Introduction to

Nervous System
Dennis Ivan U. Bravo, MD

Slide courtesy of Dr. Alvin Vibar

 Objectives:

Define the boundaries of the major anatomical

levels

Identify the major anatomical structures contained

in each level
 Topic Outline
Part 1 Part 2 Part 3

Anatomical Anatomical Cases for

division of level of lesion of localisation
nervous system nervous system

Basic Classification of
neuroanatomy lesion

Principle in
localisation
 Case
A 58 year-old man was referred to you because of
recent onset of

1. Left hemiparesis

2. Left-sided loss of proprioception

3. Right-sided tongue deviation

Where is the LOCATION of the lesion?

 Part 1
Basic Neuroanatomy
Divisions of the Nervous
System

ANATOMICAL

FUNCTIONAL
Divisions of the Nervous
System

ANATOMICAL

CNS PNS
 Divisions of the Nervous
System

ANATOMICAL

CNS PNS

Brain Spinal cord

 Divisions of the Nervous
System

ANATOMICAL

CNS PNS

Brain Spinal cord Nerves Plexus Ganglia

Divisions of the Nervous
System

ANATOMICAL

FUNCTIONAL
 Divisions of the Nervous
System
FUNCTIONAL

CNS PNS

Motor Sensory

Somatic Visceral
Somatic NS ANS
Sensory Sensory
Sympathetic

Para
 Cerebrum
Associated with higher brain
function such as thought and
action.

Divided into four "lobes":

frontal lobe

parietal lobe

occipital lobe

temporal lobe.
Cerebrum
 Blood supply of cerebrum
2 Middle cerebral artery Anterior cerebral artery 1
v

Posterior cerebral artery 3

Blood supply of cerebrum
Basal nuclei
 Basal nuclei

Caudate

Putamen

Globus pallidus

Claustrum
 Diencephaon

Thalamus (dorsal thalamus)

Hypothalamus
Epithalamus
Subthalamus (ventral thalamus)
 Thalamus
"Inner chamber"
Midline symmetrical between cortex and
midbrain

Functions:
Relay sensory and motor signals to cerebral
cortex (information switchboard)

Regulation of consciousness, sleep, and

alertness
 Hypothalamus

Responsible for certain metabolic processes and

other activities of the autonomic nervous system.

Synthesizes and secretes certain neurohormones

(hypothalamic-releasing hormones) stimulate or
inhibit the secretion of pituitary hormones.

Controls body temperature, hunger, thirst, fatigue,

sleep, and circadian cycles.
 Brainstem
Structure inferior to and adjoining
diencephalon and structurally
continuous with the spinal cord.

Medulla oblongata
(myelencephalon), pons (part of
metencephalon), and midbrain
(mesencephalon)

Main motor and sensory innervation

to the face and neck via the cranial
nerves
Brainstem
 III
IV

VII
VI
VIII
IX
X
XI XII
 Spinal cord
The spinal cord is
located in the
vertebral foramen and
is made up of 31
segments:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
 Spinal cord
Where does the
CONUS
MEDULLARIS
end?

It occurs near
lumbar vertebral
levels 1 (L1) and
2 (L2).
 Spinal cord
Where does the
CONUS conus medullaris

MEDULLARIS
end?

It occurs near
lumbar vertebral
levels 1 (L1) and
2 (L2). dural sac
Spinal
cord
injury
Spinal
cord
injury
 Part 2
Introduction to Localization
of Nervous System Lesion
 Diagnosis of Neurologic
Disorders
Basic approach to the solution of problems Three
questions MUST be ANSWERED?

1. Is there a lesion involving the Nervous system?

2. Where is the lesion located?

3. What is the histopatholgic nature of the lesion?

 Anatomical Levels of
Nervous System
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
1 Supratentorial

Above tentorium cerebelli

Cerebrum

Basal ganglia

Thalamus

Hypothalamus

CNs I and II
1 Supratentorial
 Guide for Localisation
CEREBRUM has very SPECIFIC segmental
functions language, cognition, memory,
personality and vision

A cerebral hemisphere lesion results in

CONTRALATERAL body (motor, sensory or both)
dysfunction because of interruption of
intersegmental pathways (Descending motor and
Ascending sensory pathways)
Guide for Localisation
 Guide for Localisation
CEREBRUM has very SPECIFIC segmental
functions language, cognition, memory,
personality and vision

A cerebral hemisphere lesion results in

CONTRALATERAL body (motor, sensory or both)
dysfunction because of interruption of
intersegmental pathways (Descending motor and
Ascending sensory pathways)
Lesion

Brainstem

Contralateral
paralysis
Lesion

Brainstem

Contralateral
sensory loss
 Anatomical Levels of
Nervous System
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
2 Infratentorial

Below tentorium cerebelli

Above foramen magnum

Cerebellum

Brainstem (Midbrain, Pons

and Medulla Oblangata)

CNs III to XII

 Guide for Localisation
A lesion of the BRAINSTEM may result in segmental dysfunction
at a particular level (ex. Cranial nerve lesion) but it may also
interfere with intersegmental function (ascending sensory and
descending motor pathways) below the level of the lesion
 Guide for Localisation
CRANIAL NERVE LESIONS result in IPSILATERAL
segmental dysfunction

