posterior ⅓ of
the tongue, including the vallate papillae.
7. Tonsillar branches: sensory to the tonsils.

Vagus Nerve:
Nuclei and Types of Fibers:
-It has 5 types of nerve fibers (3 afferents, 2 afferents)
Fibers Nuclei Distribution
1. Somatic afferents Spinal nucleus of the  From posteroinferior parts
(pain, T) trigeminal N. of the external auditory
meatus and tympanic
membrane.
2. Taste afferents Nucleus solitarius  From the back of the
tongue and epiglottis.
3. General visceral Nucleus solitarius  From thoracic organs,
afferents foregut, midgut.
4. Efferent Dorsal vagal  thoracic organs (heart,
parasympathetic nucleus lungs), foregut, midgut.
5. Efferent Nucleus ambiguus.   Muscles of the
branchiomotor pharynx, palate, intrinsic
muscles of the larynx and
upper esophagus.

Extracranial Course:
- The vagus N. leaves the skull via the middle compartment of the jugular
foramen.
- Below the skull it is is joined by the cranial accessory N. to form vago-accessory
complex.
- It descends vertically in the carotid sheath posterior and between I.J.V. and
I.C.A., then posterior and between I.J.V. and C.C.A.
- It crosses the subclavian A. (first part), to enter the thorax.

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Vagus nerve

Branches of the vagus N. In the Neck:

1. Meningeal branch: →jugular foramen →cranial dura.
2. Auricular N. (of Arnold): → tympanomastoid fissure→ posterior inferior part
of the external auditory meatus and a similar part of the tympanic membrane
3. Pharyngeal branch (motor):
- Shares in the pharyngeal nerve plexus on the middle constrictor of the pharynx.
- Pharyngeal plexus is formed by :
* Pharyngeal branch of glossopharyngeal N. (sensory).
* Pharyngeal branch of the vago-accessory complex (motor).
* Branches from the superior cervical sympathetic ganglion (vasomotor).
* Distribution: to all muscles of pharynx except stylopharyngeus
(supplied directly by 9th N.) and all muscles of the palate except tensor

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palati (supplied by the 5th N.). Also, it gives sensory and sympathetic
fibers to the pharyngeal mucosa.
4. Branches to the carotid sinus and body
5. Superior laryngeal N. (mixed):
* It divides into internal and external laryngeal branches.
* Internal laryngeal N. (sensory): pierces the thyrohyoid membrane to enter
the larynx→ tongue, valleculae, epiglottis, laryngeopharynx and the
laryngeal mucosa above the level of the vocal cords.
* External laryngeal N. runs with the superior thyroid. A. →upper pole of the
thyroid lobe. Then, medial to the thyroid lobe to supply the cricothyroid
muscle.
6. Right recurrent laryngeal N. (mixed):
* The Rt. N. arises (in the neck) as the Rt.
vagus crosses the first part of the
subclavian A.
* The Lt. N. arises (in the thorax) as the
Lt. vagus crosses the arch of the aorta.
* Each nerve hooks below the
corresponding artery and ascends in the
tracheo-oesophageal groove.
* Then, deep to the thyroid lobe and enters
the larynx deep to the inferior
pharyngeal constrictor.
Distribution:
* Sensory fibers to the laryngeal mucosa
below the level of the vocal cords.
* Motor fibers to all intrinsic laryngeal
muscles except the cricothyroid muscle.
* It also supplies motor fibers to
cricopharyngeus part of inferior
pharyngeal constrictor and upper part of
esophageal musculature.
7. Cardiac branches: (superior and inferior) : →thorax to join cardiac plexuses .

The Accessory Nerve:

- It is the eleventh cranial nerve, which is purely motor and has cranial and spinal
roots.
Nuclei:
 The cranial root arises from the lower part of the nucleus ambiguus in the
medulla oblongata.
 The spinal root: arises from the anterior grey column of the upper 5 cervical
segments of the spinal cord. It ascends through the foramen magnum to join the
cranial root to form the accessory N. which passes via the jugular foramen.

Extracranial Course and Distribution:

- Below the jugular foramen, the cranial root joins the vagus to form the vago-
accessory complex.
- The cranial accessory is distributed in the pharyngeal and recurrent laryngeal
branches of vagus (to muscles of the palate, pharynx, and larynx).
- The spinal root: (slide 35,36)
* Crosses upper angle of the carotid triangle.

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* It traverses sternomastoid and crosses the posterior triangle, embedded in
its fascial roof to end deep to trapezius
* The spinal root supplies sternomastoid and trapezius muscles (it is the
only motor supply).

Accessory nerve

The Hypoglossal Nerve:

Definition: It is the 12th cranial nerve which is concerned with the supply of the
muscles of the tongue. Its somatic motor nucleus lies in the medulla
oblongata.

Extracranial Course:
- The nerve leaves the skull via the hypoglossal canal.
- It descends deep to stylohyoid and posterior belly of digastric muscle to reach the
carotid triangle, here it curves medially, and crosses (3 arteries) which are: I.C.A.,
E.C.A. and the loop formed by the lingual A. Then, it ascends to digastric triangle
and floor of the mouth.
- In the floor of the mouth, it runs on hyoglossus, and ends by piercing
genioglossus muscle and breaks up into its terminal branches.

Distribution:
[Link] 4 non-lingual branches of hypoglossal N. containing C1 fibers :
Near the base of the skull, the hypoglossal N. is joined by fibers from C1
ventral ramus which are distributed in 4 (non-lingual) branches:
1. Meningeal N.: → dura of posterior cranial fossa.
2. Upper root of ansa cervicalis, → shares in formation of ansa cervicalis.
3. N. to thyrohyoid.
4. N. to geniohyoid.

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B. Lingual branches from the hypoglossal N. (proper):
Supply all intrinsic and extrinsic muscles of the tongue except palatoglossus
muscle which is supplied by vago-accessory complex through the pharyngeal
plexus.

Clinical Anatomy:
In the lower motor neuron lesion, there is difficulty in the protrusion of the
tongue and deviation to the paralyzed side, the tongue being pushed by the
genioglossus muscle of the normal side.

Hypoglossal nerve

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The Cervical Plexus:
Formation of the Cervical Plexus: It is formed by the upper four cervical ventral rami.
Branches of the Cervical Plexus:
A. Four cutaneous branches: Lesser occipital N. (C2), great auricular (C2,3),
transverse cervical (C2,3) and supraclavicular (C3,4)
nerves. (See posterior triangle, Fig. 12).
B. Two communicating branches:
-From C1 to the hypoglossal N. It is distributed as meningeal branch, nerves to
thyrohyoid, geniohyoid and upper root of ansa cervicalis.
-Sensory (proprioceptive) to sternomastoid (C2) and trapezius (C3, C4).

The Phrenic Nerve:

Origin: It arises from C3, 4, 5 chiefly C4. It is a mixed nerve.
Course: The nerve descends scalenus anterior muscle to enter the thorax
Distribution:
-It is the sole motor supply to the diaphragm.
-It is sensory to the mediastinal and diaphragmatic pleurae, pericardium, diaphragmatic
peritoneum and biliary system

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15. Lymph Drainge of the Head and Neck

 Key facts:
1. The lymph nodes of the neck are divided into :
 Circular group which lies at the junction of the head and neck. These group
drains to the deep( vertical ) cervical lymph nodes
 Vertical group which is further subdivided into superficial group( lie close to
the superficial veins of the neck) and deep group ( lie close to I.J.V.) .
2. The deep cervical group drains into the jugular lymph trunk.

The Circular Group of Lymph Nodes:

A. The Outer Pericervical Circular Lymph Nodes :

Name Site Afferents from

1. Occipital L.N. Near the superior nucheal  Occipital part of the scalp.
line.  Upper part of the back of the
neck.
2. Posterior auricular On the mastoid process  Side of scalp.
(mastoid) L.N. behind the auricle.  Medial surface of the auricle.
[Link] Superficial to parotid  Frontal part of the scalp and
(parotid) L.N. gland ( some may be temple.
embedded in the gland.  Lateral surface of the auricle
and external auditory meatus.
 The part of the face lateral to
the facial vessels.

4. Submental L.N. In the submental triangle.  Central part of the lower lip,
chin, gums.
 Tip of the tongue, incisor teeth,
floor of the mouth.
5. Submandibular Close to the  From the submental L.N.
L.N. submandibular gland,  Side of the tongue.
some may be embedded in  Side of the floor of the mouth.
it.  Part of the face medial to the
facial vessels.

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Superficial lymph nodes of the head and neck

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The Vertical group of Lymph Nodes:

A. The Superficial Vertical Lymph Nodes:
1. Superficial cervical lymph nodes:
- They lie close to the upper part of the external jugular vein.
- They drain the lobule of the ear and the parotid region.
[Link] cervical lymph nodes:
- They lie close to the upper part of the anterior jugular vein.
- They drain the skin of the anterior part of the neck.
[Link] Deep Vertical Lymph Nodes :
This group has a vertical arrangement close to [Link] are further subdivided
into upper and lower groups by the intermediate tendon of omohyoid muscle :
A. The Upper Group :
Site : Close to IJV above the omohyoid tendon.
Special node : The jugulodigastric lymph node which lies in the angle
between the IJV and common facial V. below the
posterior belly of the digastric muscle. It is the main
lymph node of the tonsil.
Afferents : From all the circular lymph nodes.
Efferents : To the lower deep cervical lymph nodes.
B. The Lower Group :
Site : Close to IJV below the omohyoid tendon.
Special node : The jugulo-omohyoid lymph node which lies close to
the intermediate tendon of the omohyoid muscle
behind IJV. It is the terminal lymph node of the
tongue.
Afferents : From the upper deep cervical lymph nodes.
Efferents : collect to form the jugular lymph trunk which ends as
follows :
 On the right side : it ends directly in the jugulo-
subclavian venous junction or joins the right
subclavian and right broncho-mediastinal lymph
trunks to form the right lymphatic duct.
 On the left side, it joins the thoracic duct.

Vertical group of lymph nodes

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16. Temporomandibular joint

Temperomandibular Joint (T.M.J.) :
Definition: It is the site of articulation between the head of the mandible with the
mandibular fossa and the articular tubercle of the temporal bone.

Structure of T.M.J.:
A. The fibrous capsule is attached:
 Above: to margins of the mandibular fossa.
 Below: to mandibular neck.

B. Extracapsular and related ligaments: The capsule is supported medially by

sphenmandibular ligament, laterally by lateral temperomandibular ligament and
posteriorly by stylomandibular ligament

C. Intracapsular Structures:
1. The articular disc: It divides the joint cavity into upper and lower parts.
2. The synovial membrane:It lines the capsule in the upper and lower parts of the
joint cavity.

-Nerve supply: Auriculotemporal and masseteric nerves.

Movements of T.M.J.:
1. Opening the mouth: is mainly by the L. pterygoid muscles, assisted by the suprahyoid
muscles.
2. Closing the mouth: by temporalis, masseter and M. pterygoid muscles.
3. Protraction: by both lateral pterygoids assisted by both medial pterygoids.
[Link] of the protruded mandible by the posterior horizontal fibers of temporalis.
5. Side to side movement: by the lateral and medial pterygoids of one side alternating
with those of the opposite side.

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Ligaments of T.M.J

Interior of T.M.J

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NERVOUS TISSUE
Nervous tissue consists of two cell types: nerve cells (neurons) and glial cells.

Neurons
• Most of neurons consist of 3 parts; the cell body (Perikaryon), the dendrites and the axon.
• Classification of neurons:
A-They are classified according to number of processes into:
1. Unipolar: Have a single process and divides into 2 branches to form a T
[Link] branch acts functionally as a dendrite but its structure is
similar to that of axon &the other acts as axon.
The stimuli reach the dendrites travel directly to the axon without passing through
the Perikaryon.
Sites: spinal ganglia and mesencephalic nucleus of trigeminal nerve.

2. Bipolar: have one dendrite and one axon.

Sites: cochlear and vestibular ganglia in ear, retina in eye and olfactory mucosa.

3. Multipolar: have one axon and many dendrites. They take different forms:
 Stellate as the anterior horn cells in spinal cord.
 Pyramidal as pyramidal cells in cerebral cortex.
 Pyriform as purkinje cells in cerebellar cortex.

B- According to function:
1. Sensory (Efferent) neurons receive sensory stimuli as cells of dorsal root ganglion.
2. Motor (afferent) neurons control effector organs such as muscles and glands as
anterior horn cells in spinal cord.
3. Interneurons connect neurons as in retina and spinal cord.

C- According to length of axon:

1. Golgi type 1: Neurons have long axons that leaves the grey matter and enters
white matter as motor neurons in spinal cord. pyramidal cells in
cerebral cortex and purkinje cells in cerebellar cortex.
2. Golgi type 2: Neurons have short axon that does not leave the grey matter as in
interneurons in cerebral and cerebellar cortex.
• Structure:
Cell body (Perikaryon)
It is the part of the neuron containing the nucleus and surrounding cytoplasm.
Size: varies from 4 um as in granular cells in cerebellar cortex to 100 um as in
motor neurons in spinal cord.
Shape: depends on the number of cell processes:
Unipolar have globular shape
Bipolar have fusiform shape
Multipolar are stellate, pyramidal or pyriform.
Nucleus: It is usually large spherical & euchrornatic with a prominent nucleolus
reflecting the intense synthetic activity of these cells.

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The cytoplasm:
1 . It contains highly developer rough endoplasmic reticulum and numerous
polyribosomes suggesting that these cells synthesize structural proteins and
proteins for transport. rough endoplasmic reticulum and free ribosomes and
polysomes appear under the light microscope as basophilic granular areas called
Nissel bodies. Their number varies according to neuronal type and functional
state.

2 . The Golgi complex is present around the nucleus.

3 . Mitochondria are scattered throughout the cytoplasm.

4 . Neurofilaments (intermediate filaments with a diameter of 10nm) are abundant

in perikaryon and processes.
They bundle together as a result of the action of fixatives to form neurofibrils (2
um in diameter) that are visible by the light microscope (stained brown by Ag).
They provide structural support.

5 . Microtubules (20-28 nm in diameter)

Arranged in parallel bundles in Perikaryon and processes.
They are involved in axonal transport of neurotransmitter substances, enzymes
and other cellular constituents.

6 . Centrioles cannot be seen as neurons cannot divide.

7 . Inclusions in form of :
- Lipofuscin pigment which is golden brown
It is a residue of undigested material by lysosomes increases with age.
- Melanin pigment which is dark brown or black is found in neurons of the
substantia nigra of the mid brain.
- Lipid droplets in the cytoplasm represent energy reserve or products of
abnormal metabolism.

Processes:
Dendrites Axon
1. Usually numerous. Single.
2. Short. Long.
3. Thick. Thin
4. Branching like a tree. Not branching except at the end.
Branchesarise at acute angle. It may give collateral branches near
The cell body that arise at right angle.
5 . Becomethinner as they subdivide Has a constant diameter.
into branches.
6 . Contain Nissl bodies. Does not contain Nissl granules.
7 . Coveredby dendritic spines that ar No spines.
specialized for synaptic contacts.
8 . Carry nerve impulses to the cell Carry nerve impulses away from
body. the cell body.

The dendrites and axon have mitochondna, neurofibrils and microtubules.

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Nerve fibre:
A nerve fibre consists of an axon. The axon is covered by axolemma and contains
cytoplasm called axoplam. It arises from a conical extension of the cell body called
axon hillock.

Types of nerve fibres:

1. Unmyelinated nerve fibres: have no myelin sheath. It is subdivided into:
 Unmyelinated fibres without sheath of Schwann cells (neurolemma) as in gray matter
(Naked).
 Unmyelinated nerve fibres with sheath of Schwann cells as in sympathetic post
ganglionic fibres.

2. Myelinated nerve fibres: have myelin sheath. It is subdivided into:

 Myelinated nerve fibres without sheath of Schwann cells as in white matter.
Myelinated nerve fibres with sheath of Schwann cells as in peripheral nerve fibers. P
The sheath of Schwann
It consists of flattened cells with flattened nuclei that form a thin chain P
around the myelin of a nerve fibre.
Functions:
1. Formation of myelin sheath in the peripheral nerves .
2. Electric insulation.
3. Regeneration where axon grows from the proximal stump along the path formed
by Schwann cells.

