AJ CastroEJ Neafsey

Loyola University of ChicagoStritch School of Medicine © 2007

About this Manual.This laboratorymanual isalsoprovidedonacompact

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Introduction

Neuroanatomy is easy.Learningneuroanatomyisdifficult.“Whyis thisso?”...youask.

First,because it isanewvocabulary.Second,becausenomatterwhereyoustart,youarealwaysreferring topartsof thebrainyouhaven’t studiedyet.Third,becausestudentsalmost invariably“fail tosee theforest forthetrees,” losingsightof the important relationsbyfocusingonunimportant, trivialdetails.

This laboratorymanualemphasizesimportantfactsyoushouldknow.Examplesof important facts includethemainsensoryandmotorpathwaysand

systems, suchas thedorsalcolumn/medial lemniscalpathway, thevisualpathway,andthecorticospinalpathway.Other important topics includeunderstandingtherelationof thecerebellumandbasalganglia to therestof themotorsystem.

Examplesofunimportant facts include thenamesofthe tenor twelvedifferent raphenuclei, theexact locationof thespino-olivaryfibers in thespinalcord,andthe locationof

thefrenulum.Ifyouspendaminutestudyingtheselast three items,youhavenotonly

wastedyour timebuthaveactuallyseriouslyhinderedyour learningof theessentialsby

fillingyourmind,whichhasafinitecapacity toabsorbnewinformation,with trivia.Do

notdothis.Ratheralwaysstrive tokeepthebigpictureandtheoverallpatternbeforeyou.

AnimportantnoteaboutSelf-StudyLab1.Lab1isaself-studylabsession...forseveralreasons.Muchof thematerial, suchasgeneralanatomical

nomenclature andthe gross topographyof thebrainandspinalcord isquitebasicandstraightforward.Also,muchof thismaterial,e.g., thegrossanatomyof thevertebralcol-umnandspinalcord,blood-supply to thebrain,etc., hasbeencovered inpreviouscoursework.Additionally,manyof thestructurescoveredsuchas themeningesandbloodves-selsaregenerallypoorlypreservedormissing in thespecimensavailableforstudy.Accordingly,youshouldreadandstudythis first labexerciseprior to thesecondlabses-sionwheninstructorswillbepresent toreviewthematerialandanswerquestions.

Learning Neuroanatomy

Thismanual includessevenlaboratorysessions.Eachsession includesseveralsectionsorcomponents.Workingingroupsof four, studentsareexpectedtowork

theirwaythroughthesecomponents.Laboratory instructorswillassist.Weacknowledgethatsomeofthematerial in the earlylabsessions ispresentedwellbeforeyouhave learnedsufficient informationtoanswerrelatedquestions.Don'tbediscouraged.Don't let thisalarm(unnerve?)you.Ourobjective is toshowyouwhereyouaregoing,whatyour finaldestina-tion is,howfundamentalknowledgeabout thebrainisactuallyusedclinically.Evenifyouarenot thereyet,somesenseofyourultimategoalisuseful.Gobackto thematerial inearlysessionsas thecourseprogressesandamazeyourselfwithall thatyouhave learned.Allwhohavegonebeforeyouagreethat thiswillhappen.

LesionLessons.Pathological imagesarepresentedatthebeginningofeachlaborat o-ryexercise.Studentsareexpected toanswerthreequestionsforeachlesion lesson:

(i) locationof lesion; (ii)signsorsymptomsassociatedwith thepathology;and(iii)causeofthepathology.TheseLesionLessonswill serve tofocusyourattentiononthesubsequentneuroanatomicalmaterialpresented in the labsessionaswellas inotheraspectsof thecourse,i.e., lectureandsmallgroupsessions. In thebeginningof thecourse, asyouslowlybecomefamiliarwith thesubjectofNeuroscience, theLesionLessonsare likely toappeardifficultanddaunting.That’s OKandtobeexpected.Besmart... gobackto theselesions timeandagain,perhapsbefore thenext labsession,andyouwill readilyseehowyourknowledge israpidly increasing.

