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Brainstem and CN localization Yilkal.pptx
- 1. 1 FUNCTIONAL LOCALIZATION OF BRAINSTEMAND CRANIAL NERVES Presenter: Dr Yilkal Y ( IMR3 ) Moderator: Dr Nebiyu B ( Consultant neurologist )
- 2. 2 OUTLINES Neuroanatomy ofbrainstem Midbrain Pons Medulla oblengata Neuroanatomy of cranial nerves Functional localization of brainstem and cranial nerves References
- 3. 3 Objective By theend of this seminar you will be familiar with Anatomical organization of brainstem Functional localization of brainstem and cranial nerves Common brainstem and cranial nerve syndromes
- 4. 4 Introduction Small neuroanatomicalarea approximate 8 to 9 cm of length Act as conduit(for some as relay station) between cortex, diencephalon ,cerebellum and spinal cord. Contains the reticular formation as its central core Ten of the twelve cranial nuclei Receives blood supply from the vertebrobasilar system.
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- 6. 6 Brainstem Organization Composedof three parts: Tectum (roof) Midbrain quadrigeminal plate. pons and medulla nonfunctional tissue Tegmentum (midportion) CN motor and sensory nuclei Reticular Formation long ascending and descending tracts Base Descending corticospinal and corticobulbar fibers
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- 15. 15 Ventral mid brainsyndromes WEBER’S SYNDROME pyramidal fibers and the fascicle of cranial nerve III Contralateral hemiplegia Ipsilateral oculomotor paresis Stroke ,MS
- 16. 16 Ventral mid brainsyndromes… Claude’s syndrome dorsal midbrain tegmental lesions fascicle of cranial nerve III Red nucleus prominent cerebellar signs (e.g., asynergia, ataxia, dysmetria, dysdiadochokinesia)
- 17. 17 Ventral mid brainsyndromes… BENEDIKT’S SYNDROME affect the red nucleus, the brachium conjunctivum, and the fascicle of cranial nerve III More ventral tegmental lesions Ipsilateral oculomotor paresis, usually with a dilated pupil Contralateral involuntary movements, including intention tremor, hemichorea, or hemiathetosis, due to destruction of the red nucleus
- 18. 18 Dorsal mid brainsyndrome Parinaud’s syndrome Most often seen with hydrocephalus or tumors of the pineal region. Paralysis of conjugate upward gaze (occasionally down-gaze) Pupillary abnormalities (pupils are usually large with light-near dissociation) Convergence-retraction nystagmus on upward gaze (especially elicited by inducing upward saccades by a down- moving optokinetic target) Pathologic lid retraction (Collier’s sign) Lid lag During horizontal refixations
- 19. 19 Dorsal mid brainsyndrome…
- 20. 20 Dorsal mid brainsyndrome… TOP OF THE BASILAR SYNDROME Occlusive vascular disease of the rostral basilar artery, usually embolic Infarction of the midbrain, thalamus, and portions of the temporal and occipital lobes Disorders of eye movements Pupillary abnormalities Behavioral abnormalities Visual defects Motor and sensory deficits.
- 21. 21 PONS About 1inch (2.5 cm) long A bridge Connecting the right and left cerebellar hemispheres
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- 26. 26 Ventral pontine syndromes… Millard-Gubler Syndrome A unilateral lesion of the ventrocaudal pons Involve the basis pontis and the fascicles of cranial nerves VI and VII. Contralateral hemiplegia (sparing the face) is due to pyramidal tract involvement. Ipsilateral lateral rectus paresis (cranial nerve VI) with diplopia that is accentuated when the patient “looks toward” the lesion. Ipsilateral peripheral facial paresis (cranial nerve VII).
