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The Physiologic
 Basis of Surgery
Chapter 21: Basic Neuroscience




    Leslie Hutchins, MD
        April 9, 2009
   Basi...
Cellular Morphology:
   Unipolar Neuron




              (c) Dorling Kindersley
Cellular Morphology:
   Bipolar Neuron




              (c) Dorling Kindersley
Cellular Morphology:
  Multipolar Neuron




              (c) Dorling Kindersley
Glial Cells

    Astrocytes


    Oligodendrocytes


    Ependymal cells


    Microglia

Astrocytes
Oligodendrocytes
Schwann Cell




Figure 21.1: Concentric layers of the
Schwann cell membrane encase a
peripheral nerve axon as myelin.



...
Ependymal cells
Microglial Cells
Voltage Gated Channels and
           the Action Potential




http://highered.mcgraw-hill.com/sites/0072943696/student_vi...
Nerve Action Potential




http://highered.mcgraw-hill.com/sites/0072943696/student_view0/chapter8/animation__the_nerve_im...
Chemical Synapse




http://highered.mcgraw-hill.com/sites/0072943696/student_view0/chapter8/animation__chemical_synapse__...
Skull
The Spine
Atlas & Axis
Vertebrae




http://www.eorthopod.com/images/ContentImages/pm/pm_general_radiofreq_ablation/rf_spine_anatomy02.jpg
Ligaments




  http://www.spineuniverse.com/displaygraphic.php/3759/ligaments-BB.jpg
Spinal Cord Anatomy
    Begins

        Foramen Magnum as a
    
        continuation of the
        Medulla Oblongata
 ...
Spinal Cord Anatomy
    Gray Matter

      Ventral (motor)
       Horns
      Dorsal (sensory)
       Horns
    White M...
Spinal Cord Cross Section:
       Fiber Tracts
Cerebral Hemispheres




Figure 21.3: Lobes of the right hemisphere.




                         The Physiologic Basis of...
The Brain




  http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS016A.html
Frontal Lobe




        http://universe-review.ca/I10-80-prefrontal.jpg
Motor Homunculus




    http://thebrain.mcgill.ca/flash/i/i_06/i_06_cr/i_06_cr_mou/i_06_cr_mou_1b.jpg
Frontal Lobe




    http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS220A.html
Temporal Lobe




Figure 21.3: Lobes of the right hemisphere.




                         The Physiologic Basis of Surgery
Temporal Lobe




    http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS272A.html
Temporal Lobe




    http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS260A.html
Temporal Lobe




         http://universe-review.ca/I10-80-prefrontal.jpg
http://www.indiana.edu/~pietsch/cerebrum421label.jpg
Parietal Lobe




Figure 21.3: Lobes of the right hemisphere.




                         The Physiologic Basis of Surgery
Parietal Lobe




         http://universe-review.ca/I10-80-prefrontal.jpg
Parietal Lobe




  http://thebrain.mcgill.ca/flash/a/a_10/a_10_cr/a_10_cr_lan/a_10_cr_lan_1b.jpg
Occipital Lobe




Figure 21.3: Lobes of the right hemisphere.




                         The Physiologic Basis of Surge...
Occipital Lobe




         http://universe-review.ca/I10-80-prefrontal.jpg
Visual Radiations




          imagemanager.biostr.washington.edu/.../82455.gif
Visual Pathway




   http://www.sumanasinc.com/webcontent/animations/content/visualpathways.swf
Limbic Lobe




        www.stanford.edu/.../braintut/f_ab16limbic.gif
White Matter Tracts




           cas.bellarmine.edu/tietjen/Ethology/nerve09.gif
White Matter Tracts




           cas.bellarmine.edu/tietjen/Ethology/nerve09.gif
Arcuate Fasciculus
Corpus Callosum &
Anterior Commissure
imagemanager.biostr.washington.edu/.../82455.gif
Posterior Commissure




         http://upload.wikimedia.org/wikipedia/commons/d/d7/Gray715.png
imagemanager.biostr.washington.edu/.../82455.gif
Centrum Semiovale




            anatomyatlases.org/.../Images/Plate351.jpg
Internal Capsule




          imagemanager.biostr.washington.edu/.../82455.gif
Basal Ganglia




          http://thalamus.wustl.edu/course/cbell5.gif
Yin et al. Nature Reviews Neuroscience 7, 464–476 (June 2006) | doi:10.1038/nrn1919
Dystonia
    http://www.sciencedaily.com/videos/2006


