Samar Deb Easy and Interesting A

Introduction to Human Neuroanatomy
Human Neuroanatomy is the division of Human Anat- omy which deals with of Human Nervous System. The
Nervous System is defined as the “Master of all Systems” or the “Master System” of the body, because it controls or
regulates all bodily functions performed by other systems of the body, for example locomotor system,
gastrointestinal system, respiratory system.
PRINCIPLES OF FUNCTIONS OF NERVOUS SYSTEM (FIG. 1.1)
When nervous system exerts its action over the other systems of body, most simplified form of its action is
manifested basically as—
1. Contraction of muscles.
2. Secretion of exocrine glands.

It may be noted here that the secretion of endocrine
glands is mostly under the hormonal control.

The muscles, whose contraction is regulated by nervous system, may be voluntary (striated or skeletal) or
involuntary (nonstriated or smooth). Contraction of the voluntary muscles results in movement of a joint. The
involuntary muscles may be in the wall or in the substance of viscera, which are specifically called ‘Visceral muscle’,
e.g. in the wall of the gastrointestinal tract, or tracheobronchial tree or in the substance of any solid viscera. Again,
the involuntary muscle may be in the wall of the cardiovascular channel, e.g. in the wall of the heart (myocardium)
or in the wall of blood vessel (tunica media). It may be also in the dermis of
the skin named the Arrectores pili.
The exocrine glands influenced by the activity of the nervous system may be single and solitary like any salivary
gland or the lacrimal gland, or it may be multiple and minute, like the mucous glands of the wall of GI tract, or
respiratory tract.
So result of functions of nervous system may be summarized as follows—

1. Contractionofvoluntarymuscle(s):Resulting
movement of a joint. It may result movement of
some organs, like tongue, eyeball.

2. Contraction of involuntary muscle(s) present in:
a) Viscera: It is called visceral muscle.

b) Wall of the cardiovascular system: Myocardium of heart or smooth muscle in the wall of the
blood vessels.
c) Dermis of skin called Arrectores pili: It is
attached to the root of hair follicle. 3. Secretion of exocrine glands like:
a) Salivary glands or lacrimal gland: Large and solitary.

b) Mucous secreting glands: In the wall of GI tract or respiratory tract–many and minute.
But it is to be noticed that the functions of nervous system do not mean only the effects as mentioned above, but, in
gist it also performs the followings: (Fig. 1.1).
1. It receives and carries different information from its periphery to center, which are related to change in external
and/or internal environment.
2. It perceives or acknowledges the informations at its center.
3. It analyzes, integrates and coordinates the informations or inputs.
1
Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)
4. It commands for some effect after reception and, integration or coordination of informations.
5. It stores the informations for the memory, intelligence, learning and emotion of an individual.
SUBDIVISIONS OF NERVOUS SYSTEM (FIGS 1.2 AND 1.3)
A. Topographical Subdivision
1. Central: Part situated in the central axis of the body, known as Central Nervous System. These are Brain and
Spinal cord. Brain is the proximal expanded part situated inside the cranial cavity. Distal, narrow, tubular and
elongated part is the spinal cord which is lodged in the upper two-third of the vertebral canal. Grossly brain is
divided into three parts–Forebrain, Midbrain and Hindbrain. Spinal cord is divided into 31 segments, which are
classified regionally as Cervical-8, Thoracic-12,
Lumbar-5,Sacral-5 and Coccygeal-1.