- 27. 27 Ventral pontine syndromes… Raymond Syndrome A unilateral lesion of the ventral medial pons, which affects the ipsilateral abducens nerve fascicles and the corticospinal tract but spares cranial nerve VII . Ipsilateral lateral rectus paresis (cranial nerve VI) Contralateral hemiplegia, sparing the face, due to pyramidal tract involvement
- 28. 28 Ventral pontine syndromes… Pure Motor Hemiparesis corticospinal tracts in the basis pontis may produce a pure motor hemiplegia with or without facial involvement Dysarthria—Clumsy Hand Syndrome facial weakness and severe dysarthria and dysphagia occur along with clumsiness, impaired finger dexterity, and paresis of the hand. Ataxic Hemiparesis
- 29. 29 Ventral pontine syndromes… Locked-in Syndrome Bilateral ventral pontine lesions Quadriplegia due to bilateral corticospinal tract involvement in the basis pontis Aphonia due to involvement of the corticobulbar fibers innervating the lower cranial nerve nuclei Occasional impairment of horizontal eye movements due to bilateral involvement of the fascicles of cranial nerve VI
- 30. 30 Dorsal pontine syndromes… Foville Syndrome lesions involving the dorsal pontine tegmentum in the caudal third of the pons Contralateral hemiplegia (with facial sparing) which is due to interruption of the corticospinal tract. Ipsilateral peripheral-type facial palsy which is due to involvement of the nucleus and fascicle (or both) of cranial nerve VII. Inability to move the eyes conjugately to the ipsilateral side (gaze is “away from” the lesion) due to involvement of the PPRF or abducens nucleus, or both
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- 32. 32 PARAMEDIAN PONTINESYNDROMES Unilateral mediobasal infarcts. These patients present with severe facio-brachio- crural hemiparesis, dysarthria, and homolateral or bilateral ataxia. Unilateral mediolateral basal infarcts. Most patients show slight hemiparesis with ataxia and dysarthria, ataxic hemiparesis, or dysarthria—clumsy hand syndrome. Unilateral mediocentral or mediotegmental infarcts. Presentations include dysarthria— clumsy hand syndrome, ataxic hemiparesis with prominent sensory or eye movement disorders, and hemiparesis with contralateral facial or abducens palsy. Bilateral centrobasal infarcts. These patients have pseudobulbar palsy and bilateral sensorimotor disturbances.
- 33. 33 Lateral pontine syndrome… Marie-Foix Syndrome lateral pontine lesions, especially those affecting the brachium pontis Ipsilateral cerebellar ataxia due to involvement of cerebellar connections Contralateral hemiparesis due to involvement of the corticospinal tract Variable contralateral hemihypesthesia for pain and temperature due to involvement of the spinothalamic tract
- 34. 34 MEDULLA OBLONGATA Mostinferior region of the brain stem Becomes the spinal cord at the level of the foramen magnum Medulla is broad above, joins with pons and narrow below, continuous with spinal cord Length is about 3cm, width is about 2cm at its upper end Anteriorly covered by blood vessels Posteriorly partly by 4th ventricle
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- 38. 38 Vascular supply ofmedulla
- 39. 39 Medullary Syndromes Resultsfrom atherosclerotic occlusion of the vertebral artery, anterior spinal artery, or the lower segment of the basilar artery. Ipsilateral paresis, atrophy, and fibrillation of the tongue (due to cranial nerve XII affection). The protruded tongue deviates toward the lesion (away from the hemiplegia). Contralateral hemiplegia (due to involvement of the pyramid) with sparing of the face Contralateral loss of position and vibratory sensation (due to involvement of the medial lemniscus) Occasionally, upbeat nystagmus may occur because of dorsal extension of the infarct toward the medial longitudinal fasciculus MEDIAL MEDULLARY SYNDROME (DEJERINE’S ANTERIOR BULBAR SYNDROME)
- 40. 40 damage toa wedge-shaped area of the lateral medulla and inferior cerebellum secondary to intracranial vertebral artery or posterior inferior cerebellar artery occlusion LATERAL MEDULLARY (WALLENBERG) SYNDROME
- 41. 41 Lateral medullary syndrome… Ipsilateral facial hypalgesia and thermoanesthesia (due to trigeminal spinal nucleus and tract involvement). Ipsilateral facial pain is common. Contralateral trunk and extremity hypalgesia and thermoanesthesia (due to damage to the spinothalamic tract) Ipsilateral palatal, pharyngeal, and vocal cord paralysis with dysphagia and dysarthria (due to involvement of the nucleus ambiguus). Ipsilateral Horner syndrome (due to affection of the descending sympathetic fibers). Vertigo, nausea, and vomiting (due to involvement of the vestibular nuclei). Ipsilateral cerebellar signs and symptoms (due to involvement of the inferior cerebellar peduncle and cerebellum). Occasionally, hiccups (singultus) attributed to lesions of the dorsolateral region of the middle medulla and diplopia (perhaps secondary to involvement of the lower pons)
