NEUROLOGY | OTRP 2022

THE BRAIN: PART 2

GOLD RANK REVIEW CENTER

BASAL GANGLIA • Initiation of voluntary motor activity

• belongs to the motor circuitry o no initiation → Akinesia
o extrapyramidal • Regulation of muscle tone
• extrapyramidal lesion results in rigidity
Common Manifestations of Basal Ganglia Pathology:
o if UMN (pyramidal), it’s spasticity
• Akinesia – inability to initiate motion
3 Anatomic Structures: o best PNF pattern and technique for PD: Bilateral
• Caudate Nucleus symmetrical D2 flexion of BUE with rhythmic initiation
• Putamen ▪ sequence of performance: passive → AA → resisted
• Globus Pallidus → active
▪ position improves upper trunk extension
• Neostriatum – Caudate + Putamen
• Athetosis – slow, worm-like, writhing motions involving the
• Lentiform Nucleus – Putamen + GP
distal UE
• Corpus Striatum – Caudate + Putamen + GP
• Bradykinesia – slowness of motor performance
Functional Structures • Chorea – rapid, jerky motion
• outside the telencephalon but connected to the basal ganglia o Huntington’s Chorea – autosomal dominant inheritance
• Subthalamic Nucleus – part of the diencephalon o Sydenham’s Chorea – secondary to rheumatic fever
• Substantia Nigra – only part of the brain with melanin • Choreoathetosis – slow, worm-like and rapid, jerky motion
pigmentation • Dystonia – sustained, involuntary contraction of agonist and
o found at the level of the midbrain antagonist
o Pars Compacta – chief producer of DOPAMINE o e.g., Torticollis
▪ Parkinson’s Disease – decreased dopamine production
• Hemiballismus – wild, violent, flailing motions involving the
o Pars Reticulata
extremities

Neurotransmitter Agents o affected structure: Subthalamic Nucleus

EXCITATORY INHIBITORY • Hyperkinesis – increased motor activity

- Epinephrine - GABA** (Gamma • Hypokinesis – decreased motor activity

- Acetylcholine Aminobutyric Acid) • Rigidity – velocity independent

- Glutamate** - Glycine (in spinal cord) o Lead-Pipe – uniform resistance all throughout the ROM
- Serotonin o Cogwheel – catches; series of relaxation throughout the
- Dopamine ROM
• Tremor
• MC inhibitory neurotransmitter agent in the cerebral cortex:
o Resting Tremor – basal ganglia pathology (e.g., PD); “Pill
GABA
Rolling”
• MC excitatory neurotransmitter agent in the cerebral cortex:
o Intention Tremor – cerebellar pathology (e.g., MS)
GLUTAMATE
▪ MS = scanning speech, intention tremor, nystagmus
Functions of the Basal Ganglia: (SIN)
• Modulation of motor outflow from the cerebral cortex
o no modulation → movement disorders DIENCEPHALON
▪ Hyperkinetic – e.g., Athetosis, Chorea, etc. • lies above the midbrain below the frontal lobe
▪ Hypokinetic – e.g., Parkinson’s Disease • surrounds the 3rd ventricle
• Tetrad of PD (BRRP): Bradykinesia, Resting tremor, • 4 Major Components: (SHET)
Rigidity, Postural instability o Subthalamus – contralateral hemiballismus (PCA)

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NEUROLOGY | OTRP 2022
THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

o Hypothalamus – contains the Optic Chiasm ANTERIOR POSTERIOR

o Epithalamus – contains the Pineal gland Heat loss (alis = anterior) Heat production (paso =
▪ a pine-cone shaped gland that secretes melatonin - Vasodilation posterior