    /0504-learning_to_walk_again.htm
Diencephalon




     http://history.wisc.edu/sommerville/351/351images/pineal.jpg
Pineal Gland




     http://history.wisc.edu/sommerville/351/351images/pineal.jpg
Thalamus




   http://alpha.furman.edu/~einstein/general/neurodemo/105C.gif
Hypothalamus




         www.psycheducation.org/emotion/ltlHYPOTHL.jpg
Hypophyseal Portal System




http://i27.photobucket.com/albums/c190/lovesthesunset/anatomy%20and%20physiology/pituitaryhy...
Brainstem




    The Physiologic Basis of Surgery
Upper Mesencephalon




       http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/11.BS.lbl.html
Lower Mesencephalon




       http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/10.lbl.html
Lower Mesencephalon




      http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/9.BS.lbl.html
Upper Pons




  http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/8.BS.lbl.html
Upper Pons




  http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/7.BS.lbl.html
Middle Pons




  http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/6.BS.lbl.html
Pons




http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/5.BS.lbl.html
Medulla




 http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/4BS.lbl.html
Medulla




 http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/3BS.lbl.html
Medulla




 http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/2BS.lbl.html
Medulla




 http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/1BS.lbl.html
Cerebellum




      http://www.bartleby.com/107/Images/small/image705.jpg
Cerebellum




        http://universe-review.ca/I10-80-vermis.jpg
Cranial Nerves

                             Cranial Nerves By
                             Functional Grouping:

        ...
Cerebrovascular Physiology




    Figure 21.15: Graphic relation of cerebral blood flow (CBF) to arterial
    blood press...
Cerebrovascular Anatomy




           http://www.daviddarling.info/images/subclavian_artery.png
Cerebrovascular Anatomy




 http://wpcontent.answers.com/wikipedia/commons/thumb/f/ff/Vertebral_artery.png/250px-Vertebra...
Cerebrovascular Anatomy




http://upload.wikimedia.org/wikipedia/commons/thumb/2/2e/Circle_of_Willis_en.svg/376px-Circle_...
Cerebral Veins




      http://www1.indstate.edu/thcme/anderson/neurotext/t&c14-18.jpg
Cerebral Veins




  http://www.rci.rutgers.edu/%7Euzwiak/AnatPhys/Blood_Vessels_files/image036.jpg
Cerebrospinal Fluid




       http://www.colorado.edu/intphys/Class/IPHY3730/image/figure5-15.jpg
Neural basis of
           Consciousness
    A state of awareness of self

    and surrounding.
Anatomy of Mental Status
    Ascending reticular activating system (ARAS).

        Activating systems in the upper pons ...
The content of
               consciousness
    Sum of patient’s intellectual

    (cognitive) functions and emotions
   ...
Glasgow Coma Scale
Glasgow Coma Scale
    Individual    elements   as well as the

    sum of the    score is   important.
        GCS 9= E2...
Raised Intracranial
      Pressure




Figure 21.17: Relation between intracranial volume and
intracranial pressure. ICP, ...
Monro-Kellie Hypothesis
    ICP is stable as long as volume

    added is balanced by volume
    displaced.
    Three com...
Cerebral Perfusion
            Pressure
    CPP= MAP – ICP


    MAP = DBP + 1/3(SBP - DBP)


    CPP: 70-100 mm Hg

Herniation
Herniation
Central Herniation




     http://download.imaging.consult.com/ic/images/S1933033208702313/gr8-midi.jpg
Lateral Herniation
    Decreased LOC

    Ipsilateral oculomotor paresis, generally beginning

    with dilated nonreact...
Both syndromes
    Progress to:

        Decreased responsiveness
    

        Decorticate posturing
    

        Dec...
Herniation
    Progression leads to herniation of

    the cerbellar tonsils through the
    foramen magnum with medullar...
Increase ICP
    Managed by:

        Head elevation
    
            Improves venous return to heart
        

       ...
Brain Tumors
    Primary                           Secondary
                                 
        Neuroglial tissue...
Glioblastoma Multiforme




     http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675(06)70241-8&figureId=fig5
Pediatric Brain Tumors




        http://neurosurgery.seattlechildrens.org/assets/images/tumors_large.jpg
Extrinsic Brain Tumors




         http://www2.kumc.edu/neurosurgery/Sphenoid%20Wing%20Meningioma.jpg
Brain Metastasis




        http://www.aafp.org/afp//AFPprinter/990215ap/878.html
Chromosome
Tumor Syndrome                   Typical Tumor Types             Location
Hereditary cutaneous malignant   Dysp...
Neurotrauma
    Cerebral Contusion:

        Transient LOC attributed to traction on
    
        the upper brainstem an...
Contusion




http://upload.wikimedia.org/wikipedia/commons/thumb/0/09/Contrecoup.svg/524px-Contrecoup.svg.png
Hematomas




   http://www.merck.com/media/mmhe2/figures/MMHE_06_087_02_eps.gif
Middle Meningeal Artery




  http://chestofbooks.com/health/anatomy/Human-Body-Construction/images/Fig-56-Frontal-and-tem...
Epidural Hematoma




         http://www.med.wayne.edu/diagRadiology/TF/Neuro/N06a.gif
Subdural Hematoma




         http://www.hakeem-sy.com/main/files/subdural%20hematoma.jpg
Diffuse Axonal Injury




              http://www.pathguy.com/bryanlee/dai2.jpg
Spinal Cord Injury
Incomplete Lesion

    Any residual motor or sensory

    function more than 3 segments
    below level of injury.

    L...
Signs of Incomplete Lesion

    Sensation (including position sense)

    or voluntary movements in the lower
    extremi...
Types of Incomplete Lesions

     Central Cord Syndrome
1.

     Brown-Séquard Syndrome
2.

     Anterior Cord Syndrome
3....
Central Cord Syndrome




          http://medinfo.ufl.edu/year2/neuro/review/images/image3.jpg
Brown-Séquard Syndrome




          http://medinfo.ufl.edu/year2/neuro/review/images/image2.jpg
Anterior Cord Syndrome




        http://www.apparelyzed.com/_images/content/spine/damagecord/anterior.jpg
Complete Lesion
    No preservation of any motor and/or

    sensory function more than 3 segments
    below the level of...
Spinal Shock
      Hypotension:


         Interruption of sympathetics
    

           Loss of vascular tone below lev...
Spinal Shock
    Transient loss of neurologic

    function
        (including segmental and polysynaptic
    
        r...
Reflex Arcs




   http://www.sumanasinc.com/webcontent/animations/content/reflexarcs.swf
A natomy of the Peripheral
         Nervous S ystem
     31 pairs of spinal nerves

     (Each formed by 2 roots)
     Th...
http://members.cox.net/injections/images/snb_images/epineurium.jpg
Cervical Plexus




          http://en.wikipedia.org/wiki/File:Gray804.png
Brachial Plexus




       The Physiologic Basis of Surgery
Lumbar Plexus




      The Physiologic Basis of Surgery
Lumbosacral Plexus




         The Physiologic Basis of Surgery
Peripheral Nerve Injury
Sunderland      Seddon           Description          Recovery        Recovery Rate           Surg...
Seddon System
    Neurapraxia

        Axon is left in continuity but is focally
    
        demyelinated at site of in...
Wallerian Degeneration




       http://www.medscape.com/content/2004/00/48/00/480071/art-nf480071.fig2.gif
Sunderland Classification




          http://www.physiol.usyd.edu.au/daved/teaching/images/sunderland.gif
Clinical Nerve Injuries

     Laceration
1.

     Compression
2.

     Stretch
3.

     High-Velocity Missile Injury
4.
Laceration

    Knife wounds


    Shattered glass


    Animal bites


    Chain Saws


    Propeller Blades


    A...
Acute Compression Injuries

    Prolonged immobility:

        Extreme fatigue
    

        Alcohol Intoxication
    
...
Stretch

    As a nerve is stretched more

    that 6% to 20% of its length,
    nerve function starts to fail.
High-velocity

    Nerves directly in the path may

    be severed or torn, but most
    are injured secondarily as the
 ...
Seizures

    Generalized: Loss of

    consciousness occurs
    Partial: Consciousness is

    preserved
Postictal State

    A period of drowsiness and

    confusion following a seizure
    that occurs and clears after a
   ...
Todd Paralysis

    With partial and generalized

    seizures, a postictal
    neurologic deficit, such as
    hemipares...
Sodium Channels




http://www.uic.edu/classes/phar/phar402/Potential_Antiepileptic_Drugs_Acting_on_Glutaminergic_Receptor...
Chloride Channels




  http://www.niaaa.nih.gov/NR/rdonlyres/93D8542D-6AAE-49D0-9585-8DA49B73DD63/0/gabaa.gif
Brain Death

