Neuroanatomy | 1. Introduction to NeuroanatomyAhmed Eljack
This is the first lecture in neuroanatomy presented and taught by Ahmed Eljack to second level medical students at Alneelain University.
This lecture discussed the basics of neuroanatomy regarding anatomical terms, planes of section, anatomical divisions of the nervous system, and cells of the nervous system and their major functions.
The reference material used to make video is: Principles of Anatomy and Physiology Gerard J. Tortora, Bryan H. Derrickson.
Pons is part of brain stem, present superior to medulla, inferior to mid brain and anterior to cerebellum.
Pons means a bridge. As the name denotes, it connects other areas of brain.
Neurons extending from cerebral cortex to pons makes corticopontine tract.
Pons is connected to cerebellum by middle cerebral peduncle.
Pons has vestibular nuclei, which is part of equilibrium pathways from inner ear to brain.
Pons has also respiratory nuclei. Along with rhythmicity area of medulla, pons controls basal respiratory rhythm.
Pons also contains nuclei for cranial nerve number V, VI,VII, and VIII.
For the video, Kindly visit my you tube channel.
https://www.youtube.com/channel/UC7xXKrK7pDObSfXvk9aOgDA.
BRAINSTEM
The Brainstem lies at the base of the brain and the top of the spinal cord.
The brainstem is located in the posterior cranial fossa.
The brainstem is the structure that connects the cerebrum of the brain to the spinal cord and cerebellum.
Provides a pathway for tracts running between higher and lower neural centers.
Divided into 3 major divisions:
midbrain,
pons, and
medulla oblongata.
It is responsible for many vital functions of life, such as breathing, consciousness, blood pressure, heart rate, and sleep.
It contains many critical collections of white and grey matter.
The grey matter within the brainstem consists of nerve cell bodies and form many important brainstem nuclei. Ten of the twelve cranial nerves arise from their cranial nerve nuclei in the brainstem.
The white matter tracts of the brainstem include axons of nerves traversing their course to different structures. These tracts travel both to the brain (afferent) and from the brain (efferent) such as the somatosensory pathways and the corticospinal tracts, respectively.
Mid Brain
The midbrain is continuous with the cerebral hemisphere.
The upper posterior (i.e. rear) portion of the midbrain is called the tectum, which means "roof."
The surface of the tectum is covered with four bumps representing two paired structures: the superior and inferior colliculi.
The superior colliculi are involved in eye movements and visual processing, while the inferior colliculi are involved in auditory processing.
Another important nucleus, the substantia nigra, is located here.
The substantia nigra is rich in dopamine neurons and is considered part of the basal ganglia.
Pons
An important pathway for tracts that run from the cerebrum down to the medulla and spinal cord, as well as for tracts that travel up into the brain.
It also forms important connections with the cerebellum via fibre bundles known as the cerebellar peduncles.
Posteriorly, the pons and medulla are separated from the cerebellum by the fourth ventricle.
Home to several nuclei for cranial nerves.
Medulla
The point where the brainstem connects to the spinal cord.
Contains a nucleus called the nucleus of the solitary tract that is crucial for our survival (receives information about blood flow, along with information about levels of oxygen and carbon dioxide in the blood, from the heart and major blood vessels).
When this information suggests a discordance with bodily needs (e.g. blood pressure is too low), there are reflexive actions initiated in the nucleus of the solitary tract to bring things back to within the desired range.
Blood Supply
The brain stem receives its blood supply exclusively from the posterior circulation, including the vertebrae and basilar artery.
The medulla receives its blood supply from the vertebral via medial and lateral perforating arteries.
The pons and midbrain receive their blood from the basilar via the medial and lateral perforating arteries.
Neuroanatomy | 1. Introduction to NeuroanatomyAhmed Eljack
This is the first lecture in neuroanatomy presented and taught by Ahmed Eljack to second level medical students at Alneelain University.
This lecture discussed the basics of neuroanatomy regarding anatomical terms, planes of section, anatomical divisions of the nervous system, and cells of the nervous system and their major functions.
The reference material used to make video is: Principles of Anatomy and Physiology Gerard J. Tortora, Bryan H. Derrickson.
Pons is part of brain stem, present superior to medulla, inferior to mid brain and anterior to cerebellum.
Pons means a bridge. As the name denotes, it connects other areas of brain.