Myelin Sheath:
 Formed by rotation of Schwann cells (in peripheral nervous system) or
Oligodendroglia (in central nervous system) around the axon .
 Lipoprotein so dissolves by routine fixation and stained black by osmic acid
 By E/M appears as fused spiral laminae of plasmalemma.
 gaps called nodes of Ranvier represent the spaces between sheath cells.
 The sheath of myelin is thus divided into segments by the nodes which are called
internodal segments.
 Each Schwann cell wraps around one segment of a single axon while each
oligodendroglia cell warps around one segment of many axons (10-60).

Functions: Speed up the speed of nerve impulse,

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Peripheral Nervous System

It consists of Nerves. ganglia and nerve endings.

Peripheral Nerve
- The nerve is covered by dense connective tissue called epineurium.
- Bundles surrounded by the perineurium. It is formed of flattened epithelium like cells
joined by tight junctions.
This forms a barrier to protect the nerve fibres.
- Nerve fibres are connected by endoneurium (sheath of Henle). It consists of reticular
fibres formed by Schwann cells.

Ganglia
They are collection of nerve cells outside the central nervous system. 2 types; sensory
(spinal) and autonomic (sympathetic and parasympathetic).

Spinal ganglion Sympathetic

1. Covered by thick connective Issue 1. Covered by thin connective tissue
capsule. capsule.
2. Blood vessels are less. 2. Blood vessels are more.
3. Cells are unipolar. 3. Cells are stellate multipolar.
4. Cells have glomeruli formed by coiling 4. No glomeruli.
of the axon around the cell body before
splitting in a T form.
5. Cells are variable in size. 5 Cells are uniform in size.
6. Cells are larger. 6 Cells are smaller.
7. Cells are surrounded by large number of 7 Few satellite cells.
satellite cells.
8. Cells are arranged in groups or rows. B. Cells are scattered.
9. Cells are separated by myelinatec nerve 9. Cells are separated by umyelinated
fibres. nerve fibres.
10. No synapse between cells. 10. Synapse is present.

Synapse:
• It is the site of functional contact between neurons or between neurons and effector
cells.

Histologically: It is formed of:

1 . Presynaptic side rich in mitochondria and vesicles of chemical
transmitter (in chemical synapse). It shows separate zones of dense
cytoplasm.
2 . Synaptic cleft: 20-30 nm in width. It shows delicate fibres or granules.
3 . Postsynaptic side that has receptors for the chemical transmitter. It
shows a continuous zone of dense cytoplasm which is associated with
a network of filaments called synaptic web.

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Classification:
According to method of transmission of nerve impulse:
1. Chemical: most common in which electric impulse from presynaptic cell is
converted into chemical signal acts on the postsynaptic cell.
2. Electrical': in which ionic signals pass through gap junctions crossing the pre and
postsynaptic membranes.
According to the site of contact of the axon:
1. Axosomatic: axon forms synapse with cell body
2. Axodendritic: axon forms synapse with a dendrite.
3. Axoaxonic: axon forms synapse with an axon.

According to relative thickness of cytoplasmic densities on presynaptic and post

synaptic membranes:
1. Asymmetric: The post synaptic density is relatively thickerand the synaptic
cleft is about 30 nm wide.
2. Symmetric: The post synaptic density is almost similar to presynaptic density
and the synaptic cleft is about 20 nm wide.

Degeneration and regeneration of nerve tissue

In a wounded nerve fibre, there are two distinct types of changes. Retrograde degeneration:
In nerve cell and proximal part of nerve fibre.
 Chromatolysis: disappearance of Nissl substances with decrease in basophilic.
 Increase in volume of Perikaryon with loss of dendrites so becomes globular.
 Migration of nucleus to peripheral position.
 Disappearance of Golgi body and mitochondria.
 Fragmentation of neurofibrils.
 Lysosomes increase.

Wallerian degeneration: in distal part of nerve fibre.

 Axon: neurofibrils appear beaded, then segmented, then granular and finally disappear.
 Myelin sheath shows widening of nodes of Ranvier. The internodal
segments are termed fermentation chambers as fats split into fatty acids.
 Schwann cells proliferate giving rise to cellular columns that act as guide for the
growing axons during regeneration.
 transneuronal degeneration: changes resulting from axonal injury are not confined to the
injured neuron but extend to other neurons with which the injured neuron synapses.
This phenomenon is called (as in the visual pathway).

Stains of degeneration:
1. Silver: to demonstrate changes ir Golgi body and Neurofibrils.
2. Osmic acid to demonstration changes in myelin scheath.
3. Basic stains to demonstrate changes in Nissl granules.
4. Weigert - Pal stain to demonstrate normal tracts in white matter.
5. Marchi stain to demonstrate early stages of degeneration in myelinated nerve fibres .
Potassium dichromate is used --- oxidize the myelin of normal tracts only. Osmium is
then used so it stain early degenerated tracts but can not stain the previously oxidized.

Regeneration takes place where:

1. Macrophages remove debris and secrete interleukin 1 which stimulate Schwann cells to
secrete substances that promote nerve growth.
2. Growth of axons, in proximal part in direction of the columns of Schwann cells.
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Regeneration is efficient when the fibres and the columns of Schwann cells are directed
to the correct place.

NEUROGLIA
Glial cells are 10 times more abundant in the mammalian brain than neurons. They
surround the cell bodies and processes.

Astrocytes (Macroglia):
 Star shaped cells with multiple processes.
 They have large pale nucleus.
 They have Centrioles so can divide.
 By E/M, we see bundles of intermediate filaments -- keep their shape.
 They are ectodermal in origin.
 In grey matter and white matter.
 Functions:
1. They have processes with expanded end feet linked to endothelium of blood
capillaries so can control metabolic exchanges between nerve cell and blood.
[Link] brain barrier.
[Link] support.
[Link] process by formation of scar tissue.
 There are 2 types;
Cytoplasmic astrocytes Fibrous astrocytes
In grey matter. In white matter.
Cytoplasm is granular. Cytoplasm is fibrillary.
Many short processes. Few long processes.

Oligodendrocytes
 They are small cells which have few processes.
 Small dark nucleus.
 They have Centrioles.
 Dense dark cytoplasm rich in endoplasmic reticulum, Golgi body, ribosomes and
mitochondria.
 Ectodermal in origin.
 Present in both grey and white matter.
 There are 2 types:

Satellite Oligodendrocytes Interfasicular Oligodendrocytes

In Grey matter In white matter
Closely associated with the cell body in between bundles of axons
of neurons
Support nerve cells. Formation of myelin sheath and electric
insulation

Microglia (mesoglia):
 Small cells with many branches. The cell body and the branches are decorated by
spines.
 Oval dark nucleus.
 Cytoplasm is scanty.
 No Centrioles.

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 Mesodermal in origin.
 In grey and white matter.
 Phagocytic cells.
 Can be stained by vital stains as trypan blue.

Ependymal cells
 Line central canal of spinal cord and ventricles of brain.
 They form simple cuboidal or columnar epithelium that may be ciliated in places.
Cilia may be involved in propulsion of CSF.
 Ectodermal in origin.

Schwann cells
 In peripheral nervous system.
 Responsible for myelin production, electric insulation and regeneration.
 Ectodermal in origin.

Satellite cells
 Low cuboidal cells,
 In peripheral nervous system.
 Around nerve cells in ganglia.

Functions of neuroglial cells

Glial cell type Main functions
Astrocytes 1. Metabolic exchange.
2. Blood- brain barrier.
3. Structural support.
4. Repair processes.
Oligodendrocytes Myelin production, electric insulation.
Microglia Phagocytic activity
Schwann cells Myelin production, electric insulation,
regeneration.
Ependymal cells Lining cavities of central nervous
System

Nerve Endings: Nerve endings are either

A Receptors that receive external or internal stimuli and convert. They are
classified into;
 Exteroceptors which receive external stimuli.
 Proprioceptors which receive stimuli from the muscle.
 Interceptors which receive internal stimuli.

B. Effectors that bring efferent nerve impulses to effectors (muscle or gland).

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Nerve Endings in Epithelium

A- Receptors: are exteroceptors
1. Free nerve endings :
They are receptors for pain (nociceptors), temperature (thermo
receptors). toucl- pressure. itching.
In epidermis of skin and cornea of eye.
Myelinated nerve loses myelin below basement membrane & pass
between epithelial cells.
2. Merkel endings:
They are mechanoreceptors (prolonged touch or pressure on the skin).
They are present in the epidermis of the skin of palm and sole.
The nerve loses its myelin sheath and form a disc like expansion
under Merkel cell near the base of the epidermis.
3. Peritrichial nerve endings:
Free nerve endings incorporated in the hair follicles that respond to
touch and movement of hair (mechanoreceptors).
4. Neuroepithelim endings:
Taste buds in tongue for taste.
Organ of Corti in ear for hearing.
 Macula utriculi, macula sacculi and cristae ampullaris for equilibrium.

B- Effectors: These are autonomic nerve endings supplying glandular epithelium as

lacrimal and salivary glands. The umyelinated nerve fibres form networks
just outside the basal lamina of the epithelium. From there, branches
penetrate the lamina and end between the bases of the glandular cells.

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Nerve Endings in Connective Tissue

All are receptors;
1- Free nerve endings:
 Similar to those in epithelium.
 Present in the dermis of skin and stroma of cornea.

2- Meissner's corpuscle:
 Encapsulated, pear shaped.
 In dermal papillae of skin that is especially sensitive as tips of fingers.
 The axon enters the corpuscle after losing its myelin and spirals up between the
cell layers until it ends at the upper pole of corpuscle.
 It is a mechanorector (touch),

3- Krause's end bulb:

 Encapsulated, spherical bodies.
 Deep in the dermis of skin.
 The axon enters the corpuscle after losing its myelin and branches
repeatedly.
 It is a mechanorector (touch).

4- Ruffini's end organ:

 Encapsulated, fusiform bodies.
 Deep in dermis of skin especially in sole.
 The axon enters the capsule after losing myelin sheath and branches between
 Parallel collagen fibres inside.
 It is a mechanoreceptor that responds to tension forces.

5- Pacinian corpuscle:
Encapsulated, large ovoid up to 1 mm in length.
In dermis and hypodermic of skin, periosteum of bone, joint capsule and in
connective tissue of some organs as pancreas.
It has a thin connective tissue capsule enclosing 20-60 concentric lamellae
consisting of very thin flat cells (probably modified Schwann cells) separated by
narrow spaces filled with gel like material. Towards the centre, the lamellae
become closely packed.
The myelinated nerve fibre enters the corpuscle at one pole. Its Schwann cell
scheath becomes continuous with the capsule while the myelin scheath ends inside
the corpuscle. The naked nerve fibre runs parallel to the longitudinal axis and ends
in a small expansion,
It is a mechanoreceptor for pressure. vibration and tension. It is one of
the proprioceptors.

6- Golgi tendon organ (Tendon spindle):

 Proprioceptor nerve ending in tendons near the insertion sites of muscle fibres.
 It is formed of connective tissue scheath surrounding large bundles of collagen
fibres that are continuous with the collagen fibres of tendon.
 Sensory nerve penetrates the capsule to end around the collagen bundles.
 Collects information ac-out difference in tension among tendons and relays data
to CNS to help in coordination of muscular contraction
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Nerve Endings in Muscular Tissue

A- Receptors:
Muscle spindles:
 Proprioceptors within the skeletal muscle which are responsible for regulation of the
muscle tone through stretch reflex, participate in control of body posture and the
coordinate action of opposing muscles.
 Site: More numerous in muscle involved in fine movements as intrinsic muscle of
hand and in antigravity muscles.
 They lie parallel to muscle fibres.
 Shape: fusiform
 Size: up to 6 mm long but less than 1 mm in diameter.
 Structure: Capsule surrounding lymph filled space that contains intrafusal fibres
and nerve fibres.

Intrafusal fibres: Much smaller than skeletal muscle fibres and they have central non
striated area containing the nuclei. They are of 2 types:
Nuclear bag type: the central nuclear area is dilated.
Nuclear chain type: no dilatation and the nuclei are in the form of chain.

Afferent nerves:
Annulospiral endings: Unmyelinated large nerve fibres that envelope the non striated
central portion of intrafusal muscle fibres.

Flower-spray endings: Unmyelinated small nerve fibres that are located on striated
peripheral portion of intrafusal muscle fibres.

Efferent nerves: Gamma motor nerve fibres innervate striated portion of intrafusal muscle
fibres.

NB: Alpha motor nerve fibres innervate the extrafusal muscle fibres.

1- Spinal cord:
External Morphology
The spinal cord has different extent in adults and children:
- The cord occupies the upper ⅔ of the vertebral column. Its length is about 45 cm.
- Extent:
 In adults ,it extends from the upper border of atlas vertebra (here, it is continuous
superiorly with the medulla oblongata) down to the lower border of first lumbar
verterbra.
 In children, it descends to the third lumbar vertebra.

The spinal cord has two enlargements:

 Cervical enlargement at levels of origin of the spinal nerves (C4 T1) that form
the brachial plexus
 Lumbosacral enlargement at levels of origin of spinal nerves (L1 S3) that
form the lumbar and sacral plexuses

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The spinal cord is covered by 3 meninges:
 Pia mater: is adherent to the cord and continues below its termination as a flament
called filum terminale which is attached to the back of the coccyx.
 Arachnoid and dura maters: (end below at level of S2 vertebra) they form a tube
around the cord, sparated from it by the subarachnoid space filled with cerebrospinal
fluid (C.S.F) in which are suspended the filum terminale surrounded by spinal nerve
roots that descend below the cord forming a bundle called quada equine.
 Lumbar puncture: is done by inserting a needle into the back between the spines of
L3 & L4 or L4 & L5 to obtain asample of C.S.F or to inject a spinal anesthetic.
 Epidural anesthesia: a procedure in which an anesthetic is injected into the epidural
space especially during childbirth.

The spinal segments do not lie level with their corresponding vertebrae:
Spinal segments Vertebral column
- From level of foramen magnum down to 7th cervical
vertebra
C1 C8
- Substract one from the eight cervical spinal segments.
- From 7th cervical vertebra down to the 4th thoracic
vertebra
T1 T6
- Substract two from the upper six thoracic spinal
segments.
- From 5th thorcic vertebra down to 9th thoracic
vertebra
T7 T12
- Substract three from the 12 thoracic spinal segments.
- From 10th thoracic vertebra down to the first lumbar
Lumbar and sacral segments vertebra
- Substract four from the five lumbar spinal segments.

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Blood supply
Arterial blood supply of the spinal cord
The spinal cord is vascularised from 3 sources:
 Anterior spinal.A (single).
 Posterior spinal.A (paired).
 Spinal or radicular arteries (numerous).
1. Anterior spinal artery :
- It is formed by the union of two anterior spinal arteries, each arises from the
intracranial (4th ) part of the vertebral.A.
- The single artery, so formed, descends via the foramen magnum, runs inferiorly
on the anterior median fissure of the cord.
- Distribution:
 Branches to the medial part of the pyramid of the medulla oblongata .
 Central (end) arteries which supply the anterior ⅔ of the cross – sectional
area of the cord (anterior + lateral white columns and anterior + lateral grey
columns up to the dorsal nucleus of Clarke at the base of the dorsal horn).

2. Posterior spinal arteries:

- Each arises from the 4th part of the vertebral artery .
- Each descends via the foramen magnum close to the entry zone of the dorsal
roots.
- Distribution: They give central branches which supply the posterior ⅓ of the
cross sectional area of the cord.

N.B.: by themselves, the above mentioned 3 longitudinal vessels are just cabable
of supplying only the cervical part of the cord. Lowerdown, they become
less efficient and need to be reinforced by the radicular branches of the
spinal arteries mentioned below.

3. Radicular branches of the spinal arteries

- They arise ( on each side ) from:
 Vertebral.A.
 Deep cervical.A.
 Posterior intercostal arteries.
 Lumbar arteries.
- They pass via the intervertebral foramina to enter the vertebral canal.
- Close to the cord, each spinal artery divides into:
 Posterior radicular branch runs along the dorsal root to reach the cord.
 Anterior radicular branch runs along the ventral root to reach the cord.

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Arterial anastomoses of the spinal cord:

1. Circular anastomosis
- The radicular branches of the spinal arteries anastomose with the side branches
of the three longitudinal spinal arteries forming the arterial vasacorona,
supplying the peripheral zone of the cord .

2. Longitudinal anastomosis
- The spinal artery of the 11th posterior intercostal artery is very large and gives
rise to large radicular branches.
- Its anterior radicular artery (the great radicular artery of Adamkiewicz) reaches
the anterior median fissure of the cord, where it divides into large ascending and
descending branches anastomosing and reinforcing the anterior spinal artery.
This radicular artery is the main blood supply to the lower ⅔ of the cord.