              ←
Ancillary Exams




       http://rad.usuhs.mil/medpix/tachy_pics/thumb/synpic37280.jpg
Table 21.4 Modification of Brain Death Criteria for
    Children and Infants Less Than 5 Years Old

    Infants 7 d to 2 m...
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience
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The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience

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A review of the Basic Neuroscience Chapter I presented for the Basic Science Junior Residents Lecture

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The Physiologic Basis Of Surgery; Chapter 21: Basic Neuroscience

  1. 1. The Physiologic Basis of Surgery Chapter 21: Basic Neuroscience Leslie Hutchins, MD April 9, 2009 Basic Science Lecture
  2. 2. Cellular Morphology: Unipolar Neuron (c) Dorling Kindersley
  3. 3. Cellular Morphology: Bipolar Neuron (c) Dorling Kindersley
  4. 4. Cellular Morphology: Multipolar Neuron (c) Dorling Kindersley
  5. 5. Glial Cells Astrocytes  Oligodendrocytes  Ependymal cells  Microglia 
  6. 6. Astrocytes
  7. 7. Oligodendrocytes
  8. 8. Schwann Cell Figure 21.1: Concentric layers of the Schwann cell membrane encase a peripheral nerve axon as myelin. The Physiologic Basis of Surgery
  9. 9. Ependymal cells
  10. 10. Microglial Cells
  11. 11. Voltage Gated Channels and the Action Potential http://highered.mcgraw-hill.com/sites/0072943696/student_view0/chapter8/animation__voltage-gated_channels_and_the_action_potential__quiz_1_.html
  12. 12. Nerve Action Potential http://highered.mcgraw-hill.com/sites/0072943696/student_view0/chapter8/animation__the_nerve_impulse.html
  13. 13. Chemical Synapse http://highered.mcgraw-hill.com/sites/0072943696/student_view0/chapter8/animation__chemical_synapse__quiz_1_.html
  14. 14. Skull
  15. 15. The Spine
  16. 16. Atlas & Axis
  17. 17. Vertebrae http://www.eorthopod.com/images/ContentImages/pm/pm_general_radiofreq_ablation/rf_spine_anatomy02.jpg
  18. 18. Ligaments http://www.spineuniverse.com/displaygraphic.php/3759/ligaments-BB.jpg
  19. 19. Spinal Cord Anatomy Begins  Foramen Magnum as a  continuation of the Medulla Oblongata Terminates  Conus Medullaris  Adult: Lower Border of L1  Young Child: Upper Border  of L3 Filum Terminale  Prolongation of the  piamater Attaches to the spinal  cord at the coccyx Dural Sac  Ends at the level of the  second sacral vertebra
  20. 20. Spinal Cord Anatomy Gray Matter   Ventral (motor) Horns  Dorsal (sensory) Horns White Matter   Anterior Columns  Lateral Columns  Posterior Columns D .E . H aines, Neuroanatomy: An Atlas of Structures, Sections, and Systems, 3rd ed. (1991), U rban & Schwarzenberg E ncyclopedia Britannica, I nc.
  21. 21. Spinal Cord Cross Section: Fiber Tracts
  22. 22. Cerebral Hemispheres Figure 21.3: Lobes of the right hemisphere. The Physiologic Basis of Surgery
  23. 23. The Brain http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS016A.html
  24. 24. Frontal Lobe http://universe-review.ca/I10-80-prefrontal.jpg
  25. 25. Motor Homunculus http://thebrain.mcgill.ca/flash/i/i_06/i_06_cr/i_06_cr_mou/i_06_cr_mou_1b.jpg
  26. 26. Frontal Lobe http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS220A.html
  27. 27. Temporal Lobe Figure 21.3: Lobes of the right hemisphere. The Physiologic Basis of Surgery
  28. 28. Temporal Lobe http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS272A.html
  29. 29. Temporal Lobe http://library.med.utah.edu/WebPath/HISTHTML/NEURANAT/CNS260A.html
  30. 30. Temporal Lobe http://universe-review.ca/I10-80-prefrontal.jpg
  31. 31. http://www.indiana.edu/~pietsch/cerebrum421label.jpg
  32. 32. Parietal Lobe Figure 21.3: Lobes of the right hemisphere. The Physiologic Basis of Surgery
  33. 33. Parietal Lobe http://universe-review.ca/I10-80-prefrontal.jpg
  34. 34. Parietal Lobe http://thebrain.mcgill.ca/flash/a/a_10/a_10_cr/a_10_cr_lan/a_10_cr_lan_1b.jpg
  35. 35. Occipital Lobe Figure 21.3: Lobes of the right hemisphere. The Physiologic Basis of Surgery
  36. 36. Occipital Lobe http://universe-review.ca/I10-80-prefrontal.jpg
