Today's session will be an overview of

basic anatomy and functions of the nervous

system.
This is not in any way intended to
be an exhaustive review of neuroanatomy,
but rather we'll
focus on those clinically relevant pieces
of neuroanatomy
that you'll need for the remainder of the
course.
Many of the topics we're going to talk
about in this session we'll
come back to over and over again in
additional clinical topics that you'll
experience throughout the course.
For those of you who don't have a
background in
neuroanatomy and would like to explore it
in more depth.
It would be reasonable to obtain outside
reading in the form of a neuro-anatomy
text.
While there are many outstanding texts,
one of the texts we use frequently here at
UCSF, which you will see many slides from
in this presentation and others, is Hal
Blumenfeld's
neuro-anatomy through clinical cases.
Here are my titles.
I'm Dr. Andy Josephson.
I'll just introduce you to the fact that
throughout
our presentations, you'll see us highlight
potential conflicts of interest.
I have none to speak of, but others may.
And you should take those into
consideration.
When exploring these topics.
There are a number of learning objectives
for each of the sessions,
these, for this session are quite straight
forward; naming the key divisions of
the central nervous system and knowing
their basic fuction, including the pieces
that you see listed there; distinguishing
between the central and peripheral nervous
system.
Being able to trace the course of the
major motor pathway also known as the
cortical spinal tract.
And the two major sensory pathways, that
would
be the posterior column, or dorsal column
system.
And the spinothalamic tract.
These are three key tracts we will come
back to
over and over again in addition, we would
ask you to
identify the neuroanatomic upper and lower

motor neurons and be

able to draw them on a diagram of the
nervous system.
It is upper and lower motor neurons, this
concept that we'll come
back to to describe how we localize
lesions in the nervous system.
We'll discuss the cerebrospinal fluid, or
the CSF, and we'll ask you
to describe the path of its production to
the point of resorption.
And then we'll discuss three layers that
make up the meninges
in order from the outermost to that
closest to the brain.
So let's
begin with an overview of neuroanatomy.
Now, before we start we need to define
some important organizational pieces.
So first of all, fundamentally the nervous
system is
divided into the central nervous system or
the CNS.
And the peripheral nervous system.
Or the PMS, now what we talking about
here?
The central nervous system consists of the
brain and
the spinal cord.
The brainstem is a connector piece, that
connects the brain and spinal
cord and includes most of the major
sensory and motor pathways to the body.
Some folks will consider the brainstem as
part of the brain.
But if you want to formally divide this
into
three pieces, this is the central nervous
system.
The peripheral nervous system is quite
frankly
everything else.
That includes the peripheral nerves in the
body, the muscles and
the neuromuscular junctions that connect
the peripheral nerves with the muscle.
It is this key fundamental organization
That is
important to understand before we go any
further.
Here's a diagram of the central nervous
system, cutting up neuroanatomically,
slicing the brain and
the spinal cord.
You can see here a coronal section of the
brain.
If you look, it would be as if I sliced my
head like so.
And I'm making slices.
These are axial sections, so axial

sections would be
cutting with a knife like this is I'm
showing.
You can see immediately in these fresh
sections
that there are different colors, if you
will
to the central nervous system.
In the brain, there is this grey matter
and this white matter.
You can see a more greyish hue, and a
whitish hue.
In the brain, the grey matter is on the
outside,
whereas the white matter is mainly located
on the inside.
In the spinal cord, you'll see just the
opposite; the white
matter is on the outside, and the grey
matter is located centrally.
So what's going on here?
What is the difference between the gray
and the white matter?
Well in order to understand this, let's
first
review what's going on on a cellular
level.
This is a cartoon of the neuron.
The most important cell but not the only
cell.
In our central nervous system.
And it is made up of a cell body here,
with a nucleus in the middle.
So the cell body with a nucleus.
And then a long axon that allows it to
talk
to other nerve cells and other different
types of cells.
Please note that this diagram is a
cartoon,
in part, because it's quite out of
perportion.
In reality, in many cases, the axons
are extraordinarily long compared to the
cell body.
I'm sitting today in San Francisco, and if
I were a cell body,
given my size.
My axon might stretch across the bay to
Burkley California.
Quite a distance of some many miles.
So axons in reality are much, much longer
than you see depicted here.
There are some confusing terminology in
neuroanatomy that should be defined.
It turns out that identical structures in
the central nervous system and the
peripheral
nervous system.
Are given different names.