Venous drainage of the spinal cord:

- There are 6 longitudinal venous channels arranged as follows:
 Anteromedian and posteromedian channels.
 Right and left anterolateral channels adjacent to the ventral nerve roots.
 Right and left posterolateral channels adjacent to the dorsal nerve roots.
- These channels are interconnected on the surface of the cord, forming the
venous vasacorona.
- The channels are drained by the radicular veins which terminate in the internal
vertebral venous plexus in the epidural space.

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- The latter plexus is drained by the valveless intervertebral veins which end in:
 Vertebral veins.
 Posterior intercostal veins.
 Lumbar veins.
 Sacral veins.

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Synapse:
Definition: area of contact of two neurons without cytoplasmic continuity.

Structure of synapse:

There are many more neurotransmitters in the CNS than in the PNS

-Mechanism of synaptic transmission

- Action potential reach end of presynaptic neurone
- Open Ca++ channels
- Ca++ enter presynaptic nerve
- Release NT
- NT cross cleft
- NT sit on receptors
- According to NT if excitatory-----------open Na+ channels -----deoplarization
If inhibitory------------open K+ channels -----hyperpolarization
- Remove NT by 1-inactivation, 2-diffuse away from receptors,3-active uptake

- Properties of synaptic transmission

1- Forward direction ----from pre to post synaptic membrane
2- Delay : 0.5msec
3- Fatigue: decrease impulse discharge due to: 1- Exhaust vesicles
2- Inactivate post synaptic receptors
4-plasticity: Change function of synapse according to demand

Types of synaptic potential

Post synaptic potential Presynaptic potential

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Post synaptic potential
Excitatory post synaptic potential Inhibitory post synaptic potential
- Partial depolarization - Partial hyperpolarization
- Of post synaptic membrane - Of post synaptic membrane
- Due to excitatory transmitter - Due to inhibitory transmitter
- The membrane is facilitated (need weaker - The membrane is inhibited (need
stimulus to be excited) higher stimulus to be excited)
- Due to open of Na+ , or Ca++ channels - Due to open K+ channels or close
- To reach threshold it must be SUMMATED Ca++ channels
* Types of summation: - Can be summated
1-Temporal summation:
One presynaptic membrane is
stimulated repeatedly
2-Spatial summation:
More than one presynaptic
neuronestimulated at same time

Presynaptic potential
Presynaptic inhibition Presynaptic facilitation
(sensitization)
- 3rd neurone rd
- 3 neurone
- Inhibitory neurone - Excitatory neurone
- Anastomose with the excitatory - Anastomose with presynaptic
presynaptic membrane neurone
- The third neurone release INHIBITORY - Release excitatory transmitter
neurotransmitter - The excitatory transmitter cause –
- The inhibitory neurotransmitter cause: 1- Increase cAMP:
open K+ or Cl- channels OR Close Na+ , cause phosphorylation of K+
or Ca++ channels. channels close the K+ channels
- The close Ca++ channels prevent entry of prevent repolarization prolong
Ca++: Thus decrease release action potential
neurotransmitter 2- Keep Ca++ channels open:
Increase release of transmitter

The chemical transmitters

Small molecules Large molecules
1- Acetylcholine 1- Hypothalamic peptides
2- Amines 2- Pituitary peptides
3- Amino acids 3- Gut peptide
4- Rapidly acting 4- Released at slow rate
5- Released in large amounts 5- Cause prolonged action

NB:
- Glutamate is the most widespread excitatory neurotransmitter in the CNS.
- Glutamate receptors have been typed as either AMPA or NMDA receptors, named
after the agonists that were first used to distinguish them
-The NMDA receptor is a cation channel that is permeable to Ca2+ ions in addition
to Na+ and K+.

- GABA and glycine are the primary inhibitory neurotransmitters of the CNS

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- GABA is predominant in the brain and its main function is in local circuit
interneurons.
- GABAA receptors bind benzodiazepines, such as diazepam and
chlordiazepoxide, and barbiturates, such as phenobarbital and secobarbital. The
effect of GABA is modulated by benzodiazepines, increasing the frequency of
channel opening, and thus also GABA-induced Cl– current
- Barbiturates act by increasing the length of time that a Cl– channel remains open.
This dampening, inhibitory effect on generalized CNS activity underlies the use
of benzodiazepines and barbiturates as anti-convulsants
- Picrotoxin and bicuculline inhibit GABA receptor function and produce
widespread and sustained seizure activity due to a generalized dampening of
inhibitory synapses throughout the CNS. Penicillin inhibits GABA receptors in a
similar way and, at a high enough concentration, is also a potent convulsant

Factors affect synaptic transmission

Change in composition of Drugs Diseases
internal environment

1-Change in composition of internal environment

Water &
PH of blood Hypoxia Hypoglycemia Hormones
electrolytes
1- Alkalosis: Decrease Decrease Some increase &
Increase synaptic synaptic others decrease
synaptic transmission transmission synaptic
transmission transmission
(convulsion)
2- Acidosis:
Decrease
synaptic
transmission
(Coma)

2-Drugs
Theophylline , caffeine Strychnine Anaesthesia
theobromine
+++ synaptic transmission +++synaptic transmission Decrease synaptic
* Compete with glycine: transmission: By
Inhibitory transmitter stabilizing the membrane
hyperpolarization

3-Diseases
Tetanus Botulism toxin
*Decrease inhibitory transmitter GABA: * Block release acetyl choline:
Increase synaptic transmission Inhibit synaptic transmission

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Neuronal pool:
1- Divergence: one neurone stimulate many neurons

Function of divergence:
1- Amplification 2- Distribution of signals

2- Convergence: many neurons stimulate one neurone

Function of convergence:
1- Intensification of stimulus 2-interpretetion of information

3-Excitation field:
Number of neurons with which one neurone synapse

Discharge zone: central neurons in the excitation field

Facilitation zone: (subliminal fringe): peripheral neurons of excitation field

The stronger the stimulus the wider is the discharge zone

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Facilitation: On overlap of the facilitated zones of 2 adjacent nerves -----the out

come when they are stimulated simultaneous is greater than that when
they are stimulated separate

Occlusion: On overlap of the discharge zones of 2 neurones the out come of the 2
pools is less when stimulated simultaneous than when each nerve is
stimulated separately

INHIBITORY CIRCUITS:
1-lateral inhibition ( receprocal innervation) 2-negative feed back
1-lateral inhibition: There is an inhibitory interneurone from the presynaptic
neurone interneurone goes laterally to inhibit the peripheral
nerves
2-negative feed back: Motor neurone is stimulated
Send collateral
To inhibitory interneurone (Renshaw cell)
End on the surrounding nerves of the motor neurone cell
Inhibit the surrounding cells
Function:
1-prevent over excitation of nerves
2-sharpen motor action
3-receprocal innervation:
Def: contraction of one muscle & inhibition of the
antagonist

-Inhibitory circuits & the excitatory circuits & their function

Activating circuits
Parallel circuits Reverberating circuits
- The presynaptic neurone is connected to - Post synaptic membrane send collateral to
post synaptic neurone BY PARALLEL re stimulate itself : this is stopped by
CIRCUITS----SUCCESIVE fatigue
IMPULSES REACH OUT PUT---
PROLONG DISCHARGE

Receptors & their types

Modified nerve endings , of afferents , receive & convert stimuli into action potential
They act as: 1- Detectors---detect change in environment
2- Transducers—transform energy to action potential
3- Inform CNS

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Properties of receptors:
Specificity Excitability Adaptation
(receptor potential)
- Each receptor is sensitive - Partial depolarization Decrease frequency of
to one type of sensation - Spread passive action potential despite
(stimuli) called adequate - If reach firing level--- constant application of
stimulus form action potential stimulus
- Due to open Na+ channels * Classification of
- Depolarization receptors according to
- Number of Na+ channels adaptation:
opened is direct 1- Slow adapting
proportional to intensity receptors-pain
of stimulus receptors
- Weber Fechner law: 2- Moderate adapting
Frequency of action pot. receptors-
Is direct proportional temperature
tointensity of stimulus recep.,smell recep.
3- Rapid adapting
* Properties of receptor receptors-touch
pot.: recep (pacinian
- Local partial corpuscle, Messiner
depolarization corpuscle.
- Due to open Na+ *Mechanism of
channels adaptation:
-Not obey all or non 1-inactivation of Na+
law channels In nerve
- No absolute terminal
refractory period 2-inactivation of Na+
- Can be summated channels in first node
- Can be graded of ranvier
-Not blocked by local 3-remodelling of
anaesthesia receptors

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NB: Relation between the strength of stimulus and magnitude of receptor potential:
* The magnitude of receptor potential increases as the strength of stimulus
increases
Relation between the magnitude of receptor potential and frequency of of
impulses formed in sensory nerve:
* The more the receptor potential the greater the frequency of action potential

Sensory code:
Def: ability of the CNS to detect
1-modality ( type), 2- Locality (site) , 3- intensity of sensation
Modality of sensation Locality of sensation Intensity of sensation
Adequate stimulus: Law of projection: The intensity of stimulus is
Def: each receptor is -each part of the body sends encoded by:
specialized to receive the impulses to specific area 1-number of receptors
certain stimulus ---adequate of the brain activated by the stimulus:
stimulus
The higher intensity of
Mullers law: stimulus
Each receptor gives only
one type of sensation when stimulate more receptors
stimulated this is
irrespective of the method more action potential to
of stimulation brain

Labeled line principle: 2-frequency of impulses:

Each sensation reaches the
CNS in a specific pathway Stronger stimuli

Increase frequency of A.P.

Types of sensation:
Pain sensation Thermoreceptive Mechanoreceptive Mechanoreceptive
sensation senation sensation
1-cutaneous 1-cold Tactile: Kinestesia
2-deep 2-warm 1-touch (crude, fine) (proprioception)
3-visceral 1-sense of position
2-stereognosis 2-sense of
3-pressure movement
4-vibration
5-itch , tickle

Somatic sensory afferents:

According to velocity of conduction According to importance of sensation
1-A A alpha ---proprioception ---M---80-
A alpha 120m/second
A beta A beta ---fine touch
A delta Stereognosis-------M---35-70 m/sec
Vibration
2-B A delta ---pain ,temp. ------M—5-30m/second
C ----------slow pain -------un M. –0.5-2 m/sec
3-C

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- The somatic sensory cortex areas:
Somatic sensory cortex:
Somatic sensory area I Somatic sensory area II Somatic association area
1-in the post central gyrus 1-behind and below lower 1-behind lower part of
part of somatic sensory sensory area I area 5,7
2-receive sensation from area I
opposite side of body 2-Receive signal from
(crossed representation) 2-the body is represented *somatic sensory area I,II
as *thalamus
3-the body is represented *face anterior *visual cortex
*upside down(inverted) *arms central *auditory cortex
*large area for certain *legs posterior
areas (thumb, lips) 3-function
(spatial) 3-function Collect information to
4-function It begins to make understand meaning
it receives sensation meanings for sensory
*fine touch signals
*pressure Eg: *shape of subject in
*vibration hand
*position *texture of subject in hand
*steriognosis
*kinesthesia

- The receptors for thermal sensation:

Cold receptors Warm receptors Cold pain receptors
Hot pain receptors
F.N.E. which are attatched F.N.E. which are attatched Freezing cold or burning
to A delta , C fibers to , C fibers hot

- The Characters of thermoreceptors:

1-immediately under skin
2-cold recepotors > warm receptors
3-warm receptors adapt more rapid than cold receptors
4-thermoreceptors are located more in: *lips
*fingers
*trunk
5-mechanism of stimulation:
Change in temperature
Change metabolic rate
Release metabolites
Stimulate receptors
NB: 10 degrees change in temperature: Increase metabolites twofolds

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Range of stimulation of thermoreceptors:

Cold receptors Warm Cold pain Warm pain Anaesthesia

receptors receptors receptors (no action
potential)
* Discharge * Discharge * Discharge * Discharge * At zero
between between between above 45 degrees
temperature temperature temperature degrees
10-43 30-50 5-15 degrees
degrees degrees
* Maximal * Maximal * Maximal
discharge at discharge st discharge at
25 degrees 45 degrees 5 degrees

A-Kinesthesia
Def: ability of the brain to detect position of joint in relation to each other during
REST & Movement
Receptors are 1-Ruffini end organ----slow adapting
2-pacinian ---------------rapid adapting
Pass in dorsal column

B-Steriognosis
Def: Ability to detect shape of object put in hand with eyes closed
* This depends on previous knowledge of the object----A beta fiber
Pass in dorsal column
C-Pressure
Def: Ability to detect weight of object with eyes closed and differentiate between
weights
*Receptors –Pacinian corpuscle
Pathway ----dorsal column

Vibration sense
Def: Rhythmic repetitive pressure sense (ability to feel vibration on bony
prominences ----cause magnification of stimulus )
*tested by tunning fork
*on bony prominenses
*from below upwards
*to detect level of nerve injury
*it is tested for both sides of the body
*to test hemianaesthesia
*receptors
1-Meisner corpuscle—up to 80c/sec
2-Painian corpuscle – up to 500 c/sec
*if the vibration sense is depressed this may be
1-degenerate posterior column (Dorsal column) as in diabetes
2-Pernicious anemia
Itch and tickle :
Tickle----feel moving things on skin as insects
Itch------sense caused by chemical substance secreted beside receptors as histamine
Receptors ----free nerve endings

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Pathway----ventral spinothalamic
Crude touch Fine touch
Poor localized Well localized
Pathway---ventral spinothalamic -tactile localization
-tactile discrimination
-texture
-stereognosis

-Pain
Def: un pleasant sense due to tissue damage.
Pain receptors: they are F.N.E

- The chemical mediators

bradykinin ---most painful ,-prostaglandins .-serotonin ,-histamine ,-K+
NB: they stimulate the chemoreceptors & lower the threshold for pain stimulation for other
pain receptors.

-The distribution of pain receptors

More Less Absent (pain insensitive)
-skin Deep tissues -liver parenchyma
-periosteum -alveoli of lung
-arteries -brain
-joints
-falx
-tentorium
NB: the pain receptors are slowly or non adapting receptors

- Types of pain:
According to quality of pain According to site of origin of pain
*fast (acute) pain *cutaneous pain
*slow (chronic) pain *Deep pain
*Visceral pain

*According to quality of pain:

Fast (pricking) (acute) (immediate) pain Slow (burning) (chronic) (aching)
(throbbing) pain
-felt within 0.1 sec. -felt after 1 sec.

-of short duration -of long duration

-well localized -poor localized

-all pain receptors are stimulated by the

-accept pain from SKIN, slow burning pain
PLEURA,PERITONEUM

-the fibers are A delta fibers -occur in *SKIN , *DEEP TISSUES

-the fibers release neurotransmitter -the fibers are C fibers

GLUTAMATE

-the action potential pass in the lateral The fibers release chemical transmitter
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spinothalamic tract SUBSTANCE P

-the action potential ends in the sensory -the action potential pass in the lateral
cortex spinothalamic tract

-this type of pain is blocked by *hypoxia -The action potential end in the reticular
,*pressure formation---then thalamus---then cortex
-this type of pain is blocked by lacal
anaesthesi (cocaine)

II –According to site of origin of pain:

Cutaneous pain Deep pain Visceral pain
*produced by stimulating *produced from *produced from viscera
pain receptors in skin -muscles
-joints *conducted through C
*it is first fast pricking -tendons fibers
then followed by slow -periosteum
burning -ligaments *pain from peritoneum &
pleura is conducted along
*it is well localized for *due to A delta fibers.
1-high number of pain -inflammation *characters:
receptors in skin -ischaemia -diffuse
2-reach cortex -spasm -dull
-aching
*characters: -depressor
-diffuse -gaurding
-dull
-aching
-depressor

Example:
Inflammation of vessel
Thrombosis
Narrowing
Decrease blood supply
Release metabolites
(lactic acid)
Deep pain
1-(as in ANGINA,IN
HEART MUSCLE,)
2-(as in INTERMITTENT
CLAUDICATION in
SKELETAL MUSCLE)

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- Causes of visceral pain:
1-ischaemia 2-inflammation 3-irritation 4-distension of 5-spasm of
of peritoneal hollow viscera hollow visrea:
covering

the decrease in Release peptic ulcer Distend bladder Spasm of

blood supply proteolytic ureter
enzymes HCL increase Mechanical
accumulate stimulation Ischaemia
metabolites Stimulate pain Irritate
receptors stomach wall Release Stimulate pain
stimulate pain metabolites receptors
receptors
Stimulate
chemoreceptors

-The reaction to pain:

Autonomic reactiction Emotional reaction Motor reaction
1-Cutaneous pain 1-cry 1-FWR
*increase HR 2-depression 2-increase muscle tone
*increase BP above diseased
2-visceral pain area(rigidity of over lying
*decrease HR muscles)(muscle guarding)
*decrease BP ---to protect the inflamed
area

- Reffered pain & its mechanism:

Def: pain from diseased viscera not felt on the viscera but felt on skin area originating
from the same dermatome as the diseased viscera.

