II Sem Lecture Pysiotherapy, BS, SS, 8.05.2020

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Hello II semestr students of Physiotherapy,BeautyScience,Sport

Science!

dr Ivonka 8.05.2020

Topick: Brain/ structure, function, blood supply and


the clinical implications
1 Anatomy of the cerebrum/Internal and External
Structure
2 Lobes of the Cerebrum
3 Vasculature of the Cerebrum
4 Clinical signs of the cerebrum
5 Cerebellum/ anatomy of the cerebellum
6 The meninges
7. Clinical Relevance/Meninges

The cerebrum is the largest part of the brain, located superiorly and
anteriorly in relation to the brainstem. It consists of two cerebral
hemispheres (left and right), separated by the falx cerebri of the dura
mater. Embryologically, the cerebrum is derived from the
prosencephalon.

we will look at the anatomy of the cerebrum – its structure, function,


blood supply and the clinical implications of cerebral lesions.

The cerebrum is located within the bony cranium. It extends from the
frontal bone anteriorly to the occipital bone posteriorly. Within the
skull, the cerebrum fills the anterior and middle cranial fossae, and is
located above the tentorium cerebelli inferoposteriorly.

Internal Structure
The cerebrum is comprised of two different types of tissue – grey
matter and white matter:

Grey matter forms the surface of each cerebral hemisphere (known


as the cerebral cortex), and is associated with processing and
cognition.
White matter forms the bulk of the deeper parts of the brain. It
consists of glial cells and myelinated axons that connect the various
grey matter areas.

External Structure
Externally, the cerebrum has a highly convoluted appearance,
consisting of sulci (grooves or depressions) and gyri (ridges or
elevations). It is divided into two anatomically symmetrical
hemispheres by the longitudinal fissure – a major sulcus that runs in
the median sagittal plane. The falx cerebri (a fold of dura mater)
descends vertically to fill this fissure. The two cerebral hemispheres
are connected by a white matter structure, called the corpus
callosum.

The main sulci are:

Central sulcus – groove separating the frontal and parietal lobes.

Lateral sulcus – groove separating the frontal and parietal lobes from
the temporal lobe.

Lunate sulcus – groove located in the occipital cortex.

The main gyri are:

Precentral gyrus – ridge directly anterior to central sulcus, location of


primary motor cortex.

Postcentral gyrus – ridge directly posterior to central sulcus, location


of primary somatosensory cortex.
Superior temporal gyrus – ridge located inferior to lateral sulcus,
responsible for the reception and processing of sound.
Lobes of the Cerebrum

The cerebral cortex is classified into four lobes, according to the


name of the corresponding cranial bone that approximately overlies
each part. Each lobe contains various cortical association areas –
where information from different modalities are collated for
processing. Together, these areas function to give us a meaningful
perceptual interpretation and experience of our surrounding
environment.

1.Frontal Lobe

The frontal lobe is located beneath the frontal bone of the calvaria
and is the most anterior region of the cerebrum. It is separated from
the parietal lobe posteriorly by the central sulcus and from the
temporal lobe inferoposteriorly by the lateral sulcus.

The association areas of the frontal lobe are responsible for: higher
intellect, personality, mood, social conduct and language (dominant
hemisphere side only).

2.Parietal Lobe

The parietal lobe is found below the parietal bone of the calvaria,
between the frontal lobe anteriorly and the occipital lobe posteriorly,
from which it is separated by the central sulcus and parieto-occipital
sulcus, respectively. It sits superiorly in relation to the temporal lobe,
being separated by the lateral sulcus.

Its cortical association areas contribute to the control of: language


and calculation on the dominant hemisphere side, and visuospatial
functions (e.g. 2-point discrimination) on the non-dominant
hemisphere side.

3.Temporal Lobe

The temporal lobe sits beneath the temporal bone of the calvaria,
inferior to the frontal and parietal lobes, from which it is separated
by the lateral sulcus.

The cortical association areas of the temporal lobe are accountable


for memory and language – this includes hearing as it is the location
of the primary auditory cortex.

4.Occipital Lobe

The occipital lobe is the most posterior part of the cerebrum situated
below the occipital bone of the calvaria. Its inferior aspect rests upon
the tentorium cerebelli, which segregates the cerebrum from the
cerebellum. The parieto-occipital sulcus separates the occipital lobe
from the parietal and temporal lobes anteriorly.