  37. 37. Visual Radiations imagemanager.biostr.washington.edu/.../82455.gif
  38. 38. Visual Pathway http://www.sumanasinc.com/webcontent/animations/content/visualpathways.swf
  39. 39. Limbic Lobe www.stanford.edu/.../braintut/f_ab16limbic.gif
  40. 40. White Matter Tracts cas.bellarmine.edu/tietjen/Ethology/nerve09.gif
  41. 41. White Matter Tracts cas.bellarmine.edu/tietjen/Ethology/nerve09.gif
  42. 42. Arcuate Fasciculus
  43. 43. Corpus Callosum & Anterior Commissure
  44. 44. imagemanager.biostr.washington.edu/.../82455.gif
  45. 45. Posterior Commissure http://upload.wikimedia.org/wikipedia/commons/d/d7/Gray715.png
  46. 46. imagemanager.biostr.washington.edu/.../82455.gif
  47. 47. Centrum Semiovale anatomyatlases.org/.../Images/Plate351.jpg
  48. 48. Internal Capsule imagemanager.biostr.washington.edu/.../82455.gif
  49. 49. Basal Ganglia http://thalamus.wustl.edu/course/cbell5.gif
  50. 50. Yin et al. Nature Reviews Neuroscience 7, 464–476 (June 2006) | doi:10.1038/nrn1919
  51. 51. Dystonia http://www.sciencedaily.com/videos/2006  /0504-learning_to_walk_again.htm
  52. 52. Diencephalon http://history.wisc.edu/sommerville/351/351images/pineal.jpg
  53. 53. Pineal Gland http://history.wisc.edu/sommerville/351/351images/pineal.jpg
  54. 54. Thalamus http://alpha.furman.edu/~einstein/general/neurodemo/105C.gif
  55. 55. Hypothalamus www.psycheducation.org/emotion/ltlHYPOTHL.jpg
  56. 56. Hypophyseal Portal System http://i27.photobucket.com/albums/c190/lovesthesunset/anatomy%20and%20physiology/pituitaryhypophysealportalsystem.jpg
  57. 57. Brainstem The Physiologic Basis of Surgery
  58. 58. Upper Mesencephalon http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/11.BS.lbl.html
  59. 59. Lower Mesencephalon http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/10.lbl.html
  60. 60. Lower Mesencephalon http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/9.BS.lbl.html
  61. 61. Upper Pons http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/8.BS.lbl.html
  62. 62. Upper Pons http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/7.BS.lbl.html
  63. 63. Middle Pons http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/6.BS.lbl.html
  64. 64. Pons http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/5.BS.lbl.html
  65. 65. Medulla http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/4BS.lbl.html
  66. 66. Medulla http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/3BS.lbl.html
  67. 67. Medulla http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/2BS.lbl.html
  68. 68. Medulla http://www.anatomy.dal.ca/Human_Neuroanatomy/B_stem_Atlas/1BS.lbl.html
  69. 69. Cerebellum http://www.bartleby.com/107/Images/small/image705.jpg
  70. 70. Cerebellum http://universe-review.ca/I10-80-vermis.jpg
  71. 71. Cranial Nerves Cranial Nerves By Functional Grouping: •I, II, and VIII primarily effect sensory functions •IV, VI, XI, and XII primarily effect motor functions •III, V, VII, IX and X have mixed sensory, motor, and parasympathetic functions http://www.spjc.edu/SPG/Science/Lancraft/BSC2085/bsc2085notes/CranialNerves.jpg
  72. 72. Cerebrovascular Physiology Figure 21.15: Graphic relation of cerebral blood flow (CBF) to arterial blood pressure (ABP) with progressive vasoconstriction being responsible for the flat portion of the curve (autoregulation). Note that the curve is shifted to the right in hypertension The Physiologic Basis of Surgery
  73. 73. Cerebrovascular Anatomy http://www.daviddarling.info/images/subclavian_artery.png
  74. 74. Cerebrovascular Anatomy http://wpcontent.answers.com/wikipedia/commons/thumb/f/ff/Vertebral_artery.png/250px-Vertebral_artery.png
  75. 75. Cerebrovascular Anatomy http://upload.wikimedia.org/wikipedia/commons/thumb/2/2e/Circle_of_Willis_en.svg/376px-Circle_of_Willis_en.svg.png
  76. 76. Cerebral Veins http://www1.indstate.edu/thcme/anderson/neurotext/t&c14-18.jpg
  77. 77. Cerebral Veins http://www.rci.rutgers.edu/%7Euzwiak/AnatPhys/Blood_Vessels_files/image036.jpg
  78. 78. Cerebrospinal Fluid http://www.colorado.edu/intphys/Class/IPHY3730/image/figure5-15.jpg