Wetlabs. In thepertinent"wet" labsessions,youwillusegrossbrainspeci-mens,MRIfilmsandmodelsaswellasvariousimages inyourlabguide to

studysuperficialanatomy.Thesetopicswillalsobecoveredinmanylecturepresentationsaswellas insmallgroupsessions.Links to theRandAtlas inyourCD-basedlabguidewillbeveryuseful.

Manual layout

InternalAnatomy.Three"dry" labsessionsfocusontheinternalanatomyof theCNS.Athoroughstudyisessential todevelopinganunderstandingofmuchofneuro-science.Histologicalimagesareprovidedinyour labguide.Studiesof these imagesarefacilitatedbyuseof theRandAtlas,yourcourse textbookaswellasthemanybrainatlasesthathavebeenpublished.Student labelingof thecross-sectional figures isconsideredessential tosuccessonlaboratoryexaminations.

CaseBreaks.Clinicalcasebreaksare interspersed in the labsessions.Theseareintendedtoemphasizetheclinicalrelevanceof neuroanatomy.Fromthebriefclini-

calvignettespresented,youaretoreasonto theunderlyingcauseorclinicalcondition.Thisapproachstands incontrast to theLesionLessonswhereyoudeducefromtheneuropatholo-gytotheclinicalcondition.The“intercoursequestions”are intendedtoprovide integrationacrossdisciplinesofstudy.

ReviewQuestions.Asimplied thesequestionsare intendedtoreviewyourlaborato-ryknowledge,butalsoandveryimportantly they shouldhelp integrate thisknowl-

edge intoallaspectsof thecourse. In thiswaytheyserve toreviewmore thanthelabmateri-al.Returningbacktothesequestionsfromtimetotimewill serveasagaugeofyourprogressinunderstandingneuroscience.

MRICorrelations.Animportantaspectofneurology,andperhaps ofallclinical fields, isa familiarityofMRIimages.Theidentificationofbrainstruc-

ture fromMRIimages,asderivedfromyourstudyof thegrossbrainandinternalanatomy,isconsideredespecially relevantclinically.Links to theRandAtlaswillbemostuseful.

PatientPuzzles.Presentedat theendof the labsessions,mostof thesearebeststudiedfromtheCDastheycontainmovieclipsof patients.Generally, theseclips

areselected todemonstratephysician-patient interactions indemonstratingclinical signs.Like theCaseBreaks, thesecases testyourknowledge indiagnosing clinicalconditionsfromthesignsandsymptomspresented.

Manual layout (cont'd)

ContentsIntroduction

Lab I. Gross Brain & Spinal Cordand Blood Vessels

Lab II. Spinal Cord and Brain Stem

Lab III. Medulla

Lab IV. Pons and Midbrain

Lab V. Cerebral Hemispheresand Cerebellum

Lab VI. Diencephalon and Basal Ganglia

Lab VII. Limbic System and Ventricles

Additional Exercises

Lab 1. Spinal cord & Gross BrainLesion Lessons1.1. Malcom Tent1.2. Vito Powers1.3. Neal Sporin

IntroductionGeneral Topography of the BrainBrain StemCase BreakHead-On Crash

External Anatomy of the Spinal CordVertebral ColumnSpinal Cord

Review of Major Blood VesselsBlood Supply of the BrainInternal Carotid Artery (Anterior Circulation)Vertebral Arteries (Posterior Circulation)Basilar Artery

Blood Supply to the Spinal CordCase BreakDoris Locht – Secretary Headache

Meninges of the BrainDural Septae

Other Meninges-Related DescriptionsVenous SinusesSpinal Cord MeningesBrain Stem and CerebellumMidbrainPonsMedulla (oblongata)Spinal Cord

Review Questions – Meninges Gross Brain and Blood VesselsReview Questions – Brain Stem and Spinal CordMRI CorrelationPatient PuzzleOllie Hoop – The case of fluttering muscles and foot drop