- 42. 42 Reticular formation Functions Sleep and consciousness Pain modulation Cardiovascular control Respiratory control Somatic motor control
- 43. 43 Reticular formation… Thereticular formation nuclei lie in the brainstem and arranged into three longitudinal columns Median column lies in the midline and consists intermediate size neuron The nuclei of this column are termed raphe nuclei Medial column made up of large size neurons also called magnocellular column Long ascending and descending projections Lateral column Made up of small neurons also termed parvocellular nucleus Cranial nerve reflexes and visceral functions
- 44. 44 Median RF (Raphe) The midbrain raphe Gives rise to ascending serotonergic projections to higher levels of the CNS (slepping cycle ) The pontine raphe projects to the cerebellum. The medullary raphe: Gives rise to descending serotonergic projections to the spinal cord. Receive primary nociceptive (pain) Nuclei are serotonergic
- 45. 45 Medial RF Mostof the largest neurons are found in the pons and medulla Have long ascending and descending collaterals Ascending branches: Reticulo thalamics Primarily in the intralaminar nuclei of thalamus Activated the cortical EEG (waking state) Descending branches: Reticulo spinals To affect muscle tone on spinal motoneurons Pontine reticulospinals are excitatory Medullary reticulospinals are inhibitory
- 46. 46 Lateral RF 1.Dorsolateral Pons Locus Ceruleus (NE): projects throughout CNS Its connections facilitate broad CNS activation during “fight or flight Pedunculopontine Nucleus (ACh): Gives rise to cholinergic trigger for the onset of REM sleep 2. Caudal Pons- Pressor Area (NE) Ascending branches to the hypothalamus To control of autonomic activities Descending projections Concerned with the control of blood pressure 3. Medulla Dorsal Respiratory Area Chemical aspects of respiration (pCO2) Ventral Respiratory Area Mechanical aspects of respiration (inspiration, expiration)
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- 51. 51 Localization of Lesions Affectingthe Olfactory Nerve Lesions Causing Anosmia/hyposmia Age younger than 65 years 2% of the population 65-80 ---50% older than 80--- 75%
- 52. 52 Localization of Lesions Affectingthe Olfactory Nerve Neuronal olfactory disorders lesions that affect the olfactory nerve, bulb, tract or the olfactory cortex Conductive olfactory disorders conditions that affect the bony and soft tissue structures in the nasal cavity, nasopharynx, and paranasal air sinuses Bilateral anosmia Local nasal disease most common cause of transient and bilateral anosmia is the common cold several airborne toxins Unilateral anosmia Lesion affecting the olfactory nerve filaments, bulb, tract, or stria. Head injury A unilateral lesion distal to the decussation of the olfactory fibers causes no olfactory impairment.
- 53. 53 CN I… FosterKennedy Syndrome olfactory groove or sphenoid ridge masses (especially meningiomas) or space- occupying lesions of the frontal lobe Ipsilateral anosmia Ipsilateral optic atrophy Contralateral papilledema due to raised intracranial pressure secondary to the mass lesion. Pseudo–Foster Kennedy syndrome noted when increased intracranial pressure of any cause occurs in a patient who has previous unilateral optic atrophy. most often due to sequential anterior ischemic optic neuropathy (arteritic or nonarteritic) or optic neuritis
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- 56. 56 Localization of Lesionsin the Optic Pathways Impaired visual perception poor discrimination of fine details of high contrast (visual acuity), which results in difficulty with tasks such as reading a printed page Impaired color recognition impaired discrimination of objects that have little contrast with the background (contrast discrimination) visual field defects Objective deficits Along the visual pathway
- 57. 57 Localization of Lesionsin the Optic Pathways
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- 59. 59 Ocular motor system Includes The cranial nerve III (oculomotor) nucleus in the midbrain The cranial nerve IV (trochlear) nucleus at the level of the midbrain-pontine junction The cranial nerve VI (abducens) nucleus in the lower pons.