  79. 79. Neural basis of Consciousness A state of awareness of self  and surrounding.
  80. 80. Anatomy of Mental Status Ascending reticular activating system (ARAS).  Activating systems in the upper pons and midbrain and  its projections through the nonspecific thalamic nuclei and hypothalamus to the limbic and prefrontal cortex and ultimately to the cerebral hemispheres, especially the left hemisphere. Determines the level of arousal.  Cerebral hemispheres and interaction between  functional areas in cerebral hemispheres. Determines the intellectual and emotional  functioning. Interaction between cerebral hemispheres and  activating systems.
  81. 81. The content of consciousness Sum of patient’s intellectual  (cognitive) functions and emotions (affect). An isolated lesion of one hemisphere  does not impair consciousness, although it may depress affect (content of consciousness). However, structural lesions in the  brain can cause coma if they involve the ARAS and its projections.
  82. 82. Glasgow Coma Scale
  83. 83. Glasgow Coma Scale Individual elements as well as the  sum of the score is important. GCS 9= E2 V4 M3 @ 07:35  Classification:  Severe: GCS≤8  Moderate: GCS 9-12  Minor: GCS≥13 
  84. 84. Raised Intracranial Pressure Figure 21.17: Relation between intracranial volume and intracranial pressure. ICP, intracranial pressure The Physiologic Basis of Surgery
  85. 85. Monro-Kellie Hypothesis ICP is stable as long as volume  added is balanced by volume displaced. Three components:  Brain Tissue (1,500 mL)  Cerebral Blood Volume (200 mL)  Cerebrospinal Fluid (100 mL)  Expansion by any one causes rise in  ICP if volume of other two remains constant.
  86. 86. Cerebral Perfusion Pressure CPP= MAP – ICP  MAP = DBP + 1/3(SBP - DBP)  CPP: 70-100 mm Hg 
  87. 87. Herniation
  88. 88. Herniation
  89. 89. Central Herniation http://download.imaging.consult.com/ic/images/S1933033208702313/gr8-midi.jpg
  90. 90. Lateral Herniation Decreased LOC  Ipsilateral oculomotor paresis, generally beginning  with dilated nonreactive pupil and later involving lid elevation and extraocular movements Parasympathetic fibers, located around the outer  aspect of the third nerve, are compressed by the uncus. This leads to unopposed sympathetic fibers resulting in ipsilateral pupil dilation. Contralateral hemiparesis  Results from compression of ipsilateral cerebral  peduncle. Since the cortical spinal tracts decussate below the midbrain at the level of the pons, the hemiparesis is contralateral. Sustained hyperventilation 
  91. 91. Both syndromes Progress to:  Decreased responsiveness  Decorticate posturing  Decerebrate posturing  Midrange nonreactive pupils  Loss of oculocephalic and  oculovestibular reflexes Loss of corneal reflexes  Ataxic breathing patterns 
  92. 92. Herniation Progression leads to herniation of  the cerbellar tonsils through the foramen magnum with medullary compression, resulting in: Loss of motor tone  Loss of gag and cough reflexes  Apnea  Cardiovascular collapse  Death 
  93. 93. Increase ICP Managed by:  Head elevation  Improves venous return to heart  Hyperventilation  Cerebral vasoconstriction and reduces CBV  Mannitol  Decreases the brain tissue compartment by  shrinking the extracellular and perhaps intracellular space.
  94. 94. Brain Tumors Primary Secondary   Neuroglial tissues Metastic   Astrocytomas  Ependymomas  Oligodendrogliomas  Meninges  Reticuloendothelial  cells Vascular cells  intrinsic to the brain
  95. 95. Glioblastoma Multiforme http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675(06)70241-8&figureId=fig5
  96. 96. Pediatric Brain Tumors http://neurosurgery.seattlechildrens.org/assets/images/tumors_large.jpg
  97. 97. Extrinsic Brain Tumors http://www2.kumc.edu/neurosurgery/Sphenoid%20Wing%20Meningioma.jpg
  98. 98. Brain Metastasis http://www.aafp.org/afp//AFPprinter/990215ap/878.html