Neurons extending from cerebral cortex to pons makes corticopontine tract.
Pons is connected to cerebellum by middle cerebral peduncle.
Pons has vestibular nuclei, which is part of equilibrium pathways from inner ear to brain.
Pons has also respiratory nuclei. Along with rhythmicity area of medulla, pons controls basal respiratory rhythm.
Pons also contains nuclei for cranial nerve number V, VI,VII, and VIII.
For the video, Kindly visit my you tube channel.
https://www.youtube.com/channel/UC7xXKrK7pDObSfXvk9aOgDA.
BRAINSTEM
The Brainstem lies at the base of the brain and the top of the spinal cord.
The brainstem is located in the posterior cranial fossa.
The brainstem is the structure that connects the cerebrum of the brain to the spinal cord and cerebellum.
Provides a pathway for tracts running between higher and lower neural centers.
Divided into 3 major divisions:
midbrain,
pons, and
medulla oblongata.
It is responsible for many vital functions of life, such as breathing, consciousness, blood pressure, heart rate, and sleep.
It contains many critical collections of white and grey matter.
The grey matter within the brainstem consists of nerve cell bodies and form many important brainstem nuclei. Ten of the twelve cranial nerves arise from their cranial nerve nuclei in the brainstem.
The white matter tracts of the brainstem include axons of nerves traversing their course to different structures. These tracts travel both to the brain (afferent) and from the brain (efferent) such as the somatosensory pathways and the corticospinal tracts, respectively.
Mid Brain
The midbrain is continuous with the cerebral hemisphere.
The upper posterior (i.e. rear) portion of the midbrain is called the tectum, which means "roof."
The surface of the tectum is covered with four bumps representing two paired structures: the superior and inferior colliculi.
The superior colliculi are involved in eye movements and visual processing, while the inferior colliculi are involved in auditory processing.
Another important nucleus, the substantia nigra, is located here.
The substantia nigra is rich in dopamine neurons and is considered part of the basal ganglia.
Pons
An important pathway for tracts that run from the cerebrum down to the medulla and spinal cord, as well as for tracts that travel up into the brain.
It also forms important connections with the cerebellum via fibre bundles known as the cerebellar peduncles.
Posteriorly, the pons and medulla are separated from the cerebellum by the fourth ventricle.
Home to several nuclei for cranial nerves.
Medulla
The point where the brainstem connects to the spinal cord.
Contains a nucleus called the nucleus of the solitary tract that is crucial for our survival (receives information about blood flow, along with information about levels of oxygen and carbon dioxide in the blood, from the heart and major blood vessels).
When this information suggests a discordance with bodily needs (e.g. blood pressure is too low), there are reflexive actions initiated in the nucleus of the solitary tract to bring things back to within the desired range.
Blood Supply
The brain stem receives its blood supply exclusively from the posterior circulation, including the vertebrae and basilar artery.
The medulla receives its blood supply from the vertebral via medial and lateral perforating arteries.
The pons and midbrain receive their blood from the basilar via the medial and lateral perforating arteries.
Cranial nerve assessment..Simple and Easy to perform for medics and Physiothe...pawan1physiotherapy
Cranial Nerve Assessment is a crucial step in neurological assessment. By following the simple theoretical aspects it can be made on your fingertips....here is an try to make the stuff easier for you....
Unit IV -
Peripheral nervous system
Classification of peripheral nervous system: Structure and functions of
sympathetic and parasympathetic nervous system.
Origin and functions of spinal and cranial nerves.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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Neuroanatomy...Cranial nerve anatomy
1. Cranial nerve anatomy
Professor Yasser Metwally
www.yassermetwally.com
Cranial Nerve I - Olfactory Nerve
Olfactory Epithelium
The olfactory epithelium is
located in the roof, superior
conchae, and septum of the
nasal cavity.
The epithelium is kept moist
by the secretions of olfactory
glands.
Olfactory receptor cells are
bipolar nerve cells with a
peripherally directed dendrite
which terminates in a knob
from which project numerous
cilia.
The olfactory chemoreceptors
are located on these cilia.
Figure 1. Olfactory
epithelium.
Sensory Transduction and Peripheral Course of the Olfactory Nerve
I nhaled aromatic molecules dissolve in the moisture lining the olfactory epithelium and stimulate its
chemoreceptors.