The primary visual cortex (V1) is located within the occipital lobe and
hence its cortical association area is responsible for vision.
5.Limbic Lobe

Vasculature
The blood supply to the cerebrum can be simply classified into 3
distinct paired arterial branches:

Anterior Cerebral Arteries – branches of internal carotid arteries,


supplying the anteromedial aspect of the cerebrum.

Middle Cerebral Arteries – continuation of internal carotid arteries,


supplying most of the lateral portions of the cerebrum.

Posterior Cerebral Arteries – branches of the basilar arteries,


supplying both the medial and lateral sides of the cerebrum
posteriorly.
Venous drainage of the cerebrum is via a network of small cerebral
veins. These vessels empty into the dural venous sinuses –
endothelial lined spaces between the outer and inner layers of dura
mater.

Cerebrum in this matter can give rise to a range of


clinical signs.
The exact nature of the functional deficit that arises depends on the
specific lobe that has been affected:

Frontal lobe – a diverse range of presentations, often personality and


behavioural changes occur and an inability to solve problems
develops.
Parietal lobe – typically presents with attention deficits e.g.
contralateral hemispatial neglect syndrome: where the patient does
not pay attention to the side of the body opposite to the lesion.

Temporal lobe – presents with recognition deficits (agnosias) e.g.


auditory agnosia: patient cannot recognise basic sounds,
prosopagnosia: failure to recognise faces.

Occipital lobe – visual field defects: contralateral hemianopia or


quadrantanopia with macular sparing.

Global lesions – severe cognitive deficits (dementia), patients cannot


answer simple questions such as their name, today’s date

Brain diseases !!!!! please prepare!!!

Cerebellum/ anatomy of the cerebellum


The cerebellum, which stands for “little brain”, is a structure of the
central nervous system. It has an important role in motor control,
with cerebellar dysfunction often presenting with motor signs. In
particular, it is active in the coordination, precision and timing of
movements, as well as in motor learning.

During embryonic development, the anterior portion of the neural


tube forms three parts that give rise to the brain and associated
structures:

Forebrain (prosencephalon)

Midbrain (mesencephalon)
Hindbrain (rhombencephalon)

The hindbrain subsequently divides into the metencephalon


(superior) and the myelencephalon (inferior). The cerebellum
develops from the metencephalon division.

.Anatomical Location

The cerebellum is located at the back of the brain, immediately


inferior to the occipital and temporal lobes, and within the posterior
cranial fossa. It is separated from these lobes by the tentorium
cerebelli, a tough layer of dura mater.

It lies at the same level of and posterior to the pons, from which it is
separated by the fourth ventricle.

Anatomical Structure and Divisions

The cerebellum consists of two hemispheres which are connected by


the vermis, a narrow midline area. Like other structures in the central
nervous system, the cerebellum consists of grey matter and white
matter:

Grey matter – located on the surface of the cerebellum. It is tightly


folded, forming the cerebellar cortex.

White matter – located underneath the cerebellar cortex. Embedded


in the white matter are the four cerebellar nuclei (the dentate,
emboliform, globose, and fastigi nuclei).
There are three ways that the cerebellum can be subdivided –
anatomical lobes, zones and functional divisions

Anatomical Lobes

There are three anatomical lobes that can be distinguished in the


cerebellum; the anterior lobe, the posterior lobe and the
flocculonodular lobe. These lobes are divided by two fissures – the
primary fissure and posterolateral fissure.

Zones

There are three cerebellar zones. In the midline of the cerebellum is


the vermis. Either side of the vermis is the intermediate zone. Lateral
to the intermediate zone are the lateral hemispheres. There is no
difference in gross structure between the lateral hemispheres and
intermediate zones

Functional Divisions

The cerebellum can also be divided by function. There are three


functional areas of the cerebellum – the cerebrocerebellum, the
spinocerebellum and the vestibulocerebellum.

Cerebrocerebellum – the largest division, formed by the lateral


hemispheres. It is involved in planning movements and motor
learning. It receives inputs from the cerebral cortex and pontine
nuclei, and sends outputs to the thalamus and red nucleus. This area
also regulates coordination of muscle activation and is important in
visually guided movements.

Spinocerebellum – comprised of the vermis and intermediate zone of


the cerebellar hemispheres. It is involved in regulating body
movements by allowing for error correction. It also receives
proprioceptive information.

Vestibulocerebellum – the functional equivalent to the


flocculonodular lobe. It is involved in controlling balance and ocular
reflexes, mainly fixation on a target. It receives inputs from the
vestibular system, and sends outputs back to the vestibular nuclei.