2. Peripheral: This is known as Peripheral Nervous
System. This is peripheral outflow or peripheral extensions from Central Nervous System in the form of
peripheral nerves. The peripheral nerves are divided into two groups as–
a) Proximal (Cranial): Cranial nerves, 12 pairs arising as outflow from brain.
b) Distal (Caudal): Spinal nerves, 31 pairs, each pair arising from each segment of spinal cord.
Central Nervous System may be compared as the Director of an office, and Peripheral Nervous System as the
Field Staff. Like the Director, Central Nervous System gathers information from and gives direction to the
Peripheral Nervous System, whose duty is to convey information and also to carry out the order from its Director,
i.e. Central Nervous System, for action.
Stored for
• Memory
• Intelligence • Learning
• Emotions
Sensory information • Received
and
• Perceived
• Analyzed • Integrated and
• Coordinated
Command or directions given
Sensory information
Carried from undermentioned receptors
Due to change in external/internal environment
Motor effect Produced in the
form of
Exteroceptor • Touch
• Pressure • Pain
• Temperature
Proprioceptors
• Sensation from muscles and tendons • Sensation from joints
Inputs
Fig. 1.1 Diagrammatic representation of principles of function of nervous system
• Contraction of
• Contraction of involuntary muscles
voluntary muscles • Secretion of exocrine glands
Outputs
3
Midbrain Pons
Medulla oblongata
Cerebrum
Cerebellum
Brain
Brain
Brainstem
Spinal cord
Spinal nerves
Lower spinal nerve forming cauda equina
Filum terminale
i. Contractions of voluntary muscles to move the joints or to move some organs like tongue, eyeball.
ii. Contractions of involuntary muscles like—
1. a) Visceral muscles.
2. b) Smooth muscles in the wall of cardiovascular
channel.
3. c) Smooth muscles in the root of hair follicle of
skin, known as Arrectores pili.
iii. Secretions of exocrine glands which may be either
single, large, solitary, e.g. Salivary glands or tiny innumerable, for example–mucous glands of gastrointestinal
and respiratory tract.
Out of these different functions—The contractions
of voluntary muscles is controlled or regulated as per one’s own desire and is known as voluntary function,
whereas others are not under one’s own control, called involuntary function.
Fundamental difference between the Cranial and Spinal nerves:

All the spinal nerves contain sensory (incoming) fibers carrying impulse (information) towards the central nervous
system and motor fibers (outgoing) carrying impulse (directions) away from the central nervous system to the
effector organ, that is why all the spinal nerves are mixed nerves. But some cranial nerves are mixed like spinal
nerves and some are either purely motor or purely sensory.
B. Functional Subdivision
It is already understood that nervous system controls various bodily functions. The simplified form of functions
controlled by nervous system are the followings:
Fig. 1.2 Central nervous system
4
A cranial nerve among 12 pairs may be
BRAIN
SPINAL
C• O
R
D
or
Motor*
Sensory* Mixed*
Each of the 31 pairs of spinal nerves

is
mixed*
• Motor fibers of cranial nerves carry out command or effects
• Sensory fibers of cranial nerve carry sensory information
• Sensory fibers of cranial nerve carry sensory information
Motor fibers of spinal nerve
carry out command or effects
Central nervous system

• Acts as director
• Receives information • Analyze it
• Sends command
Peripheral nervous system
• Acts as field staff

• Carries informations inwards
• Carries out directions or orders
outwards
With the help of this background knowledge, it is to be noted that — functionally the nervous system is classified
as — Somatic and Autonomic (Figs 1.4A and B).
A. Somatic Nervous System: It is that division of nervous system which controls or regulates the voluntary
functions, i.e. functions which can be performed as well as controlled as per one’s own desire. It is contraction of
voluntary or skeletal muscles.
B. Autonomic Nervous System: It is that division of nervous system which controls or regulates involuntary
functions, e.g. functions which can neither be preformed nor can be regulated as per one’s own desire. These are
contraction of involuntary or smooth muscles and secretion of exocrine glands.
Two parallel components of autonomic nervous system:
They are called sympathetic and parasympathetic nervous system. These two systems have anta-gonistic actions
on the “same” target organ, e.g. Parasympathetic nervous system contracts the muscles in wall of hollow viscera
like GI tract (peristaltic movements), but relaxes the sphincters; whereas the sympathetic nervous system causes
the opposite action on the same target organ. Again in some cases either of them has the influence, e.g. mucous
glands of respiratory or alimentary tract are under control of parasympathetic nervous system, whereas secretion
of sweat glands are controlled by sympathetic system.
Fig. 1.3 Central and peripheral part of nervous system
5
Somatic peripheral outflow
Exteroceptive
sensory fibers
Pain – Temperature Pressure – Touch
Proprioceptive sensory fibers
from muscles and tendons
Motor fibers
To the effector organ, i.e. the voluntary muscles
Fig. 1.4A Schematic representation of somatic nervous system (centers and outflow)
Sensory fibers
From all viscera
Sympathetic motor
G
C Para- sympathetic
motor
1.Motor fibers to involuntary
muscles
2. Secretomotor fibers to
exocrine glands
Fig. 1.4B Schematic representation of autonomic nervous system (centers and outflow) [G – Autonomic ganglia – Synaptic junction between
preganglionic and postganglionic neurons]
Central nervous system brain and spinal cord
Somatic nervous system Centers:
Brain
and spinal cord [31 segments]
Central nervous system brain and spinal cord
Autonomic nervous system Centers:
Sympathetic
T1 – L2 (L3) segments of spinal cord
Parasympathetic
• Nuclei of 3rd, 7th, 9th, 10th
cranial nerves
• S2–4 segments of spinal cord
Autonomic peripheral outflow