Olfactory receptor cells initiate action potentials in response to these chemical stimuli. I ntracellular studies
show the presence of a slow rising receptor (generator) potential followed by a spike discharge from the
receptor cell.
The peripheral processes of the receptor cells assemble into small bundles and pass through the cribiform
plate of the ethmoid bone to synapse on secondary sensory neurons in the olfactory bulb.
Figure 2. Peripheral course of the olfactory nerve.e
2. M ajor projections of the olfactory areas
All three olfactory areas interface with various autonomic centers via a complex communications network.
The principal pathways include:
M edial forebrain bundle - provides information from all three olfactory areas to the hypothalamus.
Stria medullaris- carries olfactory information from the rhinencephalon to the habenular nucleus.
Stria terminalis - carries information from the amygdala to the anterior hypothalamus and preoptic
area of the cortex.
From the hypothalamus and habenular nucleus information is sent to the reticular formation and various
cranial nerve nuclei involved in visceral responses. Examples include the dorsal motor nucleus of the vagus
which mediates nausea, gastric motility and secretion, and intestinal peristalsis and the superior and inferior
salivatory nuclei which mediate salivation.
Figure 3. M ajor projections of the olfactory areas.
Cranial Nerve I I I - Oculomotor nerve Nerve Oculomotor nerve palsy
Consists of two components with distinct functions:
The somatic motor component of CN I I I plays a major role in controlling the muscles responsible for the
precise movement of the eyes for visual tracking or fixation on an object.
The visceral motor component is involved in the pupillary light and accomodation reflexes.
Supplies four of the six
extraocular muscles of the
Somatic motor eye and the levator
(general somatic efferent) palpebrae superioris
muscle of the upper
eyelid.
Parasympathetic
Visceral motor innervation of the
3. (general visceral efferent) constrictor pupillae and
ciliary muscles.
Figure 4. Overview of occulomotor nerve components.
Overview of the Somatic M otor Component
There are six extraocular muscles in each orbit.
The somatic motor component of CN I I I innervates the following four extraocular muscles of the eyes:
4. I psilateral inferior rectus muscle
I psilateral inferior oblique muscle
I psilateral medial rectus muscle
Contralateral superior rectus muscle
The remaining extraocular muscles, the superior oblique and lateral rectus muscles, are innervated by the
trochlear nerve (CN I V) and abducens nerve (CN VI ), respectively.
The somatic motor component of CN I I I also innervates the levator palpebrae superioris muscles bilaterally.
These muscles elevate the upper eyelids.
Figure 5. Overview, somatic motor component of CN I I I .
Actions of the Extraocular M uscles
The actions of all six extraocular muscles are summarized in the table below:
Primary Secondary Tertiary
M uscle I nnervation
action action action
Medial
CN III Adduction -- --
rectus
Superior
CN III Elevation Intortion Adduction
rectus
Inferior
CN III Depression Extortion Adduction
rectus
Inferior
CN III Extorsion Elevation Abduction
oblique
Superior
CN IV Intorsion Depression Abduction
oblique
Lateral
CN VI Abduction -- --
rectus
5. A knowledge of the origins and points of insertion of the extraocular muscles on the eye relative to the axes of
motion of the eye is critical to understanding the actions of these muscles.
Figure 6. Origins and points of insertion of the extraocular muscles on the eye
M edial Rectus M uscle
The medial rectus muscle originates from the tendinous ring of the orbit and inserts on the medial border of
the eye. Contraction of this muscles leads to adduction of the eye.
Figure 7. M uscles of adduction.
Superior Rectus M uscle
The superior rectus muscle originates from the tendinous ring of the orbit and inserts on the superior surface
of the eye slightly medial to the eyes vertical axis of rotation. Due to these factors, contraction of the superior
rectus results in elevation, intorsion, and adduction of the eye. The primary action of the superior rectus
muscle (elevation of the eye) can be isolated by having the patient look laterally and then upwards.
6. Figure 8. M uscles of elevation.
Somatic motor component - origin and central course
The somatic motor component of CN I I I originates from the oculomotor nucleus located in the rostral
midbrain at the level of the superior colliculus.
Like other somatic motor nuclei, the oculomotor nucleus is located near the midline just ventral to the
cerebral aqueduct.