▪ connects to the retina (more light = low melatonin); - Sweating - Vasoconstriction

thus, it serves as internal body clock - Panting - Shivering

o Thalamus – largest part of the diencephalon - Piloerection

o vasodilation causes heat dissipation

THALAMUS ▪ that’s why when in fever, you’re red d/t dilation to release heat
o sweating evaporates the heat into the air
• sensory “relay” station of the brain:
o shivering produces heat d/t muscle contractions
o pain, temperature, touch, vision, auditory, taste,
o panting (increased respiration) because exhaling releases heat
proprioception o piloerection is muscle contraction so it produces heat
o except: OLFACTION • Regulates ANS (sympathetic and parasympathetic)
• integrates, correlates, and relays information for: o Sympathetic = Posterior Hypothalamus
o sensory o Parasympathetic = Anterior Hypothalamus
o motor • Endocrine function
o conscious o regulates pituitary gland (“master gland”)
o limbic ▪ Anterior Pituitary releases 7 hormones (PITUitary):
o visual ▪ Posterior Pituitary releases 2 hormones:
• Anti-Diuretic Hormone (Vasopressin) – causes
Specific Nuclei and Their Functions: vasoconstriction; impt. for water conservation
• Lateral Geniculate Body (LGB) – vision (LaGBu) • Oxytocin
• Medial Geniculate Body (MGB) – auditory ▪ Q1: Patient has no access to water. What happens to
• Ventral Posteromedial Nucleus (VPMN) – taste and ADH? INCREASE
proprioception of head & neck ▪ Q2: Patient has diabetes insipidus. What happens to
• Ventral Posterolateral Nucleus (VPLN) – proprioception of ADH? DECREASE (Polyuria + Polydipsia)
trunk and limbs, pain, temperature, touch • Thirst Center
• Feeding Center
Thalamic Pain Syndrome (“Dejerine Rousy Syndrome”) o hunger – Lateral hypothalamic area (L = lamon)
• aka “Central Post-Stroke Pain Syndrome” o satiety – Ventromedial hypothalamic area (V = vusog)
• PCA supplies blood to the Thalamus o Clinical Correlation: Eating Disorders
o occlusion results in sensory disturbances (pain) and ▪ Anorexia nervosa – loss of appetite
partial or complete paralysis of one side of the body ▪ Bulimia nervosa – binge-eating followed by self-
induced vomiting
HYPOTHALAMUS • Regulates emotions
• vital in homeostasis • Sexual behavior
• Circadian rhythm
Functions:
o Insomnia – Anterior Hypothalamus problem
• Temperature Regulation Center of the brain
o Posterior Pre-optic and Anterior Hypothalamic Area –
structures of the hypothalamus involved in temperature
regulation
o (N) temp: 36.5-37.5 deg

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NEUROLOGY | OTRP 2022
THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

MESENCEPHALON / MIDBRAIN RHOMBENCEPHALON

• Metencephalon
o Cerebellum
o Pons
• Myelencephalon
o Medulla Oblongata

PONS AND MEDULLA

• Pons – large bulging mass bet. medulla and midbrain
• Medulla – connected to pons superiorly and terminates at
the foramen magnum to continue as spinal cord
Structures:
Functions:
• Tectum – roof of midbrain
• Primary Respiratory Center (involuntary)
o contains Corpora Quadrigemina o voluntary control of respiration: Cerebral Cortex
• Cerebral Peduncles o 2 Respiratory Centers in the Pons: (PULA)
o Tegmentum – contains the Red Nucleus ▪ Apneustic – lower pons
o Crus Cerebri ▪ Pneumotaxic – upper pons
o Respiratory Centers in the Medulla:
Description of Each Component:
▪ Dorsal Respiratory Area – for rhythm of respiration
• Basis
▪ Ventral Respiratory Area – for inspiratory and
o base of the midbrain (anterior)
expiratory functions
o contains Crus Cerebri and Substantia Nigra (dopamine)
• Vasomotor Center
• Tegmentum
o for blood pressure regulation
o contains Red Nucleus – for motor coordination
• Vagal / Cardiac Center
▪ Rubrospinal Tract – from red nucleus to cervical part
o to decrease HR (CN 10)
of spinal cord; for UE flexion facilitation
• Vomiting / Emetic Center
• Decorticate – UE flexed, LE extended; better
• Coughing, Yawning, Sneezing Centers
prognosis (GCS 3 = decorTHREEcate)
o afferent of sneezing: CN5 v.1
o lesion is at the level of the midbrain
o efferent of sneezing: CN 9, 10
o better prognosis bc it spares the rubrospinal
tract (still have UE flexion)
Respiratory Activating System (RAS)
• Decerebrate – all fours extended (GCS 2)
• Reticular Formation – midbrain + pons + MO
o lesion is above the level of the midbrain
• located in the Brainstem
• Tectum (roof; posterior)
• for arousal and control of sleep-wake cycle
o contains Corpora Quadrigemina, separated by the
• RAS is activated by painful stimulus (e.g., trapezius pinch,
quadrigeminal plate: supraorbital pain elicitation)
▪ Superior Colliculi – for visual reflexes (See) • 5 Levels of Consciousness:
▪ Inferior Colliculi – for auditory reflexes o Alert
o Tectospinal Tract – head turning reflexes following o Lethargic – drowsy
sudden sounds or visual images o Obtunded – awakened then sleeps
o Parinaud’s Syndrome – impaired upward gaze o Stupor – responds to pain
▪ lesion site: dorsal midbrain near the superior colliculi o Coma