Entire half of face

is paralysed
indicating Facial nerve/
nuclei lesion
 Guide for Localisation

Cerebellum:

Dysmetria, dysdiadochokinesia, ataxia, intention

tremor, dysarthria with "scanning" speech,
disturbance of equilibrium, wide based gait,
nystagmus, dysmetria on heel-to-shin.
 Anatomical Levels of
Nervous System
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
3 Spinal

Located below foramen

magnum

Contained within the

vertebral column

Spinal cord, spinal nerves

within the vertebral column
3 Spinal
3 Spinal
 Guide for Localisation
SPINAL CORD LESIONS

CERVICAL segments affect ARM function

LUMBAR LEG function

SACRAL BLADDER, BOWEL and SEXUAL functions

A lesion of the Spinal cord may result in segmental

dysfunction at a particular level, but it also interfere with
intersegmental functions (ascending sensory or
descending motor pathways) below the level of the lesion
 Anatomical Levels of
Nervous System
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
4 Peripheral

Located outside the skull

and vertebral column

Include CNs and Spinal

nerves and their peripheral
branches
4 Peripheral
 Guide for Localisation

PERIPHERAL lesions cause an IPSILATERAL

segmental deficit (usually sensory or motor or both)

Local (mononeuropathy): findings along a

particular nerve distribution

Diffuse (polyneuropathy)- "glove and stocking"

distribution
Mononeuropathy
 Anatomical Levels of
Nervous System
1 Supratentorial

2 Infratentorial

3 Spinal

4 Peripheral
Characterising Lesions of Nervous
System
A Topography
B Morphology
C Development of symptoms
D Evolution of symptoms
E Etiology
A Topography

Anatomical location of pathologic process and a

judgment as to whether the abnormality is:

1. Focal strictly confined to a single circumscribed

anatomical area

2. Diffuse distributed over wide areas; may involve

only a single level or it may be distributed over
multiple levels; bilateral
B Morphology
Gross and histologic appearance of the abnormal
area and a judgment whether the pathologic
process is:

1. Non-mass altering cellular function in the area of

lesion but is not significantly interfering with
neighboring functions; NOT compressing,
destroying or damaging nearby structures

2. Mass is of sufficient size and volume to interfere

with neighboring cell functions
C Development of symptoms

1.Acute within minutes

2.Subacute within days
3.Chronic within weeks, months
or years
D Evolution of symptoms
1. Transient when symptoms have resolved
completely after onset

2. Improving when symptoms have decreased from

their maximum but have not completely resolved

3. Progressive when symptoms continue to

increase in severity; addition of new symptoms

4. Stationary when symptoms remain unchanged

after reaching maximum severity
E Etiology

1. Degenerative 5. Toxic
2. Neoplastic metabolic

3. Vascular 6. Traumatic

4. Inflammatory 7. Immunologic
E Etiology
Neoplastic chronic, progressive, focal
ex. Tumors

Degenerative chronic, progressive,

diffuse
ex. Alzheimers ; Parkinsons
 Part 3
Cases for Localisation
 Case 1

A 25 y/o male fell to the ground hitting his lower back

against the gutter when his motorbike skidded on the
wet road. When he tried to get up, he was unable to
move his right leg. He was brought to the hospital
and upon examination, he could NOT FEEL the
VIBRATION of the tuning fork on his right foot.
 Case 1
1. Identify the level of the lesion?

2. Within the level you have selected, the responsible lesion is

most likely:

a. Focal on the Right side

b. Focal on the Left side

c. Focal but involving midline

d. Non- focal and diffusely located

 Case 1
3. The principal pathologic lesion responsible for the lesion is
most likely:

a. Mass lesion

b. Non mass lesion

4. The cause of responsible lesion is most likely:

a. Vascular c. Degenerative

b. Neoplastic d. Traumatic
 Case 2

A 19 y/o was involved in an automobile accident.

Two weeks later, he gradually developed
progressive headaches and personality changes.
His family also noted that his right face seemed to
droop and he had mild weakness of his arm and
leg.

Where is the LOCATION of the lesion?

Supratentorial, focal on left

 Case 3

A 24 y/o woman was involved in an automobile

accident. When examined, she had complete loss
of sensation from the level of the arms downward.
She could not move her hands or legs. She was
also incontinent.

Where is the LOCATION of the lesion?

Spinal, focal, midline

 Case 4

A 46 y/o man noted numbness and pain in the first

three digits of his right hand with use. He also had
weakness of his right thumb.

Where is the LOCATION of the lesion?

Peripheral, focal, right

 Case 4

A 21 y/o woman developed a diffuse body rash,

fever and headache. One day later, she began to
complain of neck and back pain especially with
neck flexion. After 2 days, she developed reduced
level of consciousness as well as continuing to
have fever.

Where is the LOCATION of the lesion?

Multiple levels, diffuse

 Case 5
A 58 year-old man was referred to you because of
recent onset of

1. Left hemiparesis

2. Left-sided loss of proprioception

3. Right-sided tongue deviation

Where is the LOCATION of the lesion?

The End