I n a coronal cross-section of the brainstem the oculomotor nucleus is "V-shaped" and is bordered medially by
the Edinger-Westphal nucleus and laterally and inferiorly by the medial longitudinal fasciculus which allows
communication between various brainstem nuclei.
Figure 9. Somatic motor component - origin and central course.
Fibers leaving the occulomotor nucleus travel ventrally in the tegmentum of the midbrain passing through the
red nucleus and medial portion of the cerebral peduncle to emerge in the interpeduncular fossa at the junction
of the midbrain and pons.
7. Somatic motor component - intracranial course
Upon emerging from the brainstem the oculomotor nerve passes between the posterior cerebral and superior
cerebellar arteries and pierces the dura mater to enter the cavernous sinus.
The nerve runs along the lateral wall of the cavernous sinus just superior to the trochlear nerve and enters the
orbit via the superior orbital fissure.
Figure 10. Somatic motor component - intracranial course.
Somatic motor component, final innervation
Within the orbit CN I I I fibers pass through the tendinous ring of the extraocular muscles and divide into
superior and inferior divisions.
The superior division ascends lateral to the optic nerve to innervate the superior rectus and and levator
palpebrae superioris muscles on their deep surfaces.
Figure 11. Somatic motor component, final innervation, anterior view.
The inferior division of CN I I I splits into three branches to innervate the medial rectus and inferior rectus
muscles on their ocular surfaces and the inferior oblique muscle on its posterior surface.
8. Figure 12. Somatic motor component, final innervation.
Somatic motor component, vertical gaze
The exact control of eye movements requires input from integration centers in the brain that coordinate the
output from the occulomotor, trochlear, and abducens nuclei which control the six extraocular muscles.
For eye movements in the vertical plane, the superior rectus, inferior rectus, inferior oblique, and superior
oblique muscles of the eyes must work precisely together.
The actions of these muscles is coordinated by the vertical gaze center which is thought to be located in the
periaqueductal grey matter of the midbrain at the level of the superior colliculus (its location has not yet been
positively identified).
The vertical gaze center projects to the oculomotor nuclei which control the superior rectus, inferior rectus
and inferior oblique muscles as well as to the trochlear nuclei which control the superior oblique muscles.
The center that controls torsional movements of the eye is probably close to, or the same as, the vertical gaze
center since all muscles that elevate or depress the eyes also cause them to rotate about their anterior-posterior
axis of motion.
The lateral gaze center is discussed in the abducens nerve (CN VI ) module.
9. Figure 13. Vertical gaze center, CN I I I & CN I V.
Overview of the visceral motor component
Provides parasympathetic innervation of the constrictor pupillae and ciliary muscles of the eye.
The visceral motor component of CN I I I is involved in the pupillary light and accommodation reflexes.
Figure 14. Overview of the visceral motor component.
Visceral motor component, origin and course
The visceral motor component originates from the Edinger-Westphal nucleus located in the rostral midbrain
at the level of the superior colliculus.
I n a coronal cross-section of the brainstem the Edinger-Westphal nucleus sit within the "V-shaped"
oculomotor nuclei just ventral to the cerebral aqueduct.
10. Preganglionic parasympathetic fibers course ventrally through the midbrain, interpeduncular fossa,
cavernous sinus, and superior orbital fissure along with the somatic motor fibers of CN I I I .
Figure 15. Visceral motor component, origin and course.
Visceral motor component, final innervation
Once within the orbit the preganglionic parasympathetic fibers leave the nerve to the inferior oblique muscle
to synapse in the ciliary ganglion which lies deep to the superior rectus muscle near the tendinous ring of the
extraocular muscles.
Postganglionic fibers exit the ciliary ganglion in the short ciliary nerves which enter the posterior aspect of the
eye near the point of exit of the optic nerve.
Within the eye these fibers travel forward between the choroid and sclera to innervate the ciliary muscles
(which control the shape and therefore the refractive power of the lens) and the constrictor pupillae muscle of
the iris (which constricts the pupil).
11. Figure 16. Visceral motor component, final innervation.
Visceral motor component, pupillary light reflex
Light entering the eye causes signals to be sent to the pretectal region of the midbrain via the optic nerve (CN
I I ).
The pretectal nucleus in turn projects bilaterally to the Edinger-Westphal nucleus.