CENTERS OF NERVOUS SYSTEM
Center for somatic nervous system extend throughout the whole length of brain and spinal cord, lying in central
axis of body.
That’s why it is called Central nervous system.
Centers for sympathetic and parasympathetic components of autonomic nervous system are situated in some of
the levels of brain and spinal cord.
1. a) Sympathetic center is located in first to twelfth thoracic and first and second lumbar (T 1–L2) segments
of spinal cord.
2. b) Center of parasympathetic system situated partly in brain in the form of nuclei of some cranial nerves
(3rd, 7th, 9th, 10th). Again part of its center is occupied in 2nd, 3rd, 4th sacral segments of spinal cord (S 2–
4). These centers for sympathetic and parasympathetic components of autonomic nervous system are of
course, finally controlled by posterior and anterior parts of hypothalamus of brain respectively.
COMPOSITION OF NERVOUS SYSTEM
Nervous system is composed of very delicate and sensitive tissue known as nervous tissue. In general, it is known
that a tissue is composed of cells and intercellular substance. The intercellular substance may be little or
minimum as in epithelial tissue, or
may be maximum as in connective tissue. But everywhere it is noncellular.
The structural and functional units of nervous system are cells, known as Neuron. It is noteworthy that in the
nervous system, the intercellular substance is not noncellular, rather made up of cells called Neuroglia. The
neuroglia, proportionately more in number and primarily acting as supporting element occupying the interstitial
spaces between neurons.
NEURONS
The structural as well as functional units of nervous system is Neuron.

It has two special properties—
1. Irritability— It is the power of a cell(neuron) by
which it is able to respond or react to change in the environment (known as stimulus),which may be external or
internal (outside or inside the body).
2. Conductivity— It is the power of a cell (neuron) by which the excited state (known as impulse) is propagated
from the site of stimulus for a distance to get the desired effect through ‘hand to hand’ contact of thread–like
protoplasmic processes of chain of neurons.
Structure of a Typical Neuron (Fig. 1.5)
A typical neuron is composed of—

i. Cell body: It is known as Soma or Perikaryon and ii. Processes: Thread- like protoplasmic prolongations.
Dendrites
Axon–hillock
Nissl bodies
Nucleus
Neurofibrils
Fig. 1.5 A typical neuron
Axon
Axon terminal
Processes
The processes are of two types known as Dendrites and Axons. Dendrites are the processes through which impulse
is transmitted towards the cell body. Axons transmit impulse away from the cell body. So, when an impulse passes
through a chain of neurons, it passes from axon of one neuron to the dendrite of the next neuron of the chain (Fig.
1.6).
Number of processes in a neuron— A neuron always posseses at least one process, which is axon, the number of
which is always single. A neuron may or may not have the Dendrites. If it is present, it may be one or multiple
(Fig. 1.7).
Cell body
It is the main expanded mass of cell with a centrally placed nucleus containing a prominent nucleolus. Cytoplasm
has following unique characteristics:
a) Nissl bodies (Nissl granules/Nissl substance):
These are nothing but large aggregations of pro- minently stained rough endoplasmic reticulum. These are
concerned with synthesis of enzymes which are required for productions of chemical substances known as
neurotransmitters. Nerve impulse is transmitted over the junction of
Dendrites
adjacent neurons (synapse) through those neurotransmitters. Nissl substances are absent not only in the axons
but also in the base of axons known as axon-hillock.
b) Neurofibrils: These are ultramicroscopic thread–like or fibrillar structures homologous to micro- filaments of
other cells. Neurofibrils are concerned with maintenance of architecture of neuron and acts as a storehouse of
protein called Tubulin.
Dendrites: They are fibrillar protoplasmic extensions of neuron with the following characteristics — 1. These
are the processes through which impulse
travels towards the cell body.