Mechanism of referred pain:

1-Convergence projection theory:
*The afferent pain fibers from the SKIN & the DISEASED AREA converge on the
same SGR--------------finally activate same cortical cells
*The brain project the pain to be coming from the skin as it is the commonest source for
pai

2-Facilitation theory:
The afferent fibers from the diseased viscera send stimulating fibers to the cells of the
SGR leading to facilitation
Examples:
Cardiac pain Gall bladder Gastric pain Appendix Renal pain
Felt Felt Felt Felt Felt
*retrosternal *tip of scapula *between *umbilicus *testes
*left arm umbilicus and *back
xiphoid

- Headache & its types & causes:

Def: It is a type of referred pain
*the brain itself is insensitive
*the intracranial structures which are sensitive are:

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1-dural arteries , 2-venous sinuses, 3-dura
*stimulating the pain receptors above the tentorium -----result in FRONTAL headache
*stimulating the pain receptors below the tentorium -----result in OCCIPITAL
headache

Causes (types ) of headache:

Causes of intracranial headache Causes of extracranial headache
1-Meningial irritation 1-Muscle spasm
*Meningitis
*Brain tumors 2-nasal sinuses irritation
*Operation trauma
3-Errors of refraction
2-Migraine headache
*Special type of headache 4-Otitis media
*Caused due to vascular change
Emotion 5-Toothache
VC of cerebral vessels
Ischaemia 6-anemia , CO poisoning
prodroma
Nausea,sensory hallucination ischaemia
form increase metabolites
VD
Pulsation in blood vessels
Headache

3-hypertension:
Expand cerebral vessels
Headache

4-intracranial pressure:
If decreased CSF
Descend of brain
Tract the dura
Headache

5-Alcohol headache:
The alcohol directly irritate the meninges

6-constipation
Absorb toxic subatances
Irritate meninges

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- The pain control system:
Brain opiate system Supraspinal analgesia Gate inhibition
system
*inside the body there are Pituitary & hypothalamus *The SGR act as gate for
secreted OPIOID pain impulses to reach
PEPTIDES Beta Endorphins cortex
+++peraquiductal grey
*the opioid peptides are 1- area *the gate can be closed by
ENKEPHALINES 1-RUBBING –inhibit pain
2-ENDORPHINS Secrete ENKEPHALINS 2-THINKING –inhibit
3-DYNORPHINS pain
+++Raphe magnus 3-aquipuncture
*they act on opiate
receptors inside the body Secrete SEROTONIN
to cause ANALGESIA
Pain inhibitory area in
*Opiate receptors are spinal cord
1-Delta---high affinity to
ENKEPHALINS Inhibit SGR (prevent
2-MU ---high affinity to substance P) release
ENDORPHINS
3-KAPPA –high affinity to
DYNORPHINS

*Opiate receptors are

blocked by NALOXONE

*the opioid peptides do not

cross the BBB so their IV
is not effective

The Endogenous opioid peptides:

Enkephalins Endorphins Dynorphins
*5 amino acids *30 amino acids *17 amino acids
*Meta enkephalins *Beta endorphins *potent analgesic
Leu enkephalins *in pituitary & *cause addiction
*present in SGR,limbic hypothalamus
system *secreted in STRESS
conditions ---cause
STRESS ANALGESIA

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-Lesion of the sensory system: It may be in the:
Spinal cord
1-Herpes zoster
Def: Virus of chicken pox after resolve remain in the Dorsal root
ganglia
*cause painfull red papules along the course of the nerve

3-Tabes dorsalis
Def: *syphilitic disease
*The spirochaetes attack
the posterior root
*lead to
-pain
-loss of fine touch,
Pressure, vibration, kinesthesis
*Lead to sensory ataxia (incoordination of movement in absence of
paralysis.
(+ve Romberg sign) = (patient erect when open eye then on close eye
he fall .
4-Brown sequard syndrome
(Hemisection of spinal cord)
1-At level of lesion:
On the same side
Sensory:
Loss of all sensation of this segment
Motor:
Lower motor neuron lesion
-atonia
-areflexia
2-below level of lesion:
On the same side:
Sensory:
Loss of all sensation of the dorsal column(fine touch ,pressure,
vibration, kinesthesia
Motor:
UMNL
-spasticity
On opposite side:
Sensory:
Loss of all sensation of anterolateral system(pain ,temp. crude touch ,
itch , tickle.)
Motor:
No motor loss

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Motor nervous system:

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-Stretch reflex.
Def: Reflex contraction of the muscle in response to stretch.
Components of the stretch reflex:
Stimulus –stretch of the muscle extrafusal fibers
Receptor – Muscle spindle
Afferent -thick myelinated fibers
Center – spinal cord (monosynaptic)
Efferent – thick myelinated fibers
Response – muscle contraction

- Properties of stretch reflex:

-monosynaptic
-fastest reflex in body
-restricted to stretched muscles
-does not show fatigue

Innervation of muscle spindle:

Afferent (sensory): *primary ending
*circle central part of nuclear bag and chain
*secondary ending
*circle nuclear chain only
Efferent (motor)
*dynamic gamma efferent---to peripheral contractile part of nuclear bag
*static gamma efferent ----to peripheral contractile part of nuclear chain

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Properties of stretch reflex:

-monosynaptic
-fastest reflex in body
-restricted to stretched muscles
-show receprocal innervation
-more in antigravirty muscles
-does not show fatigue

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- Types of Strech Reflex
Static stretch reflex Dynamic stretch reflex

*It is the base of MUSCLE *it is the base of TENDON JERK

TONE as the tone in the *its stimulus is SUDDEN STRETCH OF MUSCLE
antigravity muscles *the receptor is muscle spindle (NUCLEAR BAG
*its stimulus is SUSTAINED TYPE)
STRETCH of the muscle *afferent ---primary ending
*the receptor is muscle *response is SUDDEN CONTRACTION
spindle(NUCLEAR CHAIN FOLLOWED BY RELAXATION
TYPE)
*afferent ---primary &
seondary endings
*response is CONTINUOUS
CONTRACTION OF THE
MUSCLE
Facilitatory supra spinal Inhibitory supra spinal centers
centers
1-facilitatory reticular formation 1-inhibitory reticular formation
2-motor area 4 2-area 4 S (cortical suppressor area)
3-neocerebellum 3-paleocerebellum
4-vestibular nuclei 4-red nucleus
NB: 5-basal ganglia
*facilitatory reticular formation NB:*inhibitory reticular formation has no intrinsic
has intrensic activity activity

-Function of stretch reflex:

1-static stretch reflex is the base of MUSCLE TONE
2-role of stretch reflex in controlling voluntary movement.
3-clinical importance of stretch reflex
Static stretch reflex is the base of muscle tone:

Skeletal muscle tone:

It is Reflex subtetenic alternating contraction of skeletal muscle fibers that lead to
muscle tension – it occurs especially in antigravity muscles

Mechanism:
During rest the muscle is continuously stretched as length of the muscle is shorter than
the distance between the origin and insertion
The muscle tone acquire NO FATIGUE.

Causes:
1-alternating activity of different motor neurons --- alternating contraction of group of
muscle fibers and the other group relax and rest
2-the reflex contraction is SUBTETANIC

Function of muscle tone:

1-keep body position against gravity
2-keep viscera in position

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3-maintain body temperature----muscle contract ---release energy----increase
metabolic rate
4-help venous return and lymph drain
2-role of stretch reflex in controlling voluntary movements.
1-Damping function of stretch reflex:
2-servoassist function during muscle contraction:

3-Clinical importance of stretch reflex:

Tendon jerk (Deep reflexes)
(Dynamic stretch reflex)
Def: Sudden strike of tendon of muscle lead to sudden stretch of the muscle which
lead to reflex contraction of muscle followed by relaxation

Inverse stretch reflex:

Def: Marked stretch of the muscle ----lead to reflex relaxation of the muscle
Stimulus: increase tension in the muscle (as in marked stretch OR strong contraction)
Receptor---GOLGI TENDON ORGAN
*receptor
*in the tendon
*parallel with muscle fibers
*stimulated by high tension in muscle
Afferent: myelinated
Center: spinal cord (BI SYNAPTIC) (2 interneurons
Efferent: alpha motor neuron fiber inhibitory to muscle fiber
Response: relaxation of muscle (decrease muscle tone to prevent tear of muscle fibers)

Clinical application of inverse stretch reflex:

Clasp knife rigidity:
Def: resistance at first then sudden release
felx upper limb
(extensors are stretched)
stimulate muscle spindle
increase muscle tone (Resistance)
stimulate golgi tendon receptor
inhibit Alpha motor neuron
relaxation of muscle (Release)

Polysynaptic reflexes:
1-flexor withdrawal reflex:
Def: flexion & withdrawal of limb away of injurious stimulus.
Stimulus: painful stimulus on limb
Receptor: F.N.E. (free nerve ending)
Afferent: A delta fibers , C fibers
Center : spinal cord (polysynaptic)
Efferent: Alpha motor neurone
Response: flexion & withdraw of limb away of pain stimulus
-pattern of contraction depend on site of stimulation
-tetanus (there will be continuous contraction)

2- Crossed extensor reflex:

Def: Application of injurious stimulus to a limb this leads to Reflex flexion of Reflex
extension of Ipsilateral contralateral limb to support body weight

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*Properties of C.E.R.:
1-the latent period in C.E.R. LONGER than F.W.R.
2-after discharge in C.E.R. LONGER than F.W.R.
3-it has receprocal innervation

3-Reflexes of posture & locomotion:

4-superficial skin reflexes:

1-abdominal reflexes
2-cremasteric reflex
3-planter reflex

5-Autonomic reflexes:
1-micturation reflex
2-defecation reflex
3-sweating

Degenerative diseases
Neurones in the CNS are post-mitotic cells and the potential for replacement is, limited. As
such, pathological neuronal loss is likely to have serious consequences for brain function.
- Neuronal death is a common feature of a group of disorders termed neurodegenerative
disorders.
- Neuronal death in neurodegenerative disease can occur by one of two processes:
• Necrosis (usually induced by acute injury) involves cell swelling, vacuolization, and
lysis and is often associated with an inflammatory response
• Apoptosis (or programmed cell death) can be triggered by extracellular signals that
occur normally during development but can also be triggered pathologically during
neurodegenerative disease. It is characterized by cell shrinkage, nuclear chromatin
and DNA damage, and by the activation of caspases that break down certain
intracellular proteins
• Macrophages remove dead cells without inducing inflammatory responses.

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Central Nervous System

General characteristics:
1. Covered by meninges.
2. Protected by bone.
3. Soft jelly like because it does not contain connective tissue.
4. Consists of white matter and grey matter according to the distribution of myelin.

Divisions of the central nervous system:

1. Brain: it is composed of 3 subdivisions;
 Cerebrum.
 Cerebellum.
Diencephalon(thalamus, hypothalamus, subthalamus and epithalamus),
 Brain stem: formed of
Mid brain,
Pons and
Medulla.
2. Spinal cord:

Histology of spinal cord

General characteristics of spinal cord section:

1. It has a central canal.
2. It has an H- shaped grey matter in the centre.
3. It has a peripheral white matter.
4. It has a dorsal median septum and a ventral median fissure.

The central canal lined by simple cubical epithelium that is ciliated in some parts.

The Grey matter:

 Formed of nerve cells, unmyelinated nerve fibres and neuroglial cells.
 It is formed of 2 dorsal (posterior) horns and 2 ventral (anterior) horns joined by a
transverse connection called grey commissure.
 In Thoracic and upper 2 lumbar segments there are additional 2 lateral horns.
 The posterior horns contain sensory nuclei.
 The anterior horns contain motor nuclei.
 The lateral horns contain sympathetic nuclei.
 The commissure contains commissural nuclei.

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The white matter:
 It is formed of myelinated nerve fibres and neuroglial cells.
 In each half of spinal cord, it is divided into 3 columns; posterior, lateral and anterior.
 Posterior (dorsal) column: lies between dorsal median septum and posterior horn.
 It contains ascending tracts only.
 Lateral column: lies between anterior and posterior horns.
 Anterior (ventral) column: lies between ventral median fissure and anterior horn.

Anterior and lateral columns contain both ascending and descending tracts.
To identify the level of sectioning in the spinal cord 5 points should be considered

Cervical Thoracic Lumbar

1- Outline of oval rounded Rounded
section
2- Position of ventral Slightly ventral Central
central canal
3- Number & 4 horns: 2 thin 6 horns: 4 thin 4 horns; 2 thick
shape of horns diverging dorsal horns& 2 small almost parallel
of grey matter horns & 2 thick lateral horns dorsal horns
Ventral horns & 2 thick ventral
horns
4- White largest large Smallest
matter/grey
matter ratio
5- Size large small Large

Tracts of the spinal cord

Tracts are
1. Long: ascending or descending.
2. Short: both ascending and descending.

Ascending tracts of spinal cord

4 tracts carrying sensations that reach the 4 tracts that carry impulses to sub cortical
cerebral cortex level
1. Gracile tract. 1. Dorsal spinocerebellar tract.
2. Cuneate tract. 2. Ventral spinocerebellar tract.
3. Lateral spinothalamic tract. 3. Spino olivery tract.
4. Ventral spinothalamic tract. 4. Spinotectal tract.

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Pathway of Proprioception and Fine Touch from the Body
Proprioception: sense of position, movement and vibration.
Fine touch: sense of tactile localisation, tactile dis-crimination and stereognosis.

Receptors for Proprioception:

1. Muscle spindle in the muscle.
2. Tendon spindle in the tendon.
3. Pacinian corpuscle in the connective tissue capsule of joints.

Receptors for fine touch;

1. Meissner's corpuscle.
2. Ruffini's corpuscle.
3. Merkel's disc.

First order neurons:

They are the large cells in spinal ganglia. They receive impulses from receptors by peripheral
Thick myelinated nerve fibres and send them to spinal cord by central branches that enter the
spinal cord through the medial division of posterior roots.
 Branches from sacral, lumbar and lower thoracic segments ascend as gracile tract on the
same side.
 Branches from upper thoracic and cervical segments ascend as cuneate tract on the same
side.
 Gacile and cuneate tracts end In the gracile and cuneate nuclei in medulla on the same side

Second order neurons:

They are Gracil and cuneate nuclei in the medulla. They give rise to internal arcuate fibres that
cross to the opposite side at the upper half of closed medulla (sensory decussation) to form
medial lemniscus.

Third order neurons:

They are the cells of posterolateral ventral nucleus of thalamus (PLVNT). Their axons ascend
in sensory radiation to reach sensory area in post central gyrus of cerebral cortex (area 3,1,2).

Medial Lemniscus
 Definition: ascending sensory bundle in the brain stem
 Origin: gracile and cuneate nuclei in closed medulla of opposite side that give rise to
internal arcuate fibres. The fibres cross to opposite side in upper half of closed
medulla (sensory decussation).
 Course: ascend in brain stem in a medial position.
 Termination: P.L.V.N in thalamus.
 Function: carry Proprioception and fine touch from opposite side of body.

Tabes dorsalis:
 It is a bilateral progressive degeneration of gracile and cuneate tracts.
 Occurs in syphilis.
 Results in loss of proprioception and fine touch.
 The patient suffers from sensory ataxia which is a disturbance of gait, unless patient
see the movements of his limbs –--- he fall

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Pathway of pain and temperature from the body
Receptors: Free nerve endings.

First order neurons:

They are the small cells in spinal ganglia .They receive impulses from receptors by
peripheral thin myelinated nerve fibres and send them to spinal cord by central
branches that enter the spinal cord through the lateral division of posterior roots.
Fibres travel up or down 1 or 2 segments in Lissauer's tract then end in substantia
gelatinosa of rolandi nucleus.