Preganglionic parasympathetic fibers from each half of the Edinger-Westphal nucleus then project to the
ciliary ganglion of the ipsilateral orbit.
Post-ganglionic parasympathetic fibers exit the ciliary ganglion to innervate the constrictor pupillae muscle of
the ipsilateral eye.
Due to the bilateral projections from the pretectal nuclei to the Edinger-Westphal nuclei, light shined into one
eye produces pupillary constriction in both eyes.
Direct pupillary light reflex - response in the stimulated eye. Consensual pupillary light reflex - response in the
opposite eye.
Visceral M otor Component, Accomodation Reflex
Accommodation is an adaptation of the visual apparatus to facilitate near vision. This reflex involves the
following:
1. An increase in the curvature (and therefore the refractive power) of the lens
2. Pupillary constriction to help sharpen the image on the retina
3. Convergence of the eyes to fixate on the target object
The accommodation pathway is summarized below:
Fibers from the primary visual cortex project, via the visual association cortex of the occipital lobe, to
the superior colliculi and pretectal nuclei.
Axons from the superior colliculi and pretectal nuclei project to both the Edinger-Westphal and
oculomotor nuclei.
12. Signals from the Edinger-Westphal nuclei travel via the ipsilateral oculomotor nerve to reach the ciliary
and constrictor pupillae muscles of the eye. Contraction of the ciliary muscle causes the lens to increase
its curvature (and thus its refractive power), while contraction of the constrictor pupillae reduces the
size of the pupillary aperture.
Signals from the oculomotor nuclei travel via the ipsilateral oculomotor nerve to the medial rectus
muscles causing them to contract and resulting in convergence of the eyes on the object of interest.
Cranial Nerve I V - Trochlear Nerve Trochlear nerve palsy
Overview
The trochlear nerve has only a somatic motor component:
Somatic motor innervates
Somatic motor the superior oblique
(general somatic efferent) muscle of the contralateral
orbit.
The superior oblique muscle is one of the six extraocular muscles responsible for the precise movement of the
eye for visual tracking or fixation on an object.
See the occulomotor nerve (CN I I I ) chapter for a discussion of eye movements and the interaction between the
three nuclei and nerves that innervate the extraocular muscles.
13. Figure 17. Anatomic overview of the trochlear nerve.
Origin and central course
Figure 18. Anatomic overview of the trochlear nerve.
The fibers of the trochlear nerve originate from the trochlear nucleus located in the tegmentum of the
midbrain at the level of the inferior colliculus.
The nucleus is located just ventral to the cerebral aqueduct. I t is readily identifiable by its close association
with the myelinated medial longitudinal fasciculus that allows communication between various brainstem
nuclei.
Fibers leaving the trochlear nucleus travel dorsally to wrap around the cerebral aqueduct.
All fibers of the two trochlear nerves decussate (i.e. cross) in the superior medullary velum and exit the dorsal
surface of the brainstem just below the contralateral inferior colliculus.
14. Figure 19. Origin and central course.
I ntracranial course
Upon emerging from the dorsal surface of the brainstem the trochlear nerve curves around the brainstem in
the subarachnoid space and emerges between the posterior cerebral and superior cerebellar arteries (along
with CN I I I fibers).
The trochlear nerve then enters and runs along the lateral wall of the cavernous sinus with CNS I I I , V, and VI .
Figure 20. I ntracranial course.
I ntracranial course and final innervation
15. From the cavernous sinus the trochlear nerve enters the orbit through the superior orbital fissure.
CN I V does not pass through the tendinous ring of the extraocular muscles, rather it passes above the ring.
The trochlear nerve then crosses medially along the roof of the orbit above the levator palpebrae and superior
rectus muscles to innervate the superior oblique muscle along its proximal one-third:
Figure 21. Final innervation of trochlear nerve.
Clinical Correlation
The superior oblique muscle normally depresses, intorts, and abducts the eye (fig. 4-6a). Damage to the
trochlear nerve will present as:
Extorsion (outward rotation) of the affected eye due to the unopposed action of the inferior oblique
muscle.
Vertical diplopia (double vision) due to the extorted eye.
Weakness of downward gaze most noticeable on medially-directed eye. This is often reported as
difficulty in descending stairs.