2. Narrower in width.
3. Highly branched.
4. Branching of the dendrites are short known as
“Dendrite Tree”.
5. Terminal ends of dendrite tree are known as
“Dendrite Spines”.
6. Dendrites may be absent, if present it may be
single or multiple.
Axon: It is the fibrillar protoplasmic extension of neuron with following characteristics—
1. These are the processes through which impulse
travels away from the cell body.
Axons
Axodendritic Junction (Synapse)
Target organ (Skeletal muscle)
Fig. 1.6 Chain of neurons transmitting impulse (excited state of neurons) to target organ (e.g. skeletal muscle)
8
d
d
ddD Figs 1.7 A to D Neurons showing variable number of processes
A – One process – Axon, B – Two processes – One axon and one dendrite,
C – Three Processes–One axon and two dendrites, D – Many processes – One axon and many dendrites
2. Basal end is conical–known as “axon-hillock”.

3. Wider in breadth.
4. It has no terminal branching, but from the middle
of the axon branching at right-angle may takes
place known as “Collaterals”.
5. Terminalendisexpandedknownas“Telodendria”
showing knob-like or button-like endings called
axon terminals or Terminal buttons.
6. Number of axon in neuron is always constantly
one.
It is important to notice that dendrites and axons
cannot be differentiated by their relative length. Some neurons may have long axon. Again some may have long
dendrite. Fibers of median or ulnar nerve supplying small muscles of hand are example of long axon. Wher- eas
fibers of saphenous nerve carrying sensation from skin of foot are the example of very long dendrite. In both the
cases cell bodies are located in or very close to spinal cord.
Neuronal (Axonal) Transport
Chemical substances synthesized in the neuronal cell body are required to be transported through the axon at its
distal end. This is known as “Orthograde
transport” (Fig. 1.8A). These chemical substances are either concerned with the nerve conduction, when these pass
through the interneuronal junction (synapse) or these may be concerned with desired function of nerve impulse
when these reach the effector organ. Sometimes chemical substances (may be neurotoxins) liberated at the tissue
level, absorbed by axon terminals, are carried back towards the cell body of the neuron. This is known as
“Retrograde transport” (Fig. 1.8B).
Classification of Neurons
1. According to number of processes (polarity) (Figs 1.9A and B)
It is to be noted that, at one initial phase of development, neurons used to have no process. How- ever, this phase
is followed by gradual appearance of number of processes which will classify the neurons as follows:
a. Unipolar neurons
These are developmentally primitive variety of neurons with single process which is the axon. It is devoid of any
dendrites.
Axon
Toxin
Dendrite
Fig. 1.8A Orthograde transport

Neurotransmitter passing from cell body of neuron → to axon → to neuronal junction (Synapse) → to dendrite of next neuron
Neurotransmitter
Cell body Axon
Tissue
Unipolar
Fig. 1.8B Retrograde transport, – toxins liberated in tissue pass in opposite direction through axon toward cell body
Flask-shaped Pyramidal (cerebrum) Polygonal (spinal cord) (cerebellum)
Bipolar Pseudounipolar Multipolar neurons
Fig. 1.9A Types of neurons Fig. 1.9B Types of neurons
b. Bipolar neurons
These are the fusiform or spindle-shaped neurons with one dendrite and one axon arising from opposite poles.
10
These are specialized neurons found in the pathways of special senses, e.g. Retina (visual pathway), nasal
epithelium (olfactory pathway) and in the vestibulocochlear nerve (auditory pathway for hearing and
equilibrium).
c. Pseudounipolar neurons
These are neurons with round or oval shape with a common short stem of process dividing into peripheral
(dendrite) and central (axon) limbs. These neurons are called pseudounipolar because apparently they seem to
have two poles. Classical example of these are the dorsal root ganglion cells of spinal nerve lying just outside and
close to the spinal cord carrying sensory impulse from periphery towards the spinal cord.
d. Multipolar neurons
These neurons present single axon with multiple dendrites. Their shape will vary from triangular or pyramidal
to polygonal depending upon numbers
Brain
Upper motor neuron (Golgi type I) with long axon