Second order neurons

They are the cells in substantia gelatinosa of Rolandi. Their axons cross to the
opposite side anterior to the central canal in the anterior white commissure to form
lateral spinothalamic tract in the lateral column of white matter. It ascends through the
brain stem. In the pons it joins the ventral spinothalamic tract to form spinal
lemniscus that ends in the P.L.V.N of the thalamus.

Third order neurons

They are cells of posterolateral ventral nucleus of thalamus (P.L.V.N.T).
Their axons ascend in sensory radiation to reach sensory area in post central gyrus of
cerebral cortex (area 3,1,2)

Pathway of crude touch from the body

Receptors:
1. Free nerve endings.
2. Peritrichial nerve endings.
3. Merkel's disc.
4. Meissner's corpuscle.

First order neurons:

They are the medium sized cells in spinal ganglia .They receive impulses from
receptors by peripheral medium sized myelinated nerve fibres and send them to spinal
cord by central branches that enter the spinal cord through the medial division of
posterior roots. The fibres ascend in the spinal cord for few segments to synapse with
the nucleus proprius. While ascending they send collaterals to a large number of
nucleus proprius.

Second order neurons:

They are cells in nucleus proprius. Their axons cross to other side in anterior white
commissure to form the ventral spinothalamic tract in the ventral column of white
matter. It ascends through the brain stem. In the pons it joins the lateral spinothalamic
tract to form spinal lemniscus that ends in the P.L.V.N of the thalamus.

Third order neurons:

They are the cells of posterolateral ventral nucleus of thalamus (P.L.V.N.T). Their
axons ascend in sensory radiation to reach sensory area in post central gyrus of
cerebral cortex (area 3,1,2).

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Lateral spinothalamic tract Ventral spinothalamic tract

Definition Long ascending sensory tract Long ascending sensory tract in
in spinal
Origin i l d of opposite side
Cells of SGR C d of MSN of opposite side
Cells
Course Crossed. Crossed
Lateral column (all levels). ventral column of spinal cord (all
Joins ventral spinothalamic tract levels).
at the pons to form spinal Joins lateral spinothalamic tractat the
lemniscus pons to form spinal lemniscus
Termination PLVNT PLVNT
Function Pain, temperature from opposite crude touch from opposite side of the
side body

Spinal lernniscus:
1. Definition: Ascending sensory bundle in the brain stem formed by lateral and ventral
spinothalamic tracts.
2. Course: in pons --- mid brain.
3. Termination: PLVNT.
4. Function: pain, temperature and crude touch from opposite side of body.

Clinically important point:

Syringomyellia:
 Congenital dilatation of Central Canal.
 In lower cervical and upper thoracic region.
 Pressure on Lateral spinothalamic tract.
 Bilateral loss of pain and temperature in upper limbs and chest.
 Lat. Spino thalamic is intact so sensation above and below are normal.
 Touch is felt in areas of skin with lost pain and temperature (Dissociated sensory
loss).

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Pathway of sensory impulses to subcortical levels
1-Dorsal spinocerebellar tract 2-Ventral spino cerebellar tract
Origin Clark's nucleus (C8-L2), On the Cells in posterior horn of grey
same side, matter in lumbosacral region
That receives proprioceptive (laminae V-
impulses from large cells in spinal
VII), on the same and opposite side.
ganglia. on the same and opposite side,
those receive proprioceptive
impulses from large cells in spinal
ganglia.
Course Present in spinal cord (lateral Presents in spinal cord (lateral
column of white matter of at upper column of white matter at all levels)
lumbar, thoracic and cervical and brain stem.
segments) and closed medulla.
Termination enters the cerebellum through enters the cerebellum through
inferior cerebellar peduncle superior cerebellar peduncle
Function Carries proprioceptive impulses Carries proprioceptive impulses
from trunk and lower limb to from lower limb to cerebellum
cerebellum.

3-Spino-olivary tract 4-Spinotectal tract

Origin Nucleus proprius on the opposite Nucleus proprius on the opposite
side that receives proprioceptive side
impulses from gracile and cuneate
tracts
Course Ascends in lateral white column ofAscends in the all levels of spinal
spinal cord, all levels cord in lateral column and in brain
stem
Termination inferior olivary nucleus in medulla Superior colliculus in mid brain
that sends olivocerebellar fibers to
cerebellum through inferior
cerebellar peduncle.
Function Carrys proprioceptive impulses to It transmits sensory impulses to the
Cerebellum tectum, where it drives spino visual
reflexes

Short Tracts
These are tracts that start and end in the spinal cord. They are:
1. Fasciculi propri tracts:
 Arise as axons of associative neurons between sensory and motor nuclei.
 Ascend and descend for few segments just outside grey matter like a ring.
 Then enter the grey matter to terminate around the cells of other segments.
 Coordinate functions of different regions of spinal cord.
N. B.: the first to be myelinated so coordinate early movement of foetus.

2. Lissauer's tract:
 Present in all the segments at the tips of the dorsal horns.
 It arises from the small cells of spinal ganglia. The axons enter the spinal cord
through lateral division of posterior root to ascend or descend for 1 or 2 segments
 It terminates in the substantia gelatinosa of Rolandi.

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 Carries pain and temperature from the same side of the body (First order neuron).

3. Comma shaped tract:

 Present in posterior column of white matter in cervical and upper thoracic
segments.
 It is formed by short descending fibres from Cuneate tract.
 It terminates in anterior horn cells.
 It completes stretch reflex arc.

4. Septomarginal tract:
 It is present in the posterior column of white matter in thoracic, lumbar and sacral
segments.
 It is formed by short descending fibres from gracile tract.
 It terminates in anterior horn cells.
 It completes stretch reflex arc.

Descending tracts
They are divided into upper motor neuron and lower motor neuron

Upper motor neuron:

The nerve cells present in cerebral cortex or subcortical level and terminate at motor
nuclei of cranial nerves or anterior horn cells of spinal cord.

Lower motor neuron:

The motor nuclei of cranial nerves and the anterior horn cells give axons that
terminate at the muscles.
The upper motor neurons are classified into pyramidal and extrapyramidal tracts.

Pyramidal Tracts
They include:
1- Corticobulbar tract. 2- Corticospinal tract.

Corticobulbar tracts:
The fibres arise from cerebral cortex and terminate in motor nuclei of cranial nerves in
brain stem. It is further subdivided into lateral Corticobulbar and medial
Corticobulbar.

Medial Corticobulbar tract:

Origin: Motor area 8 in cerebral cortex.
Course: The fibres descend in corona radiata and then lie in the genu of internal
capsule. In the mid brain they are present in the basis pedunculi very close to
the middle line.
Termination: motor nuclei of cranial nerves 3, 4, 6 on both sides.

Lateral Corticobulbar tract:

Origin: lower ⅓ of motor area 4 in cerebral cortex.
Course: The fibres descend in the corona radiate and then in the genu of the internal
capsule. In the mid brain they pass in the basis pedunculi lateral to the
Corticospinal fibres.
Termination: They end on the motor nuclei of the cranial nerves; 5, 7, 9, 10, 11, 12
on both sides except:
 The portion of hypoglossal nerve that provides innervation for

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tongue protrusion
 The part of facial nerve that innervates the muscles of the lower
face.
They only receive contralateral innervation from the pyramidal tract.

Corticospinal tracts:
The fibres arise from cerebral cortex and terminate in anterior horn cells of the spinal cord.
Oriain: Betz cells & others in upper 2/3 of motor area 4 in cerebral cortex.
Course:
 Corona radiata in white matter.
 Genu & anterior 2/3 of posterior limb of internal capsule.
 Intermediate part of basis pedunculi in mid brain.
 Basis pontis as bundles separated by transverse pontine fibres.
 Pyramid in upper Medulla.
 Pyramidal decussation in lower part of closed medulla (Motor decussation) where
80-90% of the fibres cross to opposite side.
 In the spinal cord the crossed pyramidal tract is present in lateral column of white
matter in all levels while the direct pyramidal tract is present in anterior column of
white matter in cervical and upper thoracic levels.
Termination:
In anterior horn cells of the opposite side. Some end on the same side.
N.B.: Direct pyramidal tract crosses in the spinal cord to end on the anterior horn cells
of the opposite side. Few fibres end on the same side.
Function: control voluntary movement and increases tone and reflexes in muscles.

Extrapyramidal tracts
Descending motor fibres that do not pass through pyramids of medulla.
They can be divided into main 2 groups:
A. Extrapyramidal tracts : arise from cerebral cortex and terminate in brain stem.
B. Extrapyramidal tracts that arise from brain stem and terminate in the anterior
horn cells of the spinal cord.

Extramramidal tracts of the spinal cord

Single tracts Paired tracts
• Rubrospinal. • Ventral and lateral reticulospinal.
• Olivospinal. • Ventral and lateral tectospinal.
• Sulcomarginal. • Ventral and lateral vestibulospinal

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Tract Origin Type Site

Rubrospinal Red nucleus Crossed (ventral Cervical
tegmental decussation)
Olivospinal Inferior olivary n. Direct Cervical
Sulcomarginal Continuation of medial longitudinal bundle All levels
Reticulospinal Reticular formation Lateral:crossed All levels
Ventral: direct
Tectospinal Superior colliculus Crossed (dorsal Lateral: Cervical
in Tectum tegmental decussation) Ventral:
cervical & thoracic

Vestibulospinal Lateral: Lateral Direct Lateral: All levels.

vestibular Ventral: Cervical
nucleus
Ventral: Lateral,
medial & inferior
vestibular nuclei

Cortical control of motor action:

The motor cortex is divided into:
Primary motor cortex, (area 4) , Premotor cortex
(pyramidal area)
1-in the precentral gyrus 1-located anterior to primary motor area
2-contain large neurones 2-the body is represented
3-contain highly excitable neurones *crossed
4-neurones are giant cells (called BETZ *inverted
cells) 3-function:
5-body is represented as: *control voluntary movement need group
-crossed of muscles to act together to form a task
-inverted *inhibit stretch reflex
-depend on motor value (large area for *inhibit grasp reflex
hands , lips , less for back *contain specific areas:
6-function: 1-word formation area----memory of words
*stimulate stretch reflex 2-Head rotation area
*initiate & control fine movement 3-voluntary eye movement
4-hand skills
1-in the precentral gyrus
2-contain large neurones 1-less excitable
3-contain highly excitable neurones 2-the body is represented
4-neurones are giant cells (called BETZ *crossed
cells) *inverted
5-body is represented as: 3-function:
-crossed *control voluntary movement need group
-inverted of muscles to act together to form a task
-depend on motor value (large *inhibit stretch reflex
area *inhibit grasp reflex
for hands , lips , less for back *contain specific areas:
6-function: 1-word formation area----memory of words

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*stimulate stretch reflex 2-Head rotation area

*initiate & control fine movement 3-voluntary eye movement
7-if lesion occur in motor area 4 lead to: 4-hand skills
*paralysis of opposite side of body
*hypotonia , hyporeflexia
*loss of superficial reflexes
*+ve babiniski sign

UMNL LMNL
1-Causes: 1-causes:
*hemorrhage OR thrombosis lead to -Damage of LMN ---poliomyelitis
lesion in the posterior limb internal DM
capsule . B12 deficiency
2-Effects: myasthenia gravis
*paralysis: 2-Effects:
-wide spread paralysis. *paralysis:
-contralateral hemiplegia -on same side
-permanent loss of voluntary movement -localized paralysis
-increase muscle tone (spastic paralysis) *Reflexes:
*reflexes: -Atonia ---absent stretch reflex
A-(stretch reflex) increased tone in -Absent deep reflexes
paralyzed muscles -Absent superficial reflexes
-due to cut inhibitory pathways *Muscle:
B-exaggerated tendon jerk -marked atrophy
D-+ve babiniski sign

*muscle
-minimal wasting of paralyzed muscles
-normal response to electric stimuli (no
reaction of degeneration).

Pathways from the Face & Head

Proprioception Pathway
Receptors: muscle spindles and tendon spindles in the muscles of mastication. Pacinian
corpuscles in deep dermis.

First order neurons: are inside the CNS. They are the only exception to the rule. They are
located in the mesencephalic nucleus.

Second order neurons: The axons of the mesencephalic nucleus descend to synapse with
the cells in main sensory nucleus. Their axons cross and enter the
trigeminal lemniscus.

Third order neurons: They are the cells of PMVN of the thalamus. Their axons end in the
sensory area in cerebral cortex.

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Pain and temperature pathway

Receptors: as in body.

First order neurons: cells in the trigeminal ganglion.

Second order neurons: cells in the spinal nucleus. Their axons cross and enter the
trigeminal lemniscus.

Third order neurons: They are the cells of PMVN of the thalamus. Their axons end in the
sensory area in cerebral cortex.

Simple touch pathway

Receptors: as in body.

First order neurons: cells in the trigeminal ganglion.

Second order neurons: cells in the main sensory nucleus. Their axons cross ascend in
trigeminal lemniscus

Third order neurons: They are the cells of PMVN of the thalamus. Their axons end in the
sensory area in cerebral cortex.

Trigeminal Lemniscus:
 Definition: ascending sensory fibres carrying sensations from the face.
 Origin: second order neurons in sensory pathways from face
1. spinal nucleus of trigeminal nerve
2. Main sensory nucleus.

Their axons cross to opposite side to form trigeminal lemniscus.

 Course: in upper & middle level of pons &mid brain
 Termination: PMVNT.
 Function: carries pain, temperature, simple touch and proprioception from face and
scalp of opposite side.

- Effect of complete T.S. of spinal cord:

Permanent loss Permanat loss of Reflexes
of all sensations voluntary movements The reflexes pass by 3 stages which are
below level of below level of lesion 1-Spinal shock immediately after T.S.
lesion No neurolemmal &
No neurolemmal sheath last 2-6 weeks
sheath 2-Recovery of reflexes
*Early recovery ---immediately
follow spinal shock
*late recovery----after 6 month
3-Failure of reflexes
If infection occur

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A: Spinal shock
Def: complete loss of all reflexes below level of lesion
Reflexes lost are:
1-stretch reflex:
Its loss leads to-----Atonia , Areflexia
Blood pressure: VD ---decrease BP
Loss of Autonomic reflexes:
Loss of -----*defecation reflex
*micturition reflex
(retension with over flow)
Accumulate urine in bladder till pressure in bladder overcomes tone of
sphincter---drippling
no Sweating reflex ---skin is dry
* no erection

Duration of spinal shock:

*lower animals as frogs----1-2 hours
dogs-----days
* in humans ------------------2-6 weeks

Cause of spinal shock:

Sudden cut of the supra spinal facilitatory impulses form higher centers

Recovery of reflexes:
I- Early recovery of reflexes:
Immediately after the end of spinal shock (after 2-6 weeks).
The reflexes which return early are:
1- stretch reflex:
*first reflex to return
*the tone in the muscles are weak
*the tone appear in the flexor muscles at first---lead to ------ paraplegia
in flexion.
2-planter reflex: (NEW REFLEX APPEAR NOT PRESENT AT PAST)
Stimulus: ----scratch skin of foot
Response:----dorsiflexion of big toe (positive babiniski sign)
3- Deep reflexes:
First knee jerk appear----weak
Later Ankle jerk ----------- weak
4- Mass reflex: (NEW ABNORMAL REFLEX APPEAR NOT PRESENT AT PAST)
Stimulus: scratching the skin of the
*abdominal wall
*lower limb
lead to
Response: *evacuate bladder , & retum
*increase Blood pressure
5-Autonomic reflexes:
*the patient will be shifted to the automatic bladder & automatic
rectum (reflex micturition , reflex defecation)
*there will be increase in the BP
*there will be erection & ejaculation on manipulating the glans but not
the complete act
6- the skin will be warm , ulcers heal , good color due to increased BP

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-Late recovery: after 6 months
*marked reflex activity appear
*the tone in the extensor muscles become greater (paraplegia in extension)
*Mass reflex disappear
*FWR is accompanied by CER
*NEW REFLEXES APPEAR
1-positive supporting reaction
2-stepping reflex
NB: if the patient had :
*severe urinary tract infection
*severe bed sores
The patient will go to stage of FAILURE OF REFLEXES where reflexes
disappear and patient die

Care of patient with complete T.S. of spinal cord:

The aim of the care is to pass the patient from stage of SPINAL SHOCK to
RECOVERY OF REFLEXES
1-catheterization
2-rectal enema
3-frequent mobilization
4-antibiotics

2– Brainstem: Gross morphology

Medulla oblongata
Extent: from the lower border of pons down to the upper border of atlas vertebra.

Parts: medulla is divided into.