Figure 22. Normal action of the superior oblique muscle.
16. Figure 23. Paralysis of the superior oblique muscle.
Extortion (outward rotation) of the affected eye due to the unopposed action of the inferior oblique muscle
(Fig. 4-6b). Vertical diplopia (double vision) due to the extorted eye. Weakness of downward gaze most
noticeable on medially directed eye. This is often reported as difficulty in descending stairs. Head tilt (Fig. 4-
6b): patient will often tilt his head opposite the side of the affected eye in an attempt to compensate for the
outwardly rotated eye.
Due to its long peripheral course around the midbrain CN I V is particularly susceptible to head trauma.
Cranial Nerve VI - Abducens Nerve
Overview
Has only a somatic motor (general somatic efferent) component.
Somatic motor: innervates the lateral rectus muscle of the ipsilateral orbit.
The lateral rectus muscle is one of the six extraocular muscles responsible for the precise movement of the eye
for visual tracking or fixation on an object.
See the CN I I I section (occulomotor nerve) for a discussion of eye movements and the interaction between the
three nuclei and nerves that innervate the extraocular muscles.
17. Figure 24 Abducens nerve and the lateral rectus muscle.
The abducens nerve innervates the lateral rectus muscle of the ipsilateral orbit.
The lateral rectus muscle is responsible for lateral gaze (its contraction causes the eye to be abducted):
Figure 25. Actions of the lateral rectus muscle.
Origin and central course
The fibers of the abducens nerve originate from the abducens nucleus located in the caudal pons at the level of
the facial colliculus.
The nucleus is located just ventral to the fourth ventricle near the midline. Axons of CN VI I (facial nerve) loop
around the abducens nucleus and give rise to a bulge in the floor of the fourth ventricle - the facial colliculus.
Fibers leaving the abducens nucleus travel ventrally to exit the brainstem at the border of the pons and
medullary pyramids.
18. Figure 26. Origin and central course.
I ntracranial course
Upon exiting the brainstem the abducens nerve climbs superiorly along the ventral surface of the pons. On
reaching the apex of the petrous portion of the temporal bone the nerve makes a sharp turn anteriorly to enter
the cavernous sinus.
The abducens nerve travels along the lateral wall of the cavernous sinus with CNS I I I , I V, and V.
Figure 27. I ntracranial course of abducens nerve.
I ntracranial course and final innervation
From the cavernous sinus the abducens nerve enters the orbit through the superior orbital fissure.
CN VI passes through the tendinous ring of the extraocular muscles and innervates the lateral rectus muscle
19. on its deep surface:
Figure 28. Final innervation of abducens nerve.
Cranial Nerve VI I - Facial Nerve Facial nerve palsy
Component Overview
The facial nerve has four components with distinct functions:
20. Supplies the muscles of
facial expression;
Brancial motor
posterior belly of digastric
(special visceral efferent)
muscle; stylohyoid, and
stapedius.
Parasympathetic
innervation of the lcrimal,
submandibular, and
Visceral motor
sublingual glands, as well
(general visceral efferent)
as mucous membranes of
nasopharynx, hard and
soft palate.
Taste sensation from the
Special sensory
anterior 2/3 of tongue;
(special afferent)
hard and soft palates.
General sensation from
General sensory the skin of the concha of
(general somatic afferent) the auricle and from a
small area behind the ear.
Branchial motor fibers constitute the largest portion of the facial nerve.
The remaining three components are bound in a distinct fascial sheath from the branchial motor fibers.
Collectively these three components are referred to as the nervus intermedius.
Component Overview
21. Figure 29. Functional component overview of the facial nerve.
Branchial M otor Component
The largest component of the facial nerve.
Provides voluntary control of the muscles of facial expression (including buccinator, occipitalis and platysma
muscles), as well as the posterior belly of the digastric, stylohyoid and stapedius muscles.
Note the branchial motor components of the facial nerve:
Figure 30. Branchial motor components of the facial nerve.
Origin and Central Course
22. The branchial motor component originates from the motor nucleus of CN VI I in the caudal pons.
Fibers leaving the motor nucleus of CN VI I initially travel medially and dorsally to loop around the ipsilateral
abducens nucleus (CN VI ) producing a slight bulge in the floor of the fourth ventricle - the facial colliculus.