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- 61. 61 Oculomotor Nerve Exitsthe ventral midbrain in the interpeduncular fossa Pierces the dura mater pass below PCA and above SCA Lateral wall of the cavernous sinus Inters orbit through superior orbital fissure
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- 63. 63 Localization of lesions Supra nuclear Pupillary and accommodation reflex Horizontal gaze palsy INO Vertical gaze palsy Nuclear Fascicular Peripheral nerves
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- 67. 67 TROCHLEAR NERVE Windingaround the periaqueductal grey matter and comes out posteriorly through the opposite side. Crosses the tentorium->enters middle cranial fossa->lateral wall of cavernous sinus Enters Superior orbital fissure- >supplies Sup. Oblique muscle. Down and out movement of eyeball Reading muscle Intorsion – axis of vision is kept parallel
- 68. 68 Fourth cranialnerve palsies may cause Incomitant hypertropia hypertropia increases on head tilt toward the paralyzed side (positive Bielschowsky’s test). Excyclotropia torsion of one eye (or both) about the eye's visual axis Head tilt eliminate the hypertropia and rarely the cyclotropia
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- 70. 70 Localization of trochlearlesions
- 71. 71 Abducent nerve Exitsfrom pontomedullary junction At petrous temporal bone it makes a sharp turn forward to enter the cavernous sinus. In the cavernous sinus it runs alongside the ICA. (internal carotid artery) It then enters the orbit through the SOF and innervates the lateral rectus. The abducens nucleus is located in the pons PPRF connections-lateral conjugate gaze center. Send their axons across the midline to the opposite MLF and then third nerve nucleus.
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- 74. 74 Functional classes ofeye movements Place and maintain an object of visual interest on each fovea To allow visualization of a single, stable object. Accomplish it by Saccades Pursuit Vergence Oculocephalic reflex
- 75. 75 Functional classes ofeye movements Saccades Moves the eyes rapidly (up to 800 degrees/sec) and conjugately to fixate new targets Voluntarily in response to verbal commands in the absence of a visible target generated in the contralateral frontal cortex Reflexive saccades occur in response to peripheral retinal stimuli such as visual threat or to sounds. in the contralateral parietal cortex Horizontal vs Vertical
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- 77. 77 Localization of horizontalsaccades Supra nuclear gaze palsy Saccades away from the lesion will be slow/absent Intact VOR by ocuiocephalic manuever
- 78. 78 Localization of horizontalsaccades pathway… Interferes with ipsilateral horizontal saccade Pursuit and VOR will be impaired
- 79. 79 Localization of horizontalsaccades pathway… Ipsilateral abduction deficient No horizontal gaze deficient ,rather isotropia
- 80. 80 INO Interferes withipsilateral adduction
- 81. 81 Localization of horizontalsaccades pathway… One and half syndrome Horizontal gaze palsy ---one INO of CL--half Lesion is ipsilateral 6th nerve nucleus , PPRF and , MLF.
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- 83. 83 Vertical saccades Upward gazeDownward gaze
- 84. 84 Localization of verticalgaze Vertical supranuclear gaze palsy Impaired upward and downward saccades with intact VOR.
- 85. 85 Localization of verticalgaze… Disrupt upward saccades May result downward gaze deviation---sun set eyes
- 86. 86 Localization of verticalgaze… Impair downward saccades May cause up gaze deviation
- 87. 87 Pursuit Slowly movingtargets (up to 70 degrees/sec) to maintain the image stable on the fovea.
- 88. 88 Persuit… Lesions presentwith catch up saccades
- 89. 89 Vergence A meansof maintaining ocular alignment on an approaching or retreating object
- 90. 90 Lesions Exo /Esotropia reviled with cover testing.
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- 92. 92 Lesions Compensatory jerknystagmus Acute lesions result in absent VOR on that side Positive head impulse test
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- 94. 94 Localization Down orup beat nystagmus--- vestibular nucleus MLF---Skew deviation INC---oscillating type of skew deviation
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- 96. 96 Localization of LesionsAffecting Cranial Nerve V Supranuclear Lesions Contralateral trigeminal motor paresis ( for masseter predominant CL ) Bilateral upper motor neuron lesions (pseudobulbar palsy) anesthesia of the contralateral face. Ischemia Nuclear Lesions Motor Ipsilateral paresis, atrophy, and fasciculations of the muscles of mastication Mid pontine lesions Sensory Ipsilateral hemianesthesia of the face (due to affection of the main sensory nucleus of the trigeminal nerve), contralateral hemisensory loss of the limbs and trunk (due to spinothalamic tract affection), and ipsilateral tremor (due to affection of the brachium conjunctivum).