 Lower closed medulla: traversed by the central canal which is continuous with that
of the spinal cord.
 Upper open medulla: related to the cavity of the 4th ventricle.

External features: this includes the ventrolateral surface of the whole medulla and dorsal
surface of the closed medulla and dorsal surface of the open medulla.
A. Ventrolateral surface of the whole medulla:
- That surface is traversed by the anterior median fissure.
- Lateral to that fissure, each side of the medulla presents 3 structures separated by 2 sulci:
 Pyramid: contains corticospinal fibers.
Sulcus: for exit of the hypoglossal.N.
 Olive: overlies the inferior olivary nucleus.
Suclus for exit of glossopharyngeal, vagus and cranial accessory
nerves.
 Inferior cerebellar peduncle (I.C.P), a bundle of nerve fibers connecting the
medulla to the cerebellum.
N.B. the last 4 cranial nerves are attached to the medulla oblongata.

B. Dorsal surface of the closed medulla:

- It is traversed by the posterior median sulcus.
- Lateral to that suclus, each side of the closed medulla presents 3 tubercles:
 Gracile tubercle; overlies the gracile nucleus
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 Cuneate tubercle; overlies the cuneate nucleus
 Tuberculum cinereum; overlies the spinal nucleus of the trigeminal.N.

C. Dorsal surface of the open medulla:

- It forms the lower part of the floor of the 4th ventricle.
- It is traversed by a vertical median sulcus.
- Lateral to that sulcus, each side presents an inverted V-shaped depression called the
inferior fovea, dividing that side into 3 trigones:
 Hypoglossal trigone; overlies the hypoglossal nucleus.
 Vagal trigone; overlies the dorsal vagal nucleus.
 Vestibular trigone; overlies some vestibular nuclei.

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Pons
The pons has two borders (inferior and superior) and two surfaces (ventral and dorsal).
1. Inferior border has 3 features:
 The 2 vertebral arteries unite to form the basilar artery.
 The abducent.N. escapes between that border and the medullary pyramid.
 The facial and vestibulocochlear nerves escape below that border at the
cerebellopontine angle.

2. Superior border has 3 features:

 The basilar artery divides into two posterior cerebral arteries.
 The pons receives the two crura cerebrei of the midbrain.
 It forms the posterior boundary of the interpeduncular fossa.(see below)

3. Ventral surface has 3 features:

 Pons proper: presents the median sulcus for the basilar artery.
 Two (right, left) middle cerebellar peduncles (M.C.P). Each is formed of ponto –
cerebellar fibers, connecting the pons to the cerebellum
 Two (right, left) trigeminal nerves. Each escapes between the pons proper medial to
it and middle cerebellar peduncle lateral to it.
N.B. the middle four cranial nerves are attached to pons.

4. Dorsal surface:
- It forms the upper part of the floor of the 4th ventricle.
- It is traversed by a vertical median sulcus.
- Lateral to that sulcus, each side presents 3 features:
 Medial eminence: is a longitudinal ridge, whose lower part is a swelling called
facial colliculus. The latter is produced by the nucleus of the abducent.N
surrounded by the motor fibers of the facial.N.
 Sulcus limitans is lateral to the medial eminence. Its lower part is a depression
called superior fovea.
 Vestibular area is lateral to the superior fovea. It overlies some vestibular nuclei.

Midbrain
Extent: it extends from the upper border of pons up to the level of optic tract; here it is
continuous with the diencephalon.

External features:
- The midbrain is traversed by the cerebral aqueduct of Sylvius, which connects the 4th
and 3rd ventricles.
- The aqueduct divides the midbrain into two major parts:
 Two cerebral peduncles; ventral to the aqueduct
 Tectum of the midbrain; dorsal to the aqueduct.

A. The two cerebral peduncles

- Each is formed of 3 structures:
 Crus cerebrei.
 Substantia nigra.
 Tegmentum of midbrain.

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B. The tectum is formed of four colliculi:
 Two inferior colliculi for auditory pathway.
 Two superior colliculi for visual reflexes.
C. Special items in the midbrain:
- Two cranial nerves are attached to the midbrain.
 Oculomotor. N, emerges from its ventral aspect just medial to the crus cerebrei.
 Trochlear. N, emerges from its dorsal aspect just below the inferior colliculus.
- Two superior cerebellar peduncles (S.C.P) connect the midbrain to the cerebellum
Interpeduncular fossa
Definition: it is a trapezoid fossa at the base of the brain between the two cerebral peduncles
Boundaries:
1. Anterior: optic chiasma
2. Posterior: upper border of pons
3. Anterolateral: optic tracts
4. Posterolateral: crura cerebrei

Contents: from before backwards

1. Tuber cinerium=median eminence of the hypothalamus giving rise to the
pituitary infundibulum.
2. Mammillary bodies= two rounded nuclei of the hypothalamus.
3. Posterior perforated substance= an area pierced by central branched of the
posterior cerebral artery.
4. Both oculomotor nerves, each emerges from the medial side of a crus
cerebrei.
5. Circulus arteriosus (circle of Willis) along the margins of the
interpeduncular fossa.

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The fourth ventricle:
Definition: it is diamond – shaped cavity of the hindbrain.
Communications:
 Superiorly: is continuous with the cerebral aqueduct of midbrain.
 Inferiorly: is continuous with the central canal of the closed medulla and spinal cord.
 Its roof and lateral recesses communicate with the subarachnoid space via the
median foramen of Magendi and the two lateral foramina of Lushka.
Boundaries
A. Lateral boundaries
1. Superiorly: by the superior cerebellar peduncles as they converge towards the
midbrain.
2. Inferiorly: by gracile and cuneate tubercles and the inferior cerebellar peduncles.
B. Roof
1. Superiorly: by the superior medullary velum stretching between the two superior
cerebellar peduncles.
2. Inferiorly: by the inferior medullary velum.

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Floor of the 4th ventricle

C. Floor (rhomboid fossa).

- It is divided by the median sulcus into right and left halves.
- Again, it is divided by the medullary striae into.
 Superior part formed by the back of pons.
 Inferior part formed by the back of the open medulla.

1. Pontine part of the floor

- Each side of it presents 3 features:
 Medial eminence is a longitudinal ridge, whose lower part is a swelling
called facial colliculus. The latter is due to abducent nucleus, surrounded
by the motor fibres of the facial nerve.
 Sulcus limitans is lateral to the medial eminence. Its lower part is a
depression called superior fovea.
 Vestibular area: is lateral to the superior fovea. It overlies some
vestibular nuclei.
2. Medullary part of the floor
- Each side presents an inverted V - shaped depression called the inferior fovea
which divides each side into 3 trigones:
 Hypoglossal trigone overlies the hypoglossal nucleus.
 agal trigone overlies the dorsal vagal nucleus.
 Vestibular trigone overlies some vestibular nuclei.

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Reticular activating system: ( RAS ) :
Def: it is the ascending branches of the FACILITATORY RETICULAR FORMATION
*Fibers of the RAS go up to all area of the cerebral cortex
Function of the RAS:
1-It is responsible for ALERT,& CONSCIOUSNESS
2-If depressed -----sleep & its damage lead to coma

EEG:
The passive electroencephalogram reveals rhythms of activity at four different
frequencies:
• Alpha rhythm (8–13Hz) characterizes the awake but resting EEG
• Faster beta waves are associated with mental activity (>13Hz)
• Higher frequency gamma rhythm (35–45Hz) may be a signature of the waking
state
• Slower rhythms, theta (4–7Hz) and delta (<3.5Hz), are more common during
reduced arousal in adults.

Sleep:
Def: state of unconsciousness from which person is easily aroused.
The sleep occur in 2 alternate types which are:

Slow wave sleep(non REM) non Rapid Eye Movement

first to occur
*represent 80% of sleep
*last for 90 min.
*No-------- rapid eye movement
-dreams
-swallowing
-teeth grinding
-erection , ejaculation
*decrease –HR
-BP
-Respiratory rate
-Basal metabolic rate
-muscle tone

Rapid eye movement (REM)

Occur later after the 4th stage of non REM sleep.
*represent 20% of sleep
*Last 20 min.
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*it is accompanied by:
-dreams
-rapid eye movement
-increase HR
BP
Respiratory rate
-teeth grinding
-swallowing
-erection , ejaculation
*active inhibition of the RAS by: subcortical centers release chemical transmitters
1- serotonin
2-prostaglandin
3-acetylcholine
4-noradrenaline
inhibit RAS
The neurotransmitter systems that are prominently involved include
- noradrenergic
-serotonergic
-histaminergic
-cholinergic,

• The release of these neurotransmitters is under the control of both circadian

(light–dark cycle— in the hypothalamus) and homeostatic (fatigue)
influences
*During REM sleep, aminergic signalling is silent and cholinergic
excitatory activity is dominant
• The termination of REM sleep is driven by increased noradrenergic and
serotonergic system activity
• NREM sleep appears associated with conservation of energy and repair
mechanisms, thereby suggesting a restorative function, although it has also
been suggested to function in the iteration of information
• The brain activity associated with REM sleep may be important in brain
development and plasticity. A widely supported idea is that memory
consolidation is a major function of REM sleep
• The disruption of metabolic homeostasis that results from severe sleep
deprivation can lead to death, emphasizing the crucial role of sleep.

Consciousness
• In healthy individuals, three main states of consciousness are
recognized—
-wakefulness,
-NREM sleep,
-and REM sleep

The Glasgow Coma Scale:

This gives a reliable, objective way of recording the conscious state of a
person. It can be used by medical and nursing staff for initial and continuing
assessment. It has value in predicting ultimate outcome. Three types of
response are assessed.
-Best motor response
-Best verbal response
-Eye opening

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3– Cerebellum.
Gross Morphology:
- The cerebellum consists of two lateral cerebellar hemispheres and a median vermis
inbetween.
- Its surface shows transverse fissures between elevations called folia
- It has 2 notches, 2 surfaces, 3 fissures ,3 lobes and 3 peduncles.

A- Notches of the cerebellum:

1. Anterior notch: lies in the roof of the 4th ventricle.
2. Posterior notch: is occupied by the falx cerebellei.

B- Surfaces of the cerebellum

1- Superior surface:
 Its vermis projects higher than the two cerebellar hemisheres.
 It shows the V-shaped primary fissure between the anterior and posterior lobes.
2- Inferior surface:
 Its vermis is buried and is bounded on each side by a groove called vallecula.
 A tonsil is seen projecting on each side and the part of the vermis between the
tonsils is called the uvula.

C-Fissures of the cerebellum:

1- Primary fissure: on the superior surface fissure between the anterior and posterior
lobe
2- Posterolateral fissure: on the inferior surface. It intervens between the
flocculonodular lobe and the posterior lobes of the cerebellum.
3- Horizontal fissure: intervens between the superior and inferior surfaces.

Main fissures of the cerebellum

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D- Lobes of the cerebellum

1- Flocculonodular lobe:
-Lies on the inferior surface of the cerebellum, infront to the posterolateral fissure.
-It is formed of the two folliculi and nodule.
-Function:
 It is the oldest lobe and is called the archicerebellum.
 It has direct vestibular connections.
 Maintains equilibrium.
2- Anterior lobe: lies on the superior surface anterior to the primary fissure.
3- Posterior lobe: lies on both the superior and inferior surfaces of the cerebellum
between the primary and posterolateral fissures and has the following functions:

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- The vermal and paravermal zones of both lobes (are newer than the
archicerebellum) and together form the paleocerebellum which has the following
features:
 It has spinal connections.
 The vermal part controls the muscel tone of the trunk muscles via the
fastigial nucleus.
 The paravermal parts control the muscel tone of the limb muscles via
the interposed nucleus.
- The lateral parts of both lobes are the newest of all lobes and form the
neocerebellum. and has the following features:
 It has cerebral connection via the dentate nucleus.
 It is concerned with the coordinations of the fine skilled movements.

E- The peduncles of the cerebellum:

1- Superior cerebellar peduncle connects the cerebellum to the midbrain.
2- Middle cerebellar peduncle connects the cerebellum to the pons.
3- Inferior cerebellar peduncle connects the cerebellum to medulla oblongata.

Blood supply of the cerebellum:

Each half of the cerebellum is supplied by 3 arteries:
1- Superior cerebellar artery: is a branch of the basilar artery, supplies the superior
surface.
2- Anterior inferior cerebellar artery: is a branch of the basilar artery, supplies the
anterior part of the inferior surface.
3- Posterior inferior cerebellar artery: is a branch of the vertebral artery, supplies the
posterior part of the inferior surface.

Cerebellum
It is formed of 2 hemispheres joined by vermis.
Cerebellar cortex: 3 layers-,

Molecular layer: This outermost layer of the cerebellar cortex contains

1. Two types of inhibitory interneurons: the stellate (molecular) and
basket cells. Both stellate and basket cells form synapses onto
Purkinje cell dendrites.

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2. It also contains the dendrites of Purkinje neurons.
3. Ends of climbing fibres that synapse with dendrites of Purkinje cells.
Climbing fibers are coming from inferior olivary nucleus Each
Purkinje cell receives input from a single climbing fiber in the form
of a powerful excitatory signal.
4. Parallel axons from the granule cells (extending from granular layer)
that synapse with dendrites of purkinje cell. Each Purkinje cell
receives excitatory input from 100,000 to 200,000 parallel fibers.

Purkinje layer: This middle layer contains only one type of cells that is the Purkinje cell.
 Purkinje cells are the primary integrative neurons of the cerebellar
cortex.
 Purkinje cell is large pyriform multipolar cells arranged in one row.
 Purkinje cell dendrites are with hundreds of spiny branches reaching
up into the molecular layer.

Granular layer: The innermost layer composed of

1. Granular cells:
 Small dark closely packed nerve cells.
 Each granule cell has a few short dendrites within the granule
cell layer.
 Their dendrites make synapse with excitatory mossy fibres
coming from pontine nuclei.
 The granule cells send their T-shaped axons—known as parallel
fibers—up into the superficial molecular layer, where they form
hundreds of thousands of synapses with Purkinje cell dendrites
2. Golgi cells:
 Large cells.
 Their dendrites branch in different directions.
 Their axons synapse with granular cells to provide inhibitory
feedback on them.
It contains only nerve fibres afferent (climbing and mossy fibres) and
efferent (axons of purkinje cells).
Cerebellar nuclei are embedded in the white matter. They are 4;
1. Fastigial nucleus.
2. Globose nucleus.
3. Emboliform nucleus.
4. Dentate nucleus.

Cerebellar connections:
Superior cerebellar peduncle:
Afferent:
1. Tecto cerebellar tract.
2. Ventral spinocerebellar tract.
Efferent:
1. Cerebellothalamo cortical.
2. Cerebellorubrospinal.
Middle cerebellar peduncle:
Afferent:
1. Cerebro ponto cerebellar fibres.
2. Cerebello ponto cerebellar fibres to the other side.

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Efferent
1. Cerebello ponto cerebellar from the other side.
Superior cerebellar peduncle
Afferent
1. Dorsal spinocerebellar tract.
2. External arcuate fibres
3. Olive cerebellar fibres.
4. Vestibule cerebellar fibres.
5. Reticule cerebellar fibres.
Efferent
1. Cerebello olivary fibres.
2. Cerebello vestibular fibres.
3. Cerebello reticular fibres.