Fibers then course so as to exit the ventrolateral aspect of the brainstem at the caudal border of the pons in
conjunction with the nervus intermedius components of CN VI I .
Figure 31. Brainstem section: origin and central course of the branchial motor components of the facial nerve.
I ntracranial course
Upon emerging from the ventrolateral aspect of the caudal border of the pons, all of the components of CN
VI I enter the internal auditory meatus along with the fibers of CN VI I I (vestibulocochlear nerve).
The fibers of CN VI I pass through the facial canal in the petrous portion of the temporal bone. The course of
the fibers is along the roof of the vestibule of the inner ear, just posterior to the cochlea.
23. Figure 32. I ntracranial course- branchial motor components of the facial nerve. Facial nerve origin and inner
ear anatomy.
Extracranial Course and Final I nnervation
The posterior auricular nerve, nerve to the posterior belly of the digastric and the nerve to the stylohyoid
muscle are given off upon the facial nerve's exit from the stylomastoid foramen.
The remaining fibers enter the substance of the parotid gland and divide to form the temporal, zygomatic,
buccal, mandibular, and cervical branches to innervate the muscles of facial expression.
Figure 33. Entracranial course- branchial motor components of the facial nerve. Geniculate ganglion and
inner ear.
Voluntary Control of the M uscles of Facial Expression
Signals for voluntary movement of the facial muscles originate in the motor cortex (in association with other
cortical areas) and pass via the corticobulbar tract in the posterior limb of the internal capsule to the motor
24. nuclei of CN VI I .
Fibers pass to both the ipsilateral and contralateral motor nuclei of CN VI I in the caudal pons:
Figure 34. Extra-cranial course and final innervation; branchial motor components of the facial nerve.
Voluntary Control of the M uscles of Facial Expression
The portion of the nucleus that innervates the muscles of the forehead receives corticobulbar fibers from both
the contralateral and ipsilateral motor cortex.
The portion of the nucleus that innervates the lower muscles of facial expression receives corticobulbar fibers
from only the contralateral motor cortex.
This is very important clinically as central (upper motor neuron) and peripheral (lower motor neuron) lesions
will present differently.
25. Figure 35. Voluntary control of the muscles of facial expression. After Wilson-Pauwels, et al., 1988.
Lower M otor Neuron (LM N) Lesion
Results from damage to the motor nucleus of CN VI I or its axons.
A LM N lesion results in the paralysis of all muscles of facial expression (including those of the forehead)
ipsilateral to the lesion.
Figure 36. Voluntary control of the muscles of facial expression, detail. After Wilson-Pauwels, et al., 1988.
Clinical Correlation - Bell's Palsy
A LM N lesion of CN VI I which occurs at or beyond the stylomastoid foramen is commonly referred to as a
Bell's Palsy.
Characteristic indications of a LM N lesion or Bell's Palsy include the following, on the affected side:
M arked facial asymmetry
Atrophy of facial muscles
Eyebrow droop
Smoothing out of forehead and nasolabial folds
Drooping of the mouth corner
Uncontrolled tearing
Loss of efferent limb of conjunctival reflex (cannot close eye)
Lips cannot be held tightly together or pursed
Diificulty keeping food in mouth while chewing on the affected side
26. Figure 37. Lower M otor Neuron (LM N) Lesion.
Clinical Correlation - Upper M otor Neuron (UM N) Lesion
Results from damage to neuronal cell bodies in the cortex or their axons that project via the corticobulbar
tract through the posterior limb of the internal capsule to the motor nucleus of CN VI I .
With an UM N lesion, voluntary control of only the lower muscles of facial expression on the side contralateral
to the lesion will be lost.
Voluntary control of muscles of the forehead will be spared due to the bilateral innervation of the portion of
the motor nucleus of CN VI I that innervates the upper muscles of facial expression.
UM N lesions are usually the result of a stroke.
Figure 38. Bell's Palsy: Lower M otor Neuron (LM N) Lesion.
Characteristics of an UM N lesion of the facial nerve include:
27. Facial asymmetry
Atrophy of muscles of lower portion of the face on affected side*
No eyebrow droop*
I ntact folds on forehead*
I ntact conjunctival reflex (orbicularis oculi innervation is intact)
Smoothing of nasolabial folds on affected side
Lips cannot be held tightly together or pursed
Difficulty keeping food in mouth while chewing on affected side
* Distinguishes UM N lesions from LM N lesions.