  99. 99. Chromosome Tumor Syndrome Typical Tumor Types Location Hereditary cutaneous malignant Dysplastic nevi, melanoma 1p melanoma/dysplastic nevus syndrome von Hippel-Lindau syndrome Hemangioblastoma, 3p pheochromocytoma, renal cell carcinoma Multiple endocrine neoplasia, Pituitary tumor, parathyroid 11p type 1 adenoma, endocrine pancreatic tumors Multiple endocrine neoplasia, Pheochromocytoma, medullary 10 type 2 thyroid carcinoma Familial retinoblastoma Retinoblastoma, osteosarcoma 13q Neurofibromatosis (NF1) Neurofibroma, optic glioma, 17q neurofibrosarcoma Neurofibromatosis (NF2) Vestibular schwannoma, 22q meningioma, spinal nerve root neurofibroma Tuberous sclerosis Subependymal giant cell 16q astrocytomas hamartomas
  100. 100. Neurotrauma Cerebral Contusion:  Transient LOC attributed to traction on  the upper brainstem and reversible synaptic impairment in the reticular- activating system. More severe:  Persistent mild impairment of higher  cortical functions Boxers subjected to repeated  concussion may later show a degenerative-type dementia.
  101. 101. Contusion http://upload.wikimedia.org/wikipedia/commons/thumb/0/09/Contrecoup.svg/524px-Contrecoup.svg.png
  102. 102. Hematomas http://www.merck.com/media/mmhe2/figures/MMHE_06_087_02_eps.gif
  103. 103. Middle Meningeal Artery http://chestofbooks.com/health/anatomy/Human-Body-Construction/images/Fig-56-Frontal-and-temporal-regions-of-an-adult-skull.jpg
  104. 104. Epidural Hematoma http://www.med.wayne.edu/diagRadiology/TF/Neuro/N06a.gif
  105. 105. Subdural Hematoma http://www.hakeem-sy.com/main/files/subdural%20hematoma.jpg
  106. 106. Diffuse Axonal Injury http://www.pathguy.com/bryanlee/dai2.jpg
  107. 107. Spinal Cord Injury
  108. 108. Incomplete Lesion Any residual motor or sensory  function more than 3 segments below level of injury. Look for signs of preserved  long-track function. Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  109. 109. Signs of Incomplete Lesion Sensation (including position sense)  or voluntary movements in the lower extremities. “Sacral Sparing” sensation around  anus, voluntary rectal sphincter contraction, or voluntary toe flexion. An injury doesn’t qualify as  incomplete with preserved sacral reflexes alone. Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  110. 110. Types of Incomplete Lesions Central Cord Syndrome 1. Brown-Séquard Syndrome 2. Anterior Cord Syndrome 3. Posterior Cord Syndrome 4. Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  111. 111. Central Cord Syndrome http://medinfo.ufl.edu/year2/neuro/review/images/image3.jpg
  112. 112. Brown-Séquard Syndrome http://medinfo.ufl.edu/year2/neuro/review/images/image2.jpg
  113. 113. Anterior Cord Syndrome http://www.apparelyzed.com/_images/content/spine/damagecord/anterior.jpg
  114. 114. Complete Lesion No preservation of any motor and/or  sensory function more than 3 segments below the level of injury. Almost 3% of patients with complete  injuries on initial exam will develop some recovery within 24 hours. The persistence of complete spinal cord  injury beyond 24 hours indicates no distal function recovery Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  115. 115. Spinal Shock Hypotension:  Interruption of sympathetics  Loss of vascular tone below level of  injury Leaves parasympathetics relatively  unopposed causing bradycardia. Loss of muscle tone due to skeletal  muscle paralysis below the level of injury results in venous pooling and thus a relative hypovolemia. Blood loss from associated wounds →  true hypovolemia. Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  116. 116. Spinal Shock Transient loss of neurologic  function (including segmental and polysynaptic  reflex activity and autonomic function) below the level of spinal cord injury → flaccid paralysis & areflexia lasting various periods (usually 1-2 weeks, occasionally several months and sometimes permanently), the resolution of which yields the anticipated spasticity below the level of the lesion. Greenberg, M. Handbook of Neurosurgery: Sixth Edition. 2006; 698-713.
  117. 117. Reflex Arcs http://www.sumanasinc.com/webcontent/animations/content/reflexarcs.swf