Vasculature
The cerebellum receives its blood supply from three paired arteries:

Superior cerebellar artery (SCA)

Anterior inferior cerebellar artery (AICA)

Posterior inferior cerebellar artery (PICA)

The SCA and AICA are branches of the basilar artery, which wraps
around the anterior aspect of the pons before reaching the
cerebellum. The PICA is a branch of the vertebral artery.

Venous drainage of the cerebellum is by the superior and inferior


cerebellar veins. They drain into the superior petrosal, transverse and
straight dural venous sinuses.
Clinical Relevance:

Dysfunction of the cerebellum can produce a wide range of


symptoms and signs. The aetiology is varied; causes include stroke,
physical trauma, tumours and chronic alcohol excess.

Damage to the cerebrocerebellum and spinocerebellum presents


with problems in carrying out skilled and planned movements and in
motor learning.

A wide variety of manifestations are possible. These can be


remembered using the acronym ‘DANISH‘:

Dysdiadochokinesia (difficulty in carrying out rapid, alternating


movements)

Ataxia

Nystagmus (coarse)

Intention tremor

Scanning speech

Hypotonia

Damage to the vestibulocerebellum can manifest with loss of


balance, abnormal gait with a wide stance.

The meninges
The meninges refer to the membranous coverings of the brain and
spinal cord. There are three layers of meninges, known as the dura
mater, arachnoid mater and pia mater.
These coverings have two major functions:

Provide a supportive framework for the cerebral and cranial


vasculature.

Acting with cerebrospinal fluid to protect the CNS from mechanical


damage.

The meninges are often involved cerebral pathology, as a common


site of infection (meningitis), and intracranial bleeds.

Iwe shall look at the anatomy of the three layers, and their clinical
correlations.

Dura Mater
The dura mater is the outermost layer of the meninges, lying directly
underneath the bones of the skull and vertebral column. It is thick,
tough and inextensible.

Within the cranial cavity, the dura contains two connective tissue
sheets:

Periosteal layer – lines the inner surface of the bones of the cranium.

Meningeal layer – deep to the periosteal layer inside the cranial


cavity. It is the only layer present in the vertebral column.

Between these two layers, the dural venous sinuses are located. They
are responsible for the venous vasculature of the cranium, draining
into the internal jugular veins.

In some areas within the skull, the meningeal layer of the dura mater
folds inwards as dural reflections. They partition the brain, and divide
the cranial cavity into several compartments. For example, the
tentorium cerebelli divides the cranial cavity into supratentorial and
infratentorial compartments.

The dura mater receives its own vasculature; primarily from the
middle meningeal artery and vein. It is innervated by the trigeminal
nerve (V1, V2 and V3).

Haematomas
A haematoma is a collection of blood. As the cranial cavity is
effectively a closed box, a haematoma can cause a rapid increase in
intra-cranial pressure. Death will result if untreated.

There are two types of haematomas involving the dura mater:

Extradural – arterial blood collects between the skull and periosteal


layer of the dura. The causative vessel is usually the middle
meningeal artery, tearing as a consequence of brain trauma.

Subdural – venous blood collects between the dura and the


arachnoid mater. It results from damage to cerebral veins as they
empty into the dural venous sinuses.

Arachnoid Mater

The arachnoid mater is the middle layer of the meninges, lying


directly underneath the dura mater. It consists of layers of connective
tissue, is avascular, and does not receive any innervation.

Underneath the arachnoid is a space known as the sub-arachnoid


space. It contains cerebrospinal fluid, which acts to cushion the brain.
Small projections of arachnoid mater into the dura (known as
arachnoid granulations) allow CSF to re-enter the circulation via the
dural venous sinuses.

Pia Mater

The pia mater is located underneath the sub-arachnoid space. It is


very thin, and tightly adhered to the surface of the brain and spinal
cord. It is the only covering to follow the contours of the brain (the
gyri and fissures).
Like the dura mater, it is highly vascularised, with blood vessels
perforating through the membrane to supply the underlying neural
tissue.

Clinical Relevance: Meningitis

Meningitis refers to inflammation of the meninges. It is usually


caused by pathogens, but can be drug induced.

Bacteria are the most common infective cause. The most common
organisms are Neisseria meningitidis and Streptococcus pneumoniae.

The immune response to the infection causes cerebral oedema,


consequently raising intra-cranial pressure. This has two main effects:

Part of the brain can be forced out of the cranial cavity – this is
known as cranial herniation.

In combination with systemic hypotension, raised intracranial


pressure reduces cerebral perfusion.

Both of these complications rapidly result in death.

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