Overview of Visceral M otor Component
Parasympathetic component of the facial nerve.
Consists of efferent fibers which stimulate secretion from the submandibular, sublingual, and lacrimal glands,
as well as the mucous membranes of the nasopharynx and hard and soft palates.
Figure 39. Overview of visceral motor components of the facial nerve.
Origin and Central Course
The visceral motor component originates from a diffuse collection of cell bodies in the caudal pons just below
the facial nucleus known as the superior salivatory nucleus.
Fibers course so as to exit the ventrolateral aspect of the brainstem at the caudal border of the pons as part of
the nervus intermedius portion of CN VI I . these fibers do not loop around the abducens nucleus.
The nervus intermedius exits the brainstem just lateral to the branchial motor component.
28. Figure 40. Visceral motor component of the facial nerve: origin and central course.
I ntracranial Course
Upon emerging from the ventrolateral aspect of the caudal border of the pons, all of the components of CN
VI I enter the internal auditory meatus along with the fibers of CN VI I I (vestibulocochlear nerve).
Within the facial canal the visceral motor fibers divide into two groups to become the greater petrosal nerve
and the chorda tympani:
The greater petrosal nerve supplies the lacrimal, nasal, and palatine glands.
The chorda tympani supplies the submandibular and sublingual glands.
29. Figure 41. I ntracranial course, visceral motor component of the facial nerve.
Course of the Greater Petrosal Nerve
At the geniculate ganglion the greater petrosal nerve turns anteriorly and medially exiting the temporal bone
via the petrosal foramen and entering the middle cranial fossa.
Figure 42. Course of the greater petrosal nerve through the temporal bone.
The greater petrosal nerve passes deep to the trigeminal ganglion to enter the foramen lacerum. The nerve
traverses the foramen and enters a canal at the base of the medial pterygoid plate in conjunction with
sympathetic fibers (deep petrosal nerve) branching from the plexus following the internal carotid artery. The
parasympathetic and sympathetic fibers together make up the nerve of the pterygoid canal.
Upon exiting the pterygoid canal, pre-ganglionic parasympathetic fibers of CN VI I synapse in the
pterygopalatine ganglion which is suspended from the fibers of the maxillary division of the trigeminal nerve
(V2) in the pterygopalatine fossa.
Post-ganglionic parasympathetic fibers then follow the fibers of V2 to reach the lacrimal gland (via the
lacrimal nerve) and the mucous membranes of the nasal and oral pharynx.
30. Figure 43. Extra-cranial course of the greater petrosal nerve.
Course of the Chorda Tympani
The pre-ganglionic fibers of the chorda tympani branch from the other fibers of CN VI I as they pass through
the facial canal just posterior to the middle ear.
The fibers pass through the middle ear in close relationship with the tympanic membrane and exit the base of
the skull to enter the inferotemporal fossa:
Figure 44. Course of the chorda tympani, inner ear.
I n the inferotemporal fossa the chorda tympani joins the fibers of the lingual branch of the mandibular
division of CN V (V3).
CN VI I pre-ganglionic fibers synapse in the submandibular ganglion suspended from the lingual nerve (V3).
Post-ganglionic fibers then either enter the submandibular gland directly or again follow the lingual nerve
before branching to innervate the sublingual gland:
31. Figure 45. Distal course and final innervation of the chorda tympani.
Overview of Special Sensory Component
Consists of afferent fibers which convey taste information from the anterior 2/3 of the tongue and the hard
and soft palates.
Figure 46. Facial nerve, special sensory component.
Peripheral Course
Chemoreceptors of the taste buds located on the anterior 2/3 of the tongue and hard and soft palates initiate
receptor (generator) potentials in response to chemical stimuli.
The taste buds synapse with the peripheral processes of special sensory neurons from CN VI I . These neurons
generate action potentials in response to the taste bud's receptor potentials. The peripheral processes of these
neurons follow the lingual nerve and then chorda tympani to the petrous portion of the temporal bone (similar
to the path followed by the efferent visceral motor fibers).
32. Figure 47. Chorda tympani and the lingual nerve.
The cell bodies of these primary afferent neurons reside in the geniculate ganglion:
Figure 48. Geniculate ganglion.