  118. 118. A natomy of the Peripheral Nervous S ystem 31 pairs of spinal nerves  (Each formed by 2 roots) The spinal nerves exit through  the intervebral foramen  8 cervical  1st exits through the Occipital Bone and C1  8th exits between C7 & T1  12 thoracic  Distal to T1 each spinal nerve exits below its corresponding vertebra  5 lumbar  5 sacral  1 coccygeal
  119. 119. http://members.cox.net/injections/images/snb_images/epineurium.jpg
  120. 120. Cervical Plexus http://en.wikipedia.org/wiki/File:Gray804.png
  121. 121. Brachial Plexus The Physiologic Basis of Surgery
  122. 122. Lumbar Plexus The Physiologic Basis of Surgery
  123. 123. Lumbosacral Plexus The Physiologic Basis of Surgery
  124. 124. Peripheral Nerve Injury Sunderland Seddon Description Recovery Recovery Rate Surgery Temporary interruption to nerve Neurapraxia I Complete Fast (days-12 wks) None transmission with restoration in weeks quot;Blockedquot; nerve Complete disruption of nerve transmission II (axon) with Complete Slow (3cm/mth) None regeneration and full recovery Disruption of axon and connective tissue III (endoneurium) Varies Slow (3cm/mth) Varies Axonotmesis causing disorganised regeneration Disruption of axon, endoneurium, and inner membrane IV sheath (perineurium), None None Yes with intact outer nerve layer (epineurium) but no regeneration Complete severance Neurotmesis V None None Yes of the nerve Neuroma- Mixture of one or VI more of the above Varies depending on injury incontinuity conditions
  125. 125. Seddon System Neurapraxia  Axon is left in continuity but is focally  demyelinated at site of injury. Positioning palsies  Prolonged periods of immobilization  Axonotmesis  Axonal continuity is lost in addition to  demyelination, but the connective tissue sheath is intact. Recovery is dependent on axonal regeneration  Neurotmesis  Axonotmesis + Disruption of Connective Tissue 
  126. 126. Wallerian Degeneration http://www.medscape.com/content/2004/00/48/00/480071/art-nf480071.fig2.gif
  127. 127. Sunderland Classification http://www.physiol.usyd.edu.au/daved/teaching/images/sunderland.gif
  128. 128. Clinical Nerve Injuries Laceration 1. Compression 2. Stretch 3. High-Velocity Missile Injury 4.
  129. 129. Laceration Knife wounds  Shattered glass  Animal bites  Chain Saws  Propeller Blades  Auto Metal 
  130. 130. Acute Compression Injuries Prolonged immobility:  Extreme fatigue  Alcohol Intoxication  Drug-abuse  General anesthesia 
  131. 131. Stretch As a nerve is stretched more  that 6% to 20% of its length, nerve function starts to fail.
  132. 132. High-velocity Nerves directly in the path may  be severed or torn, but most are injured secondarily as the result of sudden stretch, with all grades of injury being observed.
  133. 133. Seizures Generalized: Loss of  consciousness occurs Partial: Consciousness is  preserved
  134. 134. Postictal State A period of drowsiness and  confusion following a seizure that occurs and clears after a few hours.
  135. 135. Todd Paralysis With partial and generalized  seizures, a postictal neurologic deficit, such as hemiparesis, can occur and usually clears over 24 to 48 hours.
  136. 136. Sodium Channels http://www.uic.edu/classes/phar/phar402/Potential_Antiepileptic_Drugs_Acting_on_Glutaminergic_Receptor_5.JPG
  137. 137. Chloride Channels http://www.niaaa.nih.gov/NR/rdonlyres/93D8542D-6AAE-49D0-9585-8DA49B73DD63/0/gabaa.gif
  138. 138. Brain Death ←
  139. 139. Ancillary Exams http://rad.usuhs.mil/medpix/tachy_pics/thumb/synpic37280.jpg
  140. 140. Table 21.4 Modification of Brain Death Criteria for Children and Infants Less Than 5 Years Old Infants 7 d to 2 mo Two examinations and two confirmatory EEGs separated by at least 48 h Infants 2 mo to 1 yr Two examinations and EEGs separated by at least 24 h unless CBG studies document no cerebral perfusion Children 1–5 yr When an irreversible cause exists, a 12-h interval between examinations is recommended. In cases of hypoxia- ischemia, a 24-h interval is recommended. If an EEG shows electrical silence or a CBF study demonstrates no cerebral perfusion, the time interval between examinations may be reduced The Physiologic Basis of Surgery

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