Function of cerebellum:
1-control posture and equilibrium
2-effect on muscle tone
3-control voluntary movement
*servocomparter function
*prevent over shoot (damping function)
*timing of movement

1-Control posture and equilibrium:

• During rapid movement
• Vestibular apparatus send impulses to vestibulocerebellum
(archicerebellum)
• To maintain equilibrium through changing muscle tone

2-Effect of cerebellum on muscle tone:

• Neocerebellum is facilitatory to SR---increase muscle tone
• Paleocerebellum is inhibitory to SR---inhibit muscle tone

3-Control voluntary movement:

A- Servocomparter function:
The spinocerebellum compares between the intended plan (intention) of
motor cortex
&
The performance of the muscles
&
It sends corrective signals to motor cortex

B-Cerebellum prevent over shoot (damping function)

*The cerebellum sends signals to stop movement at the intended point
&prevent over shoot

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C-Cerebellum function in timing of movement
*Cerebrocerebellum forms the timing for the start & termination of each
movement this helps the ability
To progress smooth from one movement to the next (this is needed in
complex movements ) writing, running

Abnormalities of cerebellum:
-Neocerebellar syndrome
-lesion in deep cerebellar nuclei
*Manifestation:
-on the same side of lesion
-hypotonia: due to loss of facilitatory effect of cerebellum on muscle tone
-Asthenia: muscle weakness ----due to difficult to maintain muscle
contraction
-Ataxia: incoordination of voluntary movement in absence of UMNL , or
LMNL
-Manifestation of ataxia:
-dysmetria----movement over shoot the intended point
-decomposition of movement
-disdiadokinesia----inability to do rapid alternating opposite movements
-dysarthria-----(stacato-speech)
Difficult to form correct speech----as the person can not progress from one
movement to another
-eye ball tremors
-kinetic tremors (intention tremors )---due to absence of damping function
-Rebound phenomenon:
Person can not stop the motor act at the intended point
-Staggering gait:
Patient walks on wide base
Speech:
Speech function depends on the categorical hemisphere
The two cerebral hemispheres involved are
1- Categorical hemisphere
Which is for the dominant hemisphere
It lies in the left hemisphere in most right handed persons
It is concerned with symbolization
Its lesion leads to: - Depression
- Language disorders

2-Representational hemisphere:
Which is for the non dominant hemisphere
It is concerned with recognition of faces and objects
If there is lesion in it there will be
- No language disorders
- Euphoria

Centers for speech are :

1- Wernikes area:
Function in comprehension of auditory and visual information

2- Brocas area :
Function in coordinating vocalization

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3- Hand skills area
If there is lesion in this area leads to motor apraxia

4- Auditory area :
Primary auditory Area 41 , 42
Auditory association area (around primary area )
Concerned with understanding meaning of spoken words

5- Visual area :
Primary visual area
Visual association area (18,19)
Concerned with understanding meaning of written words
Aphasia :
Def: Abnormalities of language function NOT due to:
-visual
-hearing or
-motor defects

Cause: Due to lesion in the categorical hemisphere

Types of aphasia:
Fluent aphasia Non fluent aphasia Global aphasia
-lesion : werniks area -brocas area -lesion in categorical
-slow speech hemisphere
-effect: -words are hard to come -impaired comprehension
Talk excessively -speech is limited to 2-3 of spoken and written
Irrelevant words words words
Patient fails to -few speech
understand meaning of
spoken or written words

-auditory aphasia
Lesion in auditory
association area
-inability to understand
meaning of spoken
words

-visual aphasia
Lesion in visual
association area
-inability to understand
written words

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4– Diencephalon

It is formed of: thalamus, hypothalamus,sumthalamus and epithalamus

Thalamus:
- It is a part of the forebrain.
- Its cavity is called the 3rd ventricle.
- It has 2 ends: (anterior, posterior) and 4 surfaces: superior, inferior, medial, lateral.

1. Anterior end: Is narrow and forms the posterior boundary of the interventricular
foramen of Monro.

2. Posterior end: Is expanded and is called the pulvinar which is grooved by the crus of
the fornix (see limbic system).

3. Superior surface: Is grooved by the body of fornix and has the following relations
 Its lateral edge is separated from the body of caudate nucleus by
the sulcus terminalis containing stria terminalis +
thalamostriate vein
 Its medial edge is related to stria habenularis (= stria medullaris
thalami).
 Its lateral part is in the floor of the body of the lateral ventricle.
 Its medial part is covered by the tela choroidae of the third
ventricle.

4. Inferior surface:
It is continuous with the hypothalamus and subthalamus from both of which, it
is separated by the hypothalamic sulcus. This sulcus extends from the
interventricular foramen to the upper end of the cerebral aqueduct of the
midbrain.
- The posterior end of that surface presents the medial and lateral geniculate
bodies, and both form the metathalamus.

5. Medial surface:
- It forms the upper part of the lateral wall of the third ventricle and is covered by its
ependyma.
- It is usually connected to the opposite medial surface by the interthalamic
adhesion.

6. Lateral surface:
- It is related to the posterior limb of the internal capsule, which separates that
surface from the lentiform nucleus.

Important thalamic nuclei

- The thalamus represents the 3rd order neuron for all sensations except olfaction (smell) in
their way to the sensory area of the sensory area of the cerebral cortex. It has 3 important
nuclei:
 Nucleus ventralis posterior for relay of the medial, pinal and trigeminal nuclei.
 Medial geniculate body (M.G.B) for auditory pathway.
 Lateral geniculate body (L.G.B) for visual pathway.

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N.B: [Link] L.G.B. form together the metathalamus

Blood supply of the thalamus

1- Posteromedial group (= thalamo – perforating arteries): supply the anterior and medial
nuclei of the thalamus.
2- Posterolateral group (= thalamo – geniculate arteries) supply the lateral thalamus and
posterior thalamus (Pulvinar, M.G.B, L.G.B).

- Venous drainage of the thalamus: by the thalamic veins, which join the thalamo –
striate vein.

Hypothalamus:
Definition: It lies below the thalamus and is responsible for the regulation for regulation
of the endocrine and autonomic functions of the body.

Boundaries:
- Anteriorly: lamina terminalis.
- Posteriorly: a plane posterior to the mammillary bodies.
- Superiorly: hypothalamic sulcus.
- Inferiorly: it projects into and forms most of the floor of the 3rd ventricle.

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Subthalamus
Definition: It is a triangular transitory zone between the midbrain tegmentum and
thalamus.

Boundaries
1. Anteriorly: a vertical line drawn behind the mammillary bodies of the
hypothalamus.
2. Posteriorly: upper end of the cerebral aqueduct of the midbrain.
3. Superiorly: hypothalamic sulcus.
4. Inferiorly: it is continuous with the tegmentum of the midbrain.

- Important nuclei: It contains the subthalamic nucleus involved in the functions of the
basal ganglia

Epithalamus:
- It is represented by the pineal body which secretes melatonin hormone in darkness
to induce sleep .

N.B: Between the two halves of the dinencphalon ,ther is a cavity calle the third
ventricle

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5 -Cerebral hemispheres: External featues &functional areas

External features
Each cerebral hemisphere has three groups of external features:

3 poles 3 borders 3 surfaces

- Frontal pole. - Superomedial border - Superolateral surface
- Temporal pole. - Inferolateral border - Medial surface
- Occipital pole. - Inferomedial border - Inferior surface

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 44principal
lobes:
sulci and 4 drawn lines divide each hemisphere into

- The 4 principal sulci

1-The central sulcus.
2- The posterior ramus of the lateral sulcus. (the lateral sulcus divides into 3 rami :
anterior, ascending , posterior).
3-Parieto – occipital sulcus.
4-Calcarine sulcus.

- The 2 drawn lines:

1. Join the parieto – occipital sulcus to the pre – occipital notch (the notch cuts the
inferolateral border 5 cm anterior to the occipital pole).
2. Join the posterior ramus of the lateral sulcus to line (1).
3. Join the medial extension of the central sulcus to the corpus callosum.
4. Join the preoccipital notch to the anterior end of the calcarine sulcus.

- The 4 lobes
1. Frontal lobe. Motor lobe.
2. Parietal lobe.
3. Temporal lobe. Sensory lobes.
4. Occipital lobe.

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Sulci and gyri on the superolateral surface of the Hemisphere
 The frontal lobe has 3 sulci and 4 gyri
3 sulci 4 gyri
-Precentral sulcus. -Precentral gyrus.
-Superior frontal sulcus. -Superior frontal gyrus
-Inferior frontal sulcus -Middle frontal gyrus
-Inferior frontal gyrus (has: pars orbitalis,
pars triangularis, pars opercularis).

 The parietal 2lobe

sulci
has 2 sulci and 3 gyri
3 gyri
- Postcentral sulcus. - Postcentral gyrus.
- Intraparietal sulcus. - Superior parietal lobule.
- Inferior parietal lobule (has
supramarginal gyrus, angular gyrus).

 Temporal lobe2 sulci

has 2 sulci and 3 gyri
3 gyri
- Superior temporal sulcus. - Superior temporal gyrus.
- Inferior temporal sulcus. - Middle temporal gyrus.
- Inferior temporal gyrus.

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 Occipital lobe has one significant sulcus:

- It presents the lunate sulcus 1 cm anterior to the occipital pole.
- Its segnificance lies in the fact that:
 Area 17 (striate area) lies posterior to it.
 Area 18 (parastriate area) lies in the depth of it.
 Area 19 (peristriate area) lies anterior to it.

 The medial surface has 6 sulci and 7 gyri

A. Sulci on the medial surface
1. Anterior and posterior paraolfactory sulci.
2. Callosal sulcus.
3. Cingulate sulcus
4. Medial end of the central sulcus.
5. Parieto – occipital sulcus.
6. Calcarine sulcus.

B. Gyri on the medial surface

1. Paraterminal gyrus.
2. Paraolfactory gyrus.
1. Cingulate gyrus.
2. Medial frontal gyrus.
3. Paracentral lobule: surrounds the medial extension o the central sulcus
4. Precuneus: on medial surface of the parietal lobe.
5. Cuneus + lingual gyrus on the medial surface of the occipital lobe.

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Sulci and gyri on the inferior surface of the Hemisphere

That surface is divided by the stem of lateral sulcus into orbital and tentorial parts.

 Orbital part has 2 sulci and 5 gyri

2 sulci 4 gyri
- Superior H – shaped - Gyrus rectus.
orbital sulcus - Anterior, posterior, medial, lateral
- temporal sulcus. orbital gyri.
- Inferior temporal sulcus.

 Tentorial part3 sulci

has 3 sulci and 4 gyri :
4 gyri
- Rhinal sulcus. - Uncus.
- Collateral sulcus. - Parahippocampal gyrus.
- Occipito – temporal - Medial occipito – temporal gyrus.
sulcus. - Lateral occipito – temporal gyrus.

Sulci and gyri on the inferior surface of the cerebral hemisphere

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6 -Cerebral hemispheres: Functional areas

Functional areas.
 I - FIRST SOMATOSENSORY AREA (S I, AREAS 3, 1, 2,
The parietal lobe has two somatosensory areas:
Site: in the postcentral gyrus + its medial extension in the posterior (sensory) part of
the paracentral lobule.
Body representation: contralateral ½ of the body is inverted; the face is lower down,
while lower limb is in the sensory part of the paracentral lobule on the medial
surface of the hemisphere.(slide 32,33,34).
Input: from nucleus ventralis posterior of the thalamus (medial, spinal, trigeminal
leminsci.

II - SOMATOSENSORY ASSOCIATION CORTEX :

- This include:
 The superior parietal lobule.
 The inferior parietal lobule.

III – POSTERIOR SPEECH CENTER OF WERNICK, S (See below)

 The temporal lobe has two areas:

I. PRIMARY AUDITORY AREA (A I).
Site: in the anterior transverse gyrus (of Heschl) in the floor of the posterior ramus of
the lateral sulcus and adjacent part in the superior temporal gyrus.
Input: auditory radiation from M.G.B of thalamus.
Output: to AII

II. SECONDARY AUDITORY (ASSOCIATION ) AREA (A II).

Site: in the posterior part of the superior temporal gyrus close to (A I).
Input: from AI

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 The occipital lobe has two visual areas:

I. PRIMARY VISUAL AREA (AREA 17),
Site: in the cuneus and lingual gyrus above and below the calcarine sulcus on the
medial surface of the occipital lobe, extending over the occipital pole as far as
the posterior edge of the lunate sulcus.
Input: optic radiation from L.G.B of thalamus.
Output: to areas 18,19

II. VISUAL ASSOCIATION AREAS (AREAS 18 , 19)

Site: they surround area 17 on both the medial and lateral aspects of the occipital lobe.
Input: from area 17.

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 The frontal lobe:

I. PRIMARY MOTOR AREA (AREA 4)
Site: it lies in the precentral gyrus and its medial extension in the anterior (motor) part
of the paracentral lobule
Body representation: muscles of the contralateral ½ of the body are inverted; face is
lower down, while the lower limb is in the motor part of the paracentral lobule.
Output: gives rise to corticonuclear and corticospinal fibers.

1. Clinically, damage to area 4 results in contralateral hemiplegia, especially evident

in the skilled, fine movements in the distal muscles of the limbs. Axial muscles are
not affected as they receive bilateral input from the anterior corticospinal tracts

N.B. Paracentral lobule of each hemisphere is concerned with the sensory and motor
functions of the contralateral lower limb and perineum

II. PREMOTOR AREA (AREA 6)

Site: it lies anterior and parallel to area 4, so that, it occupies the posterior parts of the
superior, middle and inferior frontal gyri

III. SUPPLEMENTARY MOTOR AREA :

Site: It is that part of area 6 which lies on the medial frontal gyrus anterior to
paracentral lobule.
Body representation: the face is anterior, leg is posterior.
Input: from
 The decision making area of the prefrontal cortex (for intended movement).
 The basal ganglia, which is a major input via the nucleus ventralis anterior of
the thalamus.
Output: to areas 4, 6 of the same and opposite hemispheres and cortic- ospinal fibers.

IV- FRONTAL (MOTOR) EYE FIELD (AREA 8):

Site: in the middle frontal gyrus

V- BROCA`S SPEECH AREA is discussed with the speech areas

Site: in the inferior frontal gyrus of the left hemisphere (areas 44, 45), (See below)

 The cortex has two speech areas:

- All are present only in the dominant (usually) the left cerebral hemisphere.
- They are:
 Posterior (sensory) speech area (Wernick`s area).
 Anterior (motor) speech area (Broca`s area).

I. WERNICK`S SENSORY SPEECH AREA (posterior speech centre):

Site: it includes the supramarginal and angular gyri in the inferior parietal lobule and
posterior parts of the superior and middle temporal gyri in the left hemisphere
Output: it gives rise to arcuate fasciculus (it is a special part of the superior
longitudinal fasciculus) which passes forwards to end on the Broca`s motor
area in the frontal lobe.

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II. BROCA`S MOTOR SPEECH AREA (anterior speech centre):
Site: it the inferior frontal gyrus of the left hemisphere (areas 44, 45).
Input: arcuate fasciculus from the Wernick`s area.
Output: to the head and tongue areas in area 4 of the same and opposite hemispheres.

1. Clinically damage to this area produces motor aphasia in which the patient
understands the spoken words, but can not express himself by words, although the
above – mentioned muscles are not paralysed.

Motor areas in the frontal lobe

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 The frontal lobe contains the (psychical) prefrontal cortex:

Site: it includes the remaining part of the frontal lobe as far as the frontal pole.
 The limbic system
- The limbic system functions as an integrator of information from the external
world and from within the body. Its proposed role is in the generation of
emotional experience
- Connections between the limbic system and higher cortical areas enable the
integration of emotional processing with cognitive functions such as attention,
memory, and reasoning.
- The hippocampus is involved in processes of memory storage, while the
amygdala has been implicated in learning.

 Memory:
- Memory has been categorized into two types—
- Declarative and
- Non-declarative.

 Declarative memory
- The formation and retrieval of explicit memories of facts and events specific to
an individual and involving the conscious recollection of past experiences.

 Episodic memory is the recollection of specific events occurring at a particular

time and place.
- Damage in medial temporal lobe can impair the ability to:
- Retrieve the time and place at which an event occurred
- Distinguish temporally, two or more events
- Recollect where or when a new task was learned

 -Semantic memory involves the recollection of information not associated with

time or place but relating more to meaning and function (e.g. of objects, words).

 Non-declarative memory
- -Procedural memory relates to the acquisition of skills or habits.
- The perceptual representation system is important in the recognition of objects
by their structure or form.
- Working memory, a form of memory used for the short-term retention of
information important for problem solving or reasoning, Two sub-systems
appear to operate in the transfer of working memory into long-term memory:
- A phonological loop that allows rehearsal of speech-based information
- A visuo-spatial map, located in the visual association cortex, inferior parietal
lobule, and prefrontal cortex of the right hemisphere, which retains the visual
and spatial information.

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 The limbic System and Papez circuit:

- It is a closed reverberating circuit responsible for expression of emotions and recent
memory.
- The cingulate gyrus receives recent information from all association areas of the cerebral
cortex (frontal association, parietal sensory association, occipital visual association and
temporal auditory association areas) → cingulum → anterior part of
parahippocampus gyrus → hippocampus → fornix → mammillary
bodies of the hypothalamus→ Mammillothalamic tract → anterior nuclei of
the thalamus anterior thalamic radiation→ cingulate gyrus and so on
- The hippocampus stores recent data as facilitated new synapses via a process called
long-term potentiation (LPT).
- Old memories are returned and stored in the 4 cortical association areas as memory
traces called (engrams) in the neurons. This involves the synthesis of new proteins.