- 97. 97 lesions Clinical manifestationscauses Preganglionic Trigeminal Nerve Roots ipsilateral facial pain, paresthesias, numbness, and sensory loss involvement of the neighboring cranial nerves (especially cranial nerves VI, VII, and VIII). corneal reflex is depressed and a trigeminal motor paresis may occur tumors Gasserian Ganglion Facial numbness with or without paresthesias, often associated with facial pain hemifacial or involve only select divisions of the trigeminal nerve tumors
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- 101. 101 Localization of LesionsAffecting Cranial Nerve VII FACIAL NERVE LESSIOS CLINICAL MANIFESTATIONS CAUSES Supranuclear Lesions (Central Facial Palsy) contralateral paresis of the lower portion of the face with relative sparing of upper facial function Ischemia Nuclear and Fascicular Lesions (Pontine Lesions) a peripheral type of facial nerve palsy. unilateral paralysis of all mimetic facial muscles, with loss of frontal wrinkling and facial asymmetry MILLARD-GUBLER SYNDROME FOVILLE SYNDROME EIGHT-AND-A-HALF SYNDROME PERIPHERAL FACIAL flaccid weakness of all the muscles of facial expression on the involved side, both upper and lower face Cerebellopontine Angle Lesions
- 102. 102 PERIPHERAL FACIAL LESSIONSCLINICAL MANIFESTATIONS CAUSES Meatal (Canal) Segment of the Facial Nerve in the Temporal Bone unilateral facial motor paralysis, impairment of taste over the ipsilateral anterior two-thirds of the tongue, impaired lacrimation, and deafness (rather than hyperacusis). temporal bone fracture and primary or secondary tumors. Facial Canal Distal to the Meatal Segment but Proximal to the Departure of the Nerve to the Stapedius Muscle Facial Canal Distal to the Meatal Segment but Proximal to the Departure of the Nerve to the Stapedius Muscle Ramsay Hunt syndrome Within the Facial Canal Between the Departure of the Nerve to the Stapedius and the Departure of the Chorda tympani facial motor paralysis with loss of taste on the anterior two-thirds of the tongue hearing is spared Metabolic, infectious, neoplastic… in the facial Canal Distal to the Departure of the Chorda Tympani facial motor paralysis without associated hyperacusis or loss of taste. Metabolic, infectious, neoplastic… Distal to the Stylomastoid Foramen isolated facial motor paralysis paralysis of individual facial muscles. Bell’s palsy….
- 103. 103 Vestibulocochlear nerve Eighthcranial nerve consists of two separate functional components: the auditory (cochlear) nerve concerned with hearing the vestibular nerve concerned with equilibrium
- 104. 104 The Auditory Pathways Four-tiered neuronal network Auditory (cochlear) nerve extending from the organ of Corti to the cochlear nucleus Fibers from the cochlear nucleus crossing to the contralateral inferior colliculus Fibers from the inferior colliculus extending to the medial geniculate body Fibers from the medial geniculate body projecting to the auditory cortex in the superior temporal gyrus
- 105. 105 Clinical localization SensorineuralDeafness deficit in perceiving either tones or speech, which is due to a lesion central to the oval window involve the cochlea (sensory), the cochlear nerve and nuclei (neural), or the central auditory pathways Conductive lesion located between the environment and the organ of Corti Mixed By Weber, rinne, audiogram
- 106. 106 Localization of LesionsCausing Sensorineural Deafness LESSIONS CLINICAL MANIFESTATIONS CAUSES CEREBRAL LESIONS auditory cortex do not cause complete deafness Unilateral dominant posterior temporal lesions Difficulties in localizing sounds. auditory verbal agnosia, in bilateral Ischemia BRAINSTEM LESIONS ascending auditory tracts above the level of the cochlear nuclei do not cause hearing impairment. sudden and complete bilateral deafness (central stem deafness of Brunner) Pineal and midbrain tumors PERIPHERAL NERVE LESIONS AND THE CEREBELLOPONTINE ANGLE SYNDROME Partial or complete deafness ipsilateral tinnitus. vestibular schwannoma (acoustic neuroma)
- 107. 107 Vestibular pathways Monitorsangular and linear accelerations of the head Membranous labyrinth. otolith organ (utricle and saccule) and the three semicircular canals Vestibular nerve and central pathways