This is really confusing but we should

define it up front
so that we're all not confused as we
progress through this talk.
Collections of cell bodies, areas where
the cell bodies are
packed together, in the central nervous
system, we call these nuclei.
Different from the nucleus of the cell.
These are nuclei in
the central nervous system.
In the peripheral nervous system, these
same collections
of cell bodies, we refer to as ganglia,
like
a dosor root ganglia, which you'll hear
more about
in John [UNKNOWN] lecture on the
peripheral nervous system.
Similarly, collections of axons,
likeminded bundles of axons that
are usually going to a common destination
with a common
purpose, in the central nervous system
refer to them as a tract.
I mentioned already, and we'll come back
to the very important
motor tract, and two sensory tracts of the
central nervous system.
For instance, the corticospinal tract, the
most important motor system.
In the central nervous system is a merely
a collection of axons.
In the peripheral nervous system, we call
the same collection of axons,
simply a nerve.
So, if we are talking about the median
nerve,
here in a hand that's merely a collection
of
axons like minded that are going to
innervate a
group of muscles and carrying sensation
back from those muscles.
So important to understand this difference
in terminology.
Now let's go back to our gray and white
matter.
It turns out that as a general rule, gray
matter is
where there are huge collections of cell
bodies.
Whereas white matter represents areas of
the central
nervous system where there are lots of
axons.
so that's a fundamental difference between
the grey and the white matter.
Let's go back to our diagram.
So when we see grey matter here in the

brain, it's a bunch of cell bodies.

When we see white matter, that's a bunch
of axons.
Same thing in the spinal cord.
Now one thing
you'll notice here is that I mentioned in
the
brain that there is grey matter around the
outside.
There is also some grey matter here deep
in
between the white matter in the middle of
the brain.
These are structures like the thalamus,
the
basal ganglia, that are collections of
cell bodies.
And so we refer to those as nuclei.
And when you think about the thalamus,
the thalamus for instance, is merely a
collection of various nuclei.
Each nuclei.
Is a collection of cell bodies, so its
important
to understand this difference between grey
and white matter.
Now, we're going to talk a little bit
about the brain's defenses.
The brain is the most important organ in
the body.
And, so we must protect it from
various injury.
And, we'll talk about a number of these
protections.
The first is obvious and shown by this
diagram.
There is a big, hard skull that surrounds
the brain obviously and that skull is very
important
because it protects the brain which is a
soft structure and is quite vulnerable to
being injured.
But this diagram is rather comical because
it seems
to show that the brain is sitting right in
this bony skull, with no additional
protection.
Of course that's not the case.
If the brain simply sat, sat in this bony
skull, every time we would have a minor
bump
to the head, let alone a major head
trauma,
there would be injury, bleeding, bruising
of the brain.
That would potentially a cause of
permanent injury.
So in fact, there are multiple defenses
between the brain and
the skull.

One of which is called the meninges.

This is this these areas of connective
tissue
that sit between the brain and the skull.
And here's a cross-sectional diagram.
And I will draw your attention to the fact
that there are three different layers of
the meninges.
Working from the outside in, the outermost
layer right
next to the skull is called the
dura mater, or the tough mother, in
translation.
And the dura matter is actually two layers
of tough connective tissue.
That sit right adjacent to the skull.
Below the dura matter, you will find
another layer
of connective tissue called the arachoid,
or the arachnoid matter.
And then finally just inherent to the
brain,
in fact going and diving into these little
Prevaces of the
cortex is the so-called Pia or Pia matter
so the dura
on the outside the Arachnoid in the middle
and the Pia right adherent to the brain.
These are the three layers of connective
tissue that provide
an additional protection for the brain of
the the the skull.
Now are there many important
pieces to the maninges and we will talk
about their clinical relevance.
But what I'd like to draw your attention
to now, is the
fact that that these connective tissue
layers define clinically very important
spaces.
So the space that sits between the dura
and the skull Outside the
dura, is referred to the epidural space.
The epidural space.
The space that sits below the arachnoid,
between the arachnoid
and the pea we refer to as the
subarachnoid space.
And then the layer of connective tissue
That is defined, the layer
of fluid that's to spot, defined by the
dura and the arachnoid.
Below the dura, we refer to as the sub
dural space.
So the epidural space between
the bone and the dura.
The subdural space between the dura and
the arachnoid and then finally the
arachnoid space or the sub arachnoid
space located in between the arachnoid and