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Cerebrum
Histology of cerebral cortex: it is formed of 6 layers;
1. Molecular layer.
It is formed of parallel fibres from following layers with few horizontal cells of Cajal in
between the fibres (associative neurons) .
2. External granular layer.
It is formed of small pyramidal cells (8 um) and stellate nerve cells.
3. External pyramidal layer.
It is formed of medium sized pyramidal cells (40-50um).
4. Internal granular layer.
It is formed of stellate nerve cells.
5. Internal pyramidal layer.
It is formed of large pyramidal cells (100 um).
6. Polymorphic cell layer.
It is formed of nerve cells of different types and shapes.

- The somatic sensory cortex areas:

Somatic sensory cortex:
Somatic sensory area I Somatic sensory area II Somatic association area
1-in the post central gyrus 1-behind and below lower 1-behind lower part of
part of somatic sensory area sensory area I area 5,7
2-receive sensation from I
opposite side of body 2-Receive signal from
(crossed representation) 2-the body is represented as *somatic sensory area I,II
*face anterior *thalamus
3-the body is represented *arms central *visual cortex
*upside down(inverted) *legs posterior *auditory cortex
*large area for certain areas
(thumb, lips) 3-function 3-function
(spatial) It begins to make meanings Collect information to
4-function for sensory signals understand meaning
it receives sensation Eg: *shape of subject in
*fine touch hand
*pressure *texture of subject in hand
*vibration
*position
*steriognosis
*kinesthesia

- The receptors for thermal sensation:

Cold receptors Warm receptors Cold pain receptors
Hot pain receptors
F.N.E. which are attatched F.N.E. which are attatched Freezing cold or burning
to A delta , C fibers to , C fibers hot

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[Link] hemisphere: Basal ganglia&White matter

Basal ganglia
- The basal ganglia are a group of grey matter nuclei within the cerebral hemispheres that
include the caudate ,lentiform,amygdaloid and [Link] caudate and lentiform are
collectively called corpus striatum (connected by striations).The amygdaloid and
claustrumare now excluded and considered as parts of the limbic system. Other 2 nuclei
(the subthalamic nucleus of the subthalamus and substantia nigra of the midbrain) are
included in what is now collectively called the basal motor nuclei.

 Corpus Striatum:
A-Caudate nucleus
- Shape: is comma-shaped.
- Parts: it has head ,body and tail.
- Site and relations: lies in the concavity of the lateral ventricle; its head projects
into the anterior horn; its body projects into the floor of the
trunk and its tail projects into the roof of the inferior horn. Its
head fuses with the putamen of the lentiform nucleus while its
tail fuses with the amygdaloid body.

B-Lentiform nucleus
- Shape: is like a biconvex lens.
- Parts: is divided by an external medullary lamina into large lateral part (putamen)
and a small medial part (globus pallidus) which is further subdivided by an
internal medullary lamina into pallidum I and pallidum II.
- Relations: laterally it is related to the external capsule separating it from the
claustrum and medially to the internal capsule separating it from the
head of caudate and thalamus.

 Connections and functions

- It is connected with the motor and premotor cortex by a motor loop concerned with
leaned movements. The striatum (caudate + puamen) receive afferents while the
pallidum give rise to all efferents of the basal ganglia. The motor loop involves
direct and indirect pathways.
- Reciprocal feedback circuit exists between the substantia nigra and neostriatum via
the ascendind dopaminergic nigro-striatal fibers which facilitate the direct pathway
via D1 receptors and inhibit the indirect pathway via D2 receptors. The lesion of that
pathway causes parkinsonism.

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White matter
The cerebral hemisphere has 3 types of white matter:
- Association fibers.
- Commissural fibers.
- Projection fibers.

 Association fibers
These fibers connect the different cortical areas and gyri in the same cerebral
hemisphere.
1. Superior longitudinal fasciculus.
- It extends from the frontal lobe to the temporal and occipital lobes.
2. Inferior longitudinal fasciculus.
- It extends from the occipital pole to the temporal pole.

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 Commissural fibers
These fibers connect similar functional areas in the two cerebral hemispheres

Corpus callosum :
- Definition: it is the major commissure between the two cerebral hemispheres.
However it does not connect cortical areas projecting to the distal parts of limbs.
- Parts of corpus callosum:
From before backwards, it has 4 parts: rostrum, genu, trunk, splenium.

 Projection fibers:
- Projection fibers connect the cerebral cortex to the lower levels of the brain and spinal
cord.
- The fibers may be ascending to the cortex or descending from the cortex mostly in the
internal capsule.

1. Function of BG:
1- The BG in BIRDS,& FISH do all voluntary movement
2- BG inhibit muscle tone
3- BG have a role in controlling voluntary movement:
(1) *Caudate------Convert the thoughts into plans to form complex goal
*if the caudate is damaged
-no thoughts are converted to plans
-person can not write, or draw
-no timing , no scaling of movement
(2) *the Putamen ----help to form SUBCONSCIOUS
LEARNED MOVEMENT
-store familiar automatic
movement
- as in driving, walking, writing
*damage of Putamen—Apraxia (inability to do
familiar movement with no
paralysis.
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(3) BG help planning & programming of movement
(4) BG help to take posture (position) taken by body to do certain movement
4- Lesion of BG:
5- Involuntary movements
1-Chorea----rapid
involuntary
jerky
dancing movement
due to lesion in caudate , putamen
2-Athetosis---continuous
slow
snake like movement
due to lesion in globus pallidus
3-Hemiballismus: involuntary
intense
violent movement
due to lesion in subthalamus

2. -Parkinsonism (paralysis agitans)

-A disease caused due to lesion in substantia nigra
-there is loss of Dopamine inhibitory transmitter

3. Causes of parkinsonism:
Idiopathic phenothiazine tranquilizers
-old age

4. Manifestation:
1-Rigidity:
(lead pipe) (Cog wheel) type of rigidity :
-there is resistance all through bending of limb
-occur in both antigravity , & progravity muscles
-more in flexors (person has flexed position)
2-hyperkinesia: (static tremors)
-rhythmic
-involuntary
-alternating contraction
-of antagonist muscles
-occur at distal joints
-with rate of 4-8/sec
-occur at rest
-disappear on voluntary movement
-have the form of up & down movement of mandible , or pill rolling of hands
3-Akinesia:
-difficult to initiate voluntary movement
-decrease associative movement
-mask face
-monotonous speech
-bent forward---flexors tone are stronger
-shuffling gait----short steps
no swinging arms
Treatment:
1-L-dopa----change in CNS to dopamine
2-Anticholinergic drugs---inhibit acetylcholine
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The internal capsule is the porta cerebrei of the cerebral hemisphere
Definition: internal capsule is a broad band of projection fibers, which connects the cerebral
hemispheres to the lower levels of the brain and spinal cord.

Extent: it extends from the level of the basal ganglia down to the level of the optic tract

Parts of the internal capsule:

1. Anterior limb:
- It lies between the head of caudate medial to it and lentiform nucleus lateral to it.
- It contains descending fronto-pontine fibers fibers

2-Genu:
- It lies at the junction of the anterior and posterior limbs of the internal capsule.
- It contains cortico – nuclear fibers from the lower (face) part of area 4 to the
motor nuclei of the cranial nerves

3-Posterior limb:
- It lies between thalamus medial to it and lentiform nucleus lateral to it.
- It contains:
Ascending fibers Descending fibers
- From the nucleus ventralis posterior - Cortico – spinal fibers (those for U.
of thalamus to the sensory area in limb are most anterior, those of L.
the postcentral gyrus in the parietal limb are most posterior).
lobe - Parieto-pontine fibers

4-Retrolenticular part:
- It lies behind the lentiform nucleus.
- It contains:
Ascending fibers Descending fibers
- Optic radiation from L.G.B to the - Occipito – pontine.
visual cortex in the occipital lobe

5-Sublenticular part:
- It lies below the lentiform nucleus.
- It contains:
Ascending fibers Descending fibers
- Auditory radiation from M.G.B to - Tempero – pontine fibers.
the auditory cortex in the temporal
lobe.

Blood supply of the internal capsule

- Middle cerebral.A. supplies 2 parts.
 Upper ½ of the anterior limb.
 Upper ½ of the posterior limb.

-Anterior cerebral.A. supplies 2 parts.

 Lower ½ of the anterior limb.
 Genu of the capsule.

- Anterior choroidal arteries supply the rest of the capsule.

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8– Cerebral Hemispheres: Blood supply

 Key facts:
1. The brain receives its arterial blood supply from 2 major arterial systems.
 The right and left internal carotid arteries (4th part) and together, they form
the carotid arterial system.
 The right and left vertebral arteries (4th part) which unite to form the
basilar.A. Together, they form the vertebro-basilar arterial system.
2. Both systems anastomose via the circle of Willis.
3. All these arteries lie in the subarachnoid space.

1. Anterior cerebral.A.
- It turns medially towards the medial surface of the cerebral hemisphere to run in the
callosal sulcus above corpus callosum.
- Its first segment is connected to the contralateral one by the anterior
communicating.A.
- It gives cortical branches which supply the following areas of cerebral cortex.
1. Medial surface except the occipital lobe.
2. An area (2 cm) on the superolateral surface.
3. Medial zone of the orbital part of the inferior surface.

N.B. Anterior cerebral.A. supplies the paracentral lobule (area for lower limb + perineum)

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2. Middle cerebral.A.
- It runs laterally in the stem and then in the posterior ramus of the lateral sulcus in the
superolateral surface of the cerebral hemisphere overlying the insula.
- It gives cortical branches which supply the following areas of cerebral cortex.
1. Superolateral surface except (its superior 2 cm + occipital lobe + inferior
temporal gyrus).
2. Lateral zone of the orbital part of the inferior surface.
3. Temporal pole.
N.B. middle cerebral.A. supplies sensoriomotor areas of the whole body (except that of
lower limb + perineum), frontal eye field, speech and auditory areas.

3- Posterior cerebral.A
- It crosses the lateral aspect of the cerebral peduncle to reach and runs in the calcarine
sulcus.
- Each is connected to its ipsilateral I.C.A by the posterior communicating artery
- Its cortical branches supply the following areas of the cerebral cortex
1. On the superolateral surface: occipital lobe + part of the inferior temporal
gyrus.
2. On the medial surface: occipital lobe.
3. On the inferior surface: its tentorial part except the temporal pole.
N.B. posterior cerebral.A. supplies the visual cortex. However, in the region of macula,
there is a good anastomosis between cortical branches of posterior cerebral and
middle cerebral arteries so that occlusion of posterior cerebral.A. leads to macular
sparing.

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Circle of Willis
Definition: it is an anastomotic arterial ring between the internal carotid and vertebro
– basilar systems.

Site: it lies in the subarachnoid space ventral to the interpeduncular fossa.

Formation:
- It is formed by 6 large arteries + 3 small communicating arteries.
 Right and left anterior cerebral arteries, connected by the small anterior
communicating artery.
 Right and left internal carotid arteries
 Right and left posterior cerebral arteries. Each is connected to the ipsilateral
I.C.A. by the small posterior communicating artery.
N.B. middle cerebral.A. does not share in circle of Willis but runs close to it.

Branches and distribution:

- The arteries sharing in or run close to circle of Willis give rise (on each side) to 4
groups of central branches (end arteries).
- Anteromedial and anterolateral branches.
- Posteromedial and posterolateral branches.
- These branches share in the blood supply of the inaternal capsule.
- Haemrrhage or thrombosis of these central branches lead to contralateral
hemiplegia 9upper motor neuron lesion) especially evident in the distal parts of
the limbs.

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9– Cerbral Meninges and Cebrospinal fluid

Cerebral meninges
- 3 membranes invest the brain and the spinal cord.( Dura ,arachnoid ,pia)
- 3 spaces exit between the meninges:
1- Extradural (epidural) space: contains the middle meningeal artery; thus extradural
hemorrhage is of arterial origin.
2- Subdural space: contains a film of fluidand is traversed by cerebral veins; thus-
subdural hemorrhage is of venous rigin.
3- Subarachnoid space: contains C.S.F, a delicate network of trabeculae and blood
vessels supplying the brain (hemorhage here ia arterial). That space is dilated in
certain areas called subarachnoid cisterns:
a- Pontine cistern: anterior to the pons and contains the basilar artery.
b- Interpeduncular cistern: infront of the interpeduncular fossa and contains
circle of Willis.
c- Cerbello-medullary cistern (cisterna magna): lies behind the medulla and
below the cerebellum. It receives the foramen of Magendie.
d- Cistern of the cerebral vein (cisterna ambiens): below the splenium of
corpus callosum and above the cerebellum and contains the pineal body
and great cerebral vein.
e- Cistern of the lateral fossa: on the stem of the lateral sulcus and contains
the middle cerebral artery.
f- Supracallosal cistern: above the corpus callosum and contains the anterior
cerebral artery.

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Cerbrospinal Fluid (CSF)

Formation of C.S.F
- It is mainly formed by the secretion of the choroid plexuses of the ventricular system
(90% in the lateral ventricle).
- -Little is filtered by the cerebral vessels and ependymal walls of the ventricle.
- Its volume is about 130 ml. About ½ liter is produced daily, thus it is renewed 3-4
times daily.

Ciculation of CSF
- Lateral ventricles interventricular foramina of Monro 3rd ventricle
th
→cerebral aqueduct of midbrain 4 ventricle median foramen of
Magnedi and the two lateral foramina of Lushka subarachroid space.
- Some of CSF passes inferiorly around the spinal cord and returns again. However,
most of the fluid passes upwards around the cerebral hemispheres to reach the superior
saggital sinus.

Absorption of CSF
- Mostly by arachnoid villi and granulations into the blood of the superior sagittal sinus.
- Little by perineural lymphatics around the cranial and spinal nerves.

Fucntions of CSF
1. Protection of C.N.S against shaking and trauma.
2. Removal of metabolites from the extracellular fliud spaces of C.N.C. (the brain has
no lymphatics)

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3. Maintanance of a constant intracranial pressure according to Monro-kellie statement
(The volume of CSF + blood + brain must be constant) so that, any increase in the
blood in the cranial cavity is compensated by removal of some CSF which goes to
the subarachnoid space around the spinal cord.

Applied anatomy
- Hyrocephalus: is an increase in the volume of CSF within the skull due obstruction of
the foramina of the 4th ventricle.
- Papilledoma: is edoma of the optic disc due to increased intracranial pressure
([Link] tumors). The increased intracranial pressure in the subarachnoid space
around the optic nerve causes compression of the central vein of the retina resulting in
papilledoma which cause blurring of vision and the condition is diagnosed by
ophthalmoscope (sure diagnostic sign).

Circulation of C.S.F

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The Meninges
Pia matter: (Tender mother)
 It lies on brain and spinal cord surface.
 It is formed of a single layer of modified fibroblasts that overlap each other.
 It is highly vascular.

Arachnoid matter: (like a network of threads made by a spider)

 It is formed of 2 types of cells: border cells joined by tight junctions forming a
roof and trabecular cells that hold up the roof like pillars.
 It is separated from the pia matter by subarachnoid space containing C.S.F. and
blood vessels.
 It forms with the pia matter a compound membrane called pia-arachnoid or
leptomeniges.

Dura matter: (tough mother)

 Formed of 2 fibrous layers; outer thick, inner thin.
 The 2 layers are separated at the regions of venous sinuses.

Brain Barriers
1- Blood brain barrier:
Definition: It is the barrier between the blood and the nerve cells.
Structure: It is formed of:
 Tight junction between non fenestrated endothelium lining capillaries.
 Thick continuous basement membrane (Basal lamina).
 End feet of astrocytes firmly applied on capillaries.
Function:
 Prevents harmful materials from reaching the nerve cells.
 Allows nutrients and precursors of neurotransmitters to pass by facilitated
diffusion and active transport.

2- Blood CSF harrier-

Definition: it is the barrier that separates blood from CSF.
Structure: it is formed of;
 Endothelium of choroidal capillary.
 Basement membrane of the choroidal capillary.
 Basement membrane of ependymal cells forming the choroid plexus.
 Tight junctions between ependymal cells forming the choroid plexus.
Function:
 Control of substances pass from blood to CSF.
 Maintenance and constancy of CSF.

3- Arachnoid barrier:
Definition: It is the barrier between extracerebral capillaries and subarachnoid
space
Structure: it is the arachnoid barrier layer formed of cells joined by tight junctions
and desmosomes.
Function: block substances leaving extracerebral capillaries from reaching
subarachnoid space, brain tissue and ventricles.

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