Lab 2. Spinal Cord & Brain StemLesion Lessons2.1. Holli Penya2.2. Pete Zapasta2.3. Harla Quinn2.4 Justin Tyme

Detailed Contents

Internal Anatomy of Spinal CordGray MatterWhite Matter

Cervical CordThoracic CordLumbar CordSacral and Coccygeal Cord

Spinal Cord Review ExerciseCranial NervesGross Anatomy of Brain StemDiencephalonMidbrain (Mesencephalon)PonsCerebellumMedulla (Myelencephalon)Floor of the Fourth Ventricle

Case BreakAllyn Rench – Window Washer Fall

Case BreakPhil N. Troepik – Aorta Surgery

Review ExerciseMRI CorrelationReview QuestionsReview ExercisePatient PuzzleSara Bellum – The case of tingling feet

Lab 3. MedullaLesion Lessons3.1. Mike Rowmeter3.2. Anne Chovee

Spinomedullary JunctionMedullary Level of the Pyramidal (Motor) DecussationMedullary Level of the Sensory DecussationMedullary Level of the Vagus NerveMedullary Level of the Glossopharyngeal NerveCase BreakDewey Dessmul – An old man is spinning

Medullary Level Showing Deep Cerebellar NucleiReview QuestionsMRI CorrelationPatient PuzzleRusty Bell – An unsteady young boy

Detailed Contents (cont’d)

Detailed Contents (cont’d)Lab 4. Pons & MidbrainLesion Lessons4.1. Anne T. Pasta4.2. Colin S. Terase

Pontine level of the Facial GenuBasilar PonsPontine Tegmentum

Case BreakWillie Maykitt – Double vision

Pontine Level of the Trigeminal Motor Nucleus

Case BreakPenny Pinscher – Cheek pain

Level of the Isthmus and Trochlear NerveMidbrain Level of the Inferior ColliclusMidbrain Level of the Superior ColliculusMidbrain Level of the Red NucleusMidbrain-Diencephalon TransitionReview QuestionsMRI CorrelationPatient Puzzle4.1. Al Fresco is seeing double

Lab 5. Cerebral Hemispheres & CerebellumLesion Lessons5.1. Manny Festo5.2. Phil Abuster

Cerebral HemisphereFrontal LobeParietal LobeTemporal LobeInsulaOccipital LobeMedial Aspect of the Half BrainBroadmann NomenclatureCerebellumCerebellar PedunclesCase breakLiz Tureen – Drops and sways

Study Questions – Cerebral CortexStudy Questions – CerebellumMRI ReviewPatient PuzzleSam Anella is a clumsy guy

Detailed Contents (cont’d)Lab 6. Diencephalon & Basal GangliaLesion Lessons6.1. Lou Zur6.2 Jean Poole6.3. Ann Jyna

Midbrain-Diencephalon TransitionCase BreakBilly Club – Headache and falling

Caudal ThalamusLevel of the Centromedian NucleusCaudal Mid-Thalamic LevelMid-Thalamic LevelCase BreakAustin Tayshis – Right-sided numbness

Level of the Lenticular FasciculusLevel of the Ventral Anterior and Anterior Thalamic NucleiRostral Thalamic LevelBasal Ganglia and Ventral StriatumSeptum PellucidumGenu and Rostrum of Corpus CallosumReview questionsMRI CorrelationPatient Puzzle6.1. Anna Conda bumped her head

Lab 7. Limbic System & VentriclesLesion lessons7.1. Moe Bedder7.2 Happy Teecher

Rhinencephalon and Ring of Limbic CortexCoronal (Frontal) Gross Brain SectionsCoronal MRI (T2) SeriesHorizontal (Axial) SectionsHorizontal (Axial) MRI (T1) SeriesVentriclesReview QuestionsPatient Puzzle7.1. Ray Gunn, a real pain in the neck

Additional Exercises