the pia.
In life, in health, these are merely
potential spaces where there
is small amount of fluid, or nothing,
sitting in these spaces.
But in disease, we often see problems with
these
spaces that are defined by these
connective tissues layers.
I'd like to illustrate the clinical
relevance of these spaces by talking
about a real life example and that's the
unfortunate case of Natasha Richardson.
You may recall that Ms. Richardson was a
famous actress, the
wife of Liam Neeson and although we don't
know the clinical
details personally of the case, there's a
lot to be learned
from the reports that are in the
newspapers regarding this sad story.
Ms. Richardson was a 45 year old woman
just four
or five years ago who suffered a fall
while skiing.
It turns out she was skiing On nothing
more than a relatively small bunny slope.
And she fell.
She fell and hit her head.
Initially she felt well.
She refused
medical treatment and went back to her
hotel room.
But then three hours later, she developed
a severe headache and progressively became
confused.
She was then taken to a local
hospital after emergency medical personnel
were summoned.
And then she was air lifted to a tertiary
center in Canada.
Before being air lifted to a tertiary
center in the United States.
And hours
later, this healthy woman who falls and
has something
that sounds like a relatively minor head
trauma, is dead.
So what happened here?
What is this injury that led to a healthy
woman with a head trauma dying
hours later who afterwards, just after the
injury was doing fine?
Well here's an example of a CT scan for
the same condition that Natasha
Richardson.
Suffered from.
First of all, let me orient you to
Neuroanatomy
You'll hear more about Neuroradiology and

Neuroanatomy later on
in the course, but let me just orient you
that over here is right and over here is
left.
You see the R and the l on your screen.
Remember that all neuro images have the
same orientation.
It's as if, if you're taking slices of the
head like so.
You are standing at the person's feet and
looking up
towards their head if they are lying down
on a gurney.
Therefore you can imagine the right would
be here, the left would be here.
Remember that orientation.
On a CT scan, a non-contrast CT
scan, everything that's white is something
to pay
attention to.
This white limb around the brain is merely
the skull.
On a CT scan The skull is bright, and you
know it's a CT scan because you see this
bright skull.
That's nomal.
But what's not normal is this lens-shaped
opacity here.
This bright, white area is blood.
This is acute blood.
This is bleeding that has occured in the
brain, and in fact this
bleeding That is in the epidural space.
That space that lies between the skull and
the dura that in health,
does not have any blood in it, but here is
an epidural hematoma.
Remember, that's this space here lying
between the bone and the
dura and you can imagine that if there's a
collection of fluid here, our bone,
at least in adults, is unforgiving.
The bone, the skull, will not stretch out.
That won't happen.
If fluid, blood in this case, accumulates
what will happen, is there'll be
forces that will push on the brain, and
the brain will be pushed in.
With potentially devistating consequences.
In the case of an epidural hematoma, there
are many arteries that could be damaged.
But the, classic question, when somebody
gets hit in the
head and has an epidural hematoma, is what
artery is injured.
It's often the so called, middle meningeal
artery.
That you see represented here.
A branch of the external carotid artery
that feeds some of the face and the skull