- 108. 108 Vertigo ETIOLOGIC SEARCH 1.Blood pressure evaluation in both arms 2. A detailed cranial nerve examination 3. Cerebellar testing 4. Evaluation of vestibular control of balance and movement Romberg test 5. Provocative tests head-thrust test Dix-Hallpike test caloric testing
- 109. 109 Etiologies of vertigo Three general categories: Peripheral causes (vestibular labyrinthine disease) Central causes (dysfunction of the vestibular connections) Systemic causes (e.g., endocrine, hemopoietic, metabolic diseases)
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- 113. 113 Supranuclear Lesions Bilateralcorticobulbar lesions (pseudo-bulbar palsy) severe dysphagia other pseudo-bulbar signs (e.g., pathologic laughter and crying, spastic tongue, explosive spastic dysarthria) Nuclear and Intramedullary Lesions Wallenberg syndrome syringobulbia, demyelinating disease, vascular disease, motor neuron disease, and malignancy. Extramedullary Lesions CEREBELLOPONTINE ANGLE SYNDROME JUGULAR FORAMEN SYNDROME (VERNET’S SYNDROME) WITHIN THE RETROPHARYNGEAL AND RETROPAROTID SPACE Cranial nerve VII,VIII,IX injure cranial nerves IX, X, and XI Collet-Sicard syndrome (affecting cranial nerves IX, X, XI, and XII) and Villaret’s syndrome (affecting cranial nerves IX, X, XI, and XII, the sympathetic chain, and occasionally cranial nerve VII)
- 114. 114 Localization of LesionsAffecting the Glossopharyngeal Nerve
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- 116. 116 Supranuclear Lesions supranuclearcontrol is bilateral. Bilateral upper motor neuron lesions result in pseudo-bulbar palsy Ischemia… Nuclear Lesions and Lesions Within the Brainstem Wallenberg syndrome ipsilateral palatal, pharyngeal, and laryngeal paralysis Wallenberg syndrome), tumors, syringobulbia, motor neuron disease, and inflammatory disease. Lesions Affecting the Vagus Nerve Proper complete ipsilateral vocal cord paralysis associated with unilateral laryngeal anesthesia. Neoplasm
- 117. 117 Lesions withinthe Posterior Fossa
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- 119. 119 Localization of LesionsAffecting Cranial Nerve XI muscle on the side of the hemiplegia is paretic. the hemiplegia (i.e. ipsilateral to the cerebral lesion).
- 120. 120 Supranuclear Lesions Contralateralhemiplegia, the trapezius head is turned away from the hemiplegic side indicating paresis of the sternocleidomastoid muscle on the side opposite Head turning Stroke Mass Nuclear Lesions paresis with prominent atrophy and fasciculations cord-low medulla Lesions motor neuron disease Infranuclear Lesions paresis with prominent atrophy and fasciculations LESIONS WITHIN THE SKULL AND FORAMEN MAGNUM JUGULAR FORAMEN SYNDROME (VERNET’S SYNDROME) Collet-Sicard syndrome
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- 124. 124 Localization of LesionsAffecting Cranial Nerve XII Supranuclear Lesions Above the pons lateral tongue paralysis Ipsilateral ischemia cortico-lingual pathway dysarthria Nuclear Lesions and Intramedullary paresis, atrophy, furrowing, fibrillations, and Fasciculations multiple sclerosis, syringobulbia motor neuron disease Intramedullary hypoglossal involvement Medial medullary syndrome (Dejerine’s anterior bulbar syndrome tumor, demyelinating disease, syringobulbia, and vascular insult Peripheral Lesions Deviation to side of the lession Collet-Sicard syndrome basilar skull lesion multiple lower cranial nerve palsy syndromes
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- 126. 126 References Localization inClinical Neurology 2017 DeJong’s The Neurologic Examination 8th edition CRANIAL NERVES Function and Dysfunction 3rd edition Cranial Nerves:Anatomy, Pathology, Imaging 2009 NETTER’S ATLAS OF NEUROSCIENCE 3rd Edition Brainstem Disorders 2011 NEUROANATOMICAL BASIS of CLINICAL NEUROLOGY 2nd Edition Anatomic Basis of Neurologic Diagnosis 2023 FUNCTIONAL NEUROANATOMY 2nd edition Bradley neurology 8th edition Google scholar
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Editor's Notes
- #4 Extends from the pyramidal decussation to the posterior commissure.
- #51 The basis for age-related changes in smell function is multiple and includes ossification and closure of the foramina of the cribriform plate, development of early neurodegenerative disease pathology, and cumulative damage to the olfactory receptors from repeated viral and other insults throughout life
- #60 Oculomotor system is to stabilize images of the visual world on the retina