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NEUROLOGY | OTRP 2022
THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

• Dysdiadochokinesia – difficulty performing rapid alternating

CEREBELLUM movements
o Q1: Most difficult task for patient with dysdiadochokinesia:
▪ eating
▪ brushing hair
▪ washing perineum
▪ brushing teeth
• Dysmetria – difficulty judging distance (Past Pointing Test)
o Hypermetria – overshooting
o Hypometria – undershooting
• Dyssynergia – movement decomposition
• Hypotonia

• “Little Brain” • Intention / Kinetic Tremor

• 2 hemispheres • Titubation – tremor of the head

• Midline Vermis – worm-like structure connecting the 2 • Rebound Phenomenon

hemispheres • Nystagmus – rhythmic oscillation of the eyes

• ipsilateral representation • Dysarthria (Scanning Speech)

o R/L side movements = R/L hemisphere of cerebellum • Ataxia

o Trunk movements = Vermis • Asthenia – generalized muscle weakness

• Lesion to the vermis: Truncal Ataxia Lobes of the Cerebellum:

PALEOCEREBELL NEOCEREBELLU ARCHICEREBELLU
• Cerebellar Cortex, 3 Layers:
UM M M
o Molecular
“Spinocerebellum Largest lobe “Floculonodular”
o Purkinje Cell Layer – characteristic cell of cerebellum
” or
o Granular
Includes Vermis Newest lobe “Vestibulocerebell
Functions: um”
• Balance Anterior lobe Posterior lobe Oldest lobe
o (+) Rhomberg’s Sign Postural Tone Coordination Balance
▪ (+) with Eyes open – Cerebellar lesion - truncal ataxia - dysdiadochokin - nystagmus
• impaired balance - hypotonia esia - gait ataxia
• “Cerebellar Ataxia” - dysmetria
▪ (+) with Eyes closed – Dorsal Column Pathway - dyssynergia
lesion - intention
• impaired proprioception tremor
• “Sensory Ataxia” - rebound
• Coordination phenomen
o Dexterity – fine motor skills
o Agility
• Muscle Tone
o lesion results in: Hypotonia
CEREBRAL CIRCULATION
Manifestations of Cerebellar Pathology:
Cerebrospinal Fluid

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THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

• chief producers: Choroid Plexus o anterior: ICA; posterior: vertebrobasilar a.

o by the ependymal cells (lines the ventricles) • first branch of ICA: ophthalmic a.
• amount produced: 500 mL/day • largest branch of ICA: MCA
• Functions of the CSF: • terminal branch of basilar a.: PCA
o Homeostasis • first branch of basilar a.: AICA (anterior inferior cerebellar a.)
o Shock absorption • PICA: branch of vertebral a.
o Nutrition – contains glucose
o Drains unwanted substances
• CSF Flow:
o Choroid Plexus → Lateral Ventricle → Foramen of
Monroe → 3rd Ventricle → Aqueduct of Sylvius → 4th
Ventricle → 2 Foramen of Lushka and 1 Foramen of
Magendie → Subarachnoid Space → Arachnoid
Villi/Granulation → Dural Venous Sinuses → Venous
Drainage
o arachnoid villi – absorbs the CSF
• Clinical Correlation:
o Hydrocephalus – accumulation of CSF in the head
▪ Communicating Hydrocephalus
• obstruction of CSF outside the ventricles (in the
SAS)
▪ Non-communicating Hydrocephalus
• obstruction of CSF inside the ventricles

CIRCLE OF WILLIS
• aka “Circulus Arteriosus”
• located at the base of the brain

Components of Circle of Willis:

• 2 ACA (Anterior Cerebral a.)
• 1 ACOM (Ant. Communicating a.)
• 2 ICA (Internal Carotid a.)
• 2 PCOM (Post. Communicating a.)
• 2 PCA (Posterior Cerebral a.)
• WALANG MCA

Significance of Circle of Willis: COLLATERAL FLOW

• Brain tissue – tissue in the body most sensitive to ischemia
o crucial period: 5-6 mins
▪ results in irreversible brain damage
Trivia: Anterior vs Posterior Circulation

• artery connecting the ant. with the post. circulation: PCOM a. ANTERIOR POSTERIOR

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NEUROLOGY | OTRP 2022
THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

ICA VBA (supplies the brainstem) • PCA – medial and inferior, temporal, occipital
- ACA • MCA – lateral frontal, parietal, temporal (except occipital)
- MCA
- Ophthalmic a.
2 Main Characteristics: 4 Main Characteristics:
- Amaurosis Fugax - CN abnormalities
(monocular blindness) (Dysphagia, Diplopia,
- (+) Aphasia (lahat ng Dizziness, Dysarthria)
aphasia MCA siya) - Coma
- Cerebellar manifestation
- Symmetrical involvement
Patient looks AWAY from
the hemiplegic side

• CN abnormalities are prominent bc VBA is near the cranial

nerves already
o Dysphagia (CN 9, 10)
o Diplopia (CN 4, 6)
o Dizziness (CN 8)
o Dysarthria (CN 12, 5, 7, 10)
• Coma – RAS is affected
• Cerebellar manifestation – ataxia

Cerebellar Blood Supply:

• Superior Cerebellar a. (SCA) – from basilar a.
o supplies the midbrain
• Anterior Inferior Cerebellar a. (AICA) – from basilar a.; first
branch
o supplies the pons
• Posterior Inferior Cerebellar a. (PICA) – from vertebral a.
o supplies the medulla oblongata
o lesion: Wallenberg Syndrome
• Q1: Wallenberg Syndrome
o ACA
o PCA
o MCA
o VA
•

Main Arteries Supplying the Cerebrum:

Clinical Manifestations:
• ACA – medial frontal, medial parietal
ACA MCA PCA

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NEUROLOGY | OTRP 2022
THE BRAIN: PART 2
GOLD RANK REVIEW CENTER

LE > UE UE > LE Visual impairment ▪ Wernicke’s (area 22) is in lateral temporal area (MCA
Astasia Aphasia Visual agnosia lower division) Frontal lobe (area 44)
Apraxia
Color agnosia
Abasia (Ideomotor and
(Dyschromatopsia) MAIN STEM
ideational)
Temporal lobe (area 22)
Abulia Astereognosis Memory defect
(+) Palmar grasp Unilateral neglect Prosopagnosia
supplies Basal • Lenticulostriate a. = “Cerebral Artery of Apoplexy”

Ganglia and • Q1: Memory problem:

Alexia w/o agraphia o MCA
Posterior Limb of
(+) Gegenhalten (can write but not
Internal Capsule o PCA (supplies the temporal lobe)
read)
(Lenticulostriate o ACA

a.—branch of MCA) • Q2: Lesion to the MCA main stem:

Urinary Supplies Thalamus o Broca’s aphasia (lesion to the MCA upper div.)
MC occluded o Wernicke’s aphasia (lesion to the MCA lower div.)
incontinence and Subthalamus
Artery of o Global aphasia

Heubner (media Homonymous hemianopsia

striate artery)
Thalamic Pain
Syndrome (Dejerine
Rousy Syndrome)
Hemiballismus

• Homunculus – cortical map representing the body upside

down
o Motor Homunculus (frontal lobe)
▪ largest representation: HANDS
o Sensory Homunculus (parietal lobe)
▪ largest representation: HANDS and FACE (lips)
• ACA = legs; MCA = Mcdo arms
• ACA
o Astasia – inability to stand
o Abasia – inability to walk
o Abulia – “Akinetic Mutism”
o Gegenhalten – resistance to passive movement related
with grasp
• MCA
o Aphasia – MCA supplies all lateral areas (except occipital)
▪ Broca’s (area 44) is in lateral frontal area (MCA upper
division)

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