that is easily injured because it sits

just below the temporal bone.
This soft piece of skull
here that if you get hit can cause injury
to the Middle Meningeal Artery.
And when the Middle Meningeal Artery is
injured.
The blood that flows from it often bleeds
into the epidural space.
Why is that a problem?
Well because it causes something termed
herniation.
You'll hear about this more in Wade Smith
lecture on coma.
But the idea is the following,
the brain is situated in the cranial
vault.
There's a lot of things in the skull, but
most of it is brain.
There is some blood running through the
blood vessels.
There is some cerebral spinal fluid, as
we'll talk about.
But there's not room for additional
substances to be deposited.
When somebody has an epidural hematoma,
such as this, Something's gotta give.
And as I said, the skull will not bulge
out,
but rather the brain will bulge in like
you see depicted here.
And what will happen.
Is the brain more herniate?
In other words it will be squeezed out of
the cranial cavity.
The most common form of herniation is
depicted by number three here.
So called uncle herniation.
The uncus is a point of the temporal lobe.
That sits right next to the brain stem.
And the brain stem is an essential part.
Of our central nervous system.
It helps us breath.
It helps us talk.
It houses all of the nuclei of the cranial
nerves, numbers three through 12.
And it carries the major motor and sensory
pathways to
the body, connecting the brain with the
rest of the body.
If the brain stem is injured The person
dies.
And here you can see that this mass effect
from an epidural hematoma has caused uncal
herniation, where the uncas presses on the
brain stem, and if the
brain stem is displaced just a few
millimeters, it will lead to death.
And, that is the mechanism why people die
with epidural hematomas.

So, why this so called, lucid period, as

is described in literature.
Why was Natasha Richardson just fine after
the injury for a few hours.
Was able to go back to her hotel room and
said, no, no, I'm doing well.
Well it's because
this blood takes a while to accumulate.
Early on there might be just a little bit
of bleeding which causes no pressure on
the brain.
Might lead to a mild headache or no
symptoms whatsoever.
But then over the coming minutes to hours,
this blood will build up and
as it builds up there will be more and
more pressure on the brain.
And that will lead potentially to this
Herniation syndrome.
A very importance clinical piece to
understand.
The difficulties that can exist with
Epidural Hemotomas.
Now one of the saddest parts of this case
and other
cases with Epidural Hematomas is that this
is a treatable disorder.
This is a disorder That if found early
enough can
be treated and the patient can make a full
recovery.
And the treatment is something called
trepanation, or making a burr hole.
The idea as depicted by this painting is
that one takes A
drill, and makes a hole in the skull that
is no more than the size of a quarter.
And if you make this hole in the skull,
then that blood can drain out.
You can make a hole that communicates the
epidural space with
the outer part of the skull, and that
allows that blood
to be drained out so that it won't
accumulate and push on the brain itself.
Now there's a sad story.
Trepanation has been used actually since
the
1800's and perhaps a little bit before
that.
And previously it was used for migraines,
for seizuers, and a
sad element, for phsyciatric diseases or
just to let the evil spirits out.
We don't use
obviously trepanation for these
conditions, they
doesn't treat these conditions at all.
But we still use this today.
We use it to treat patients who have

epidural hematomas and subdural hematomas.

And we also use it to insert pressure
monitors in the neuro intensive care
unit, so that we can monitor the pressure
of the brain serially over time.
So an old-fashioned
procedure that's still used today.
This can be done in an operating room, but
in emergency situations it can be used at
the bedside.
In the emergency department or the
intensive care unit
To treat a condition like an epidural
hematoma successfully.
Now we're going to draw our attention now
to the ventricular system.
It turns out that if you slice open the
brain, you will see all of this brain
matter
that we've talked about, but in the middle
of
the brain, you will see some fluid filled
spaces.
And this ventricular system here Carries
the majority of the cerebral spinal fluid.
An important substance that flows within
the brain and around the brain.
So it's important to understand that the
cerebral
spinal fluid how it's produced and where
it's absorbed.
The cerebral spinal fluid is produced in a
series of specialized organelles called
choroid plexus which sits in the middle of
these large ventricular spaces.
That sit in the middle of the brain.
The spinal fluid then flows and bays the
whole brain and the spinal cord
providing yet another layer of protection.
Imagine we don't just have a brain and
connective tissue and then the skull.
The brain is bait.
It is sitting in a pool of water,
providing yet
another Layer of protection should you
have any head trauma.
Trauma to the head, the skull, or the
spinal cord.
So this spinal fluid then is produced in
the
corrid plexis, circulates around the brain
and the spinal cord.
Before it's absorbed in these specialized
organelles, termed the arachnoid villi
that sit in the subarachnoid space.
Remember the subarachnoid space between
the arachnoid and the pia.
And these arachnoid villi will absorb CSF
that has been flowing,
it turns out that our entire volume of

cerebral spinal fluid,

which is produced in the coride plexus,
then flows around the
brain and spinal chord, and then is
absorbed in the arachnoid villi,
is produced around three times per day.
So eight hours from now.
All of the cerebral spinal fluid that is
in your central nervous system will
be gone, and will be replaced with a fresh
set of cerebral spinal fluid.
A dynamic process that is ongoing.
Now there are a lot of clinically relevant
pieces to cerebral spinal fluid.
First of all, we often sample cerebral
spinal fluid.
Through a through a procedure called
lumbar puncture or a spinal tap.
Here is how the procedure is done.
The patient is placed in this position.
Lying on the side of the bed.
This is the procedure that's just done at
the
bedside in the office or in the emergency
department.
Any needle is placed In the small of the
back to withdraw spinal fluid.
And here you can see the needle being
placed.
The needle
is generally placed between the fourth and
fifth vertebrae in the lumbar spine.
The spinal cord itself terminates in
adults.
Around the first lumbar vertebral level.
So in fact when you.
Put a needle in between L4 and L5, you're
well below where the spinal cord is.
There is no chance of you injuring
the spinal cord itself.
And the needle is placed, and spinal fluid
is withdrawn and sent for analysis.
There's a number of reasons why this would
be done clinically, but
perhaps the most important is to
diagnose a life-threatening threatening
condition, meningitis.
So bacterial meningitis, which is an
infection of the meninges,
of the spinal fluid, can lead to death if
not treated
immediately with antibiotics.
And it is obtaining this spinal fluid
through a
lumbar puncture That allows us to analyze
the fluid,
find out the responsible organism, and
then direct treatment
to curing, what again is a potentially
life-threatening disorder.

Now another important clinically-relavent

piece of cerebral spinal fluid
is so-called hydrocephalis, which means
water on the brain.
Here's an instance where a patient's
ventricular system Has become too large.
And a too large ventricular system can
lead to
a number of abnormalities, problems with
gate, problems with
bladder control, problems with cognition
ultimately if it gets
large enough can lead to the same type of
herniation.
That can occur when there's too much blood
in the brain.
So hydrocefulous is too
much cerebral spinal fluid.
Why would that happen?
Well actually there's two different types
of hydrocefulous.
Two different flavors if you will.
Type number one is so called obstructive
or non communicating hydrocefulous.
In this form of hydrocefulous, there is
some
sort of obstruction of this normally Open
ventricular system.
There's a mass, tumor, I'll show you an
example in
a minute that does not allow for the
normal communication
between the ventricular system.
As a result, spinal fluid keeps being
produced by the corade plexus.
But it cannot have appropriate egress
throughout this system.
That's obstructive or non-communicating
hydrocephalus.
In this form of hydrocephalus one or more
of the ventricles would be enlarged.
But some, below the level of the
obstruction, would be of normal size.
The other flavor is so-called
non-obstructive or
communicating hydrocephalus.
In this case the lesion Is here, at the
level of the arachnoid villi, also called
the arachnoid granulations.
For whatever reason, these become
non-functional and
aren't able to absorb spinal fluid
normally.
As a result, spinal fluid is produced, the
ventricular system
enlarges Because it simply cannot be
absorbed at a normal rate.
What would cause this?
Well, if there was a former or
current episode of bacterial meningitis

for instance.
Where meningitis, inflammation of the
meninges, scars down The arachnoid layer.
And therefore scars down these arachnoid
villi, so they can't normally absorb.
In the case of communicating
hydrocephalus,
all the ventricles would be enlarged
symmetrically.
Because the problem is not one or more of
them
being obstructed, rather it's at the end
of this pathway.
Not being able to absorb spinal fluid.
So here's an example of obstructive
hydrocephalus, you see the
patient right here has a mass sitting in
his brain.
In this case it's a large anerysim.
And you see that the ventricular system,
above that, is quite enlarged and
asymmetrically so.
With the left-hand side of the ventricular
system being much more enlarged than the
right-hand side
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