of dendrites so also the polarity. For example, the neurons of motor area of cerebral cortex are pyramidal or
triangular whereas the motor neurons of spinal cord are polygonal and neurons of cerebellum are flask-shaped.
2. According to length of axon (Figs 1.10A and B)
a. Golgi type I (Fig. 1.10A)
Axons of these neurons are long in comparison to their multiple short dendrites, viz. ‘Pyramidal Neurons’ of
motor area of cerebral cortex, ‘Anterior horn cells’ of spinal cord , ‘Purkinje cells’ of cerebellum.
Axons of pyramidal cells of cerebral cortex form long descending tracts passing through the spinal cord. Axons of
anterior horn cells of spinal cord form long peripheral nerves supplying voluntary muscles. Purkinje cells axons
form efferent fibers from cerebellar cortex to relay in cerebellar nuclei situated in its white matter.
b. Golgi type II (Fig. 1.10B)
Axons of these neurons are short, similar to the length of the dendrites. Classical example of these
Interneurons of spinal cord
Stellate (star-shaped) neuron of

cerebellum (Golgi type II with short axon) B
Long axon
Spinal cord
Lower motor neuron (Golgi type I) with long axon
Figs 1.10A and B A. Golgi type I neuron (with long axon), B. Golgi type II neuron (with short axon)
11
Cerebrum (Brain)
Thalamus (Brain)
Tertiary sensory neurons
Secondary sensory neurons
Primary sensory neurons (Posterior root ganglion cell)
Peripheral process from sensory end organ
Fig. 1.11 Types of sensory neurons

Spinal cord
neurons are stellate cells of cerebellar cortex, which have short axon and multiple short dendrites giving a star-
shaped appearance. It forms synaptic connection with too many neurons.
It is important to note that some of the neurons may have single long dendrite. For example, fibers present in the
sensory nerves carrying sensory impulse from the periphery are the long dendrites of sensory neurons present
in the posterior root ganglia of spinal nerve.
3. According to function of neuron
a. Sensory neuron (Fig. 1.11)
These neurons carry sensory impulse from a receptor (sensory end organ) through the dendrite towards the
center of nervous system finally through axon. From the sensory end organ or receptor situated at the periphery
of the body, the sensory nerve impulse needs to pass through a chain of neurons as the relay system to reach the
center of nervous system. The participating neurons in this “chain” are classified as primary, secondary and
tertiary neurons (Fig. 1.11).
Primary sensory (First order) neurons: They start from the receptor or sensory end organ to enter
the central nervous system. Their cell bodies are situated outside the central nervous system. Only exception is
the cell group of mesencephalic nucleus of trigeminal nerve, whose cell bodies lie inside central nervous system.
Secondary sensory (Second order) neu-rons: They are situated at the level of spinal cord which receive
impulse from 1st order of neurons.
Tertiary sensory (Third order) neurons: They relay the sensation from the secondary neurons to the final
target, i.e. cerebral cortex. First group of these neurons are situated in the thalamus. The second or final group is
situated in the sensory area of cerebral cortex.
b. Motor neuron (Fig. 1.10A)
These neurons carry outgoing motor impulse from central nervous system to the peripherally situated effector
organs which are either muscles or glands.
Types of motor neuron:
In somatic nervous system—Upper motor neuron and Lower motor neuron.
i. Upper motor neuron: These motor neurons are situated in motor areas of brain above the level
12
of spinal cord and brainstem (Midbrain, Pons
and Medulla).
ii. Lower motor neuron: These motor neurons are
situated in spinal cord.
4. Classification of neurons in relation to neuronal junction(synapse) – (Fig. 1.12)
Functions of a neuron depends upon the transmission of impulse through a chain of successive neurons. The
junction of neuronal chain is known as Synapse or Ganglion (pl. Ganglia).When related to a particular synapse,
the neurons are classified as—
a) Presynaptic (Preganglionic) neuron: Proximal to a synapse
b) Postsynaptic (Postganglionic) neuron: Distal to the synapse.
In somatic nervous system, both the pre and postganglionic neurons are situated inside the central nervous
system except the first order of sensory neuron which lies outside of central nervous system, e.g. Posterior root
ganglia cells of spinal nerve. But in autonomic nervous system the preganglionic neuron is situated inside the
central nervous system and postganglionic neuron is situated outside the central nervous system.
NEURONAL JUNCTION (SYNAPSE) (FIG. 1.12)
It has already been noticed that, when a neuron is stimulated due to change in the environment,
Presynaptic neuron
external or internal, impulse or action potential is generated.But activity of nervous system depends on
transmission or conduction of nerve impulse or action potential through a chain of neurons. In the chain neurons
are approximated or apposed closely to each other. This site of apposition or contact between two neurons is
known as synapse. Though, it is simple to understand, but in 1891, neuronal theory of Waldeyer first established
that at the synapse or neuronal junction of two successive neurons are contiguous, but not continuous to each
other. It was then detected that some chemical substances called “Neurotransmitters” jump across the synaptic
junction to carry the nerve impulse or action potential of the neuronal chain.
Fundamental points to remember regarding the synapse:

1. Twosuccessiveneuronsarecontiguousinthesyn- apse but not continuous.
2. Chemical substance released in the proximal neuron (presynaptic neuron) passes to distal or postsynaptic
neuron, through which impulse is transmitted.
3. Impulse under physiological condition travels through the synapse in one direction only.
4. Single end of an axon, known as axon terminal will form synapse with single dendritic spine.
5. Multiple end button of one presynaptic neuron may form synapse with dendrites of multiple neurons or
multiple dendrites of single neuron.
Postsynaptic neuron
A. Axodendritic synapse
B. Axosomatic synapse
Fig. 1.12 Common varities of synapses
C. Axoaxonic synapse
13
Mitochondria
Presynaptic vesicle containing Neurotransmitter
Exocytosis Receptor
Synaptic web
Types of Synapse (Fig. 1.12)
So far, it is already understood that axon of presynaptic neuron forms synapse with the dendrons of
postsynaptic neuron. But truly speaking axon of a neuron may form synapse with any component of another
neuron, e.g. dendrite, cell body, even the axon also. So, the synapses are grossly classified as–
1. Axodendritic:Synapsebetweenaxonofpresynaptic and dendron of postsynaptic neuron.
2. Axosomatic: Synapse between axon of presynaptic and cell body or soma of postsynaptic neuron.
3. Axoaxonic: It is considered as a lateral synapse. In this type, axon of lateral neuron form synaptic
connection with axon of another neuron which is lying in the regular neuronal chain.
Besides the above mentioned commoner types of
synapses, other types are somatodendritic, somato- somatic and dendrodendritic.
Structure of a typical axodendritic synapse (Fig. 1.13)
A typical axodendritic synapse is composed of following three parts. These are—
i. Presynaptic membrane of axon of proximal neuron. ii. Synaptic cleft between axon and dendrite.
iii. Postsynaptic membrane of dendrite of distal neuron.
Presynaptic Membrane
Thickened cell membrane of the axon terminal at the site of synapse is called presynaptic membrane.
Neurofibrils
Axoplasm Axon terminal
Presynaptic membrane Synaptic cleft containing
fluid rich in polysaccharide
Postsynaptic membrane
Beneath this membrane the axoplasm shows some specialized features. The cytoplasm is condensed with
presence of number of mitochondria. It also contains many membrane bound vesicles which contain chemical
substances known as neurotransmitter. The vesicles are very tiny, 40–50 nm (nanometer) in diameter. One mm
(micrometer) is 1/1000 of a millimeter and one nm (nanometer) is 1/1000 of a mm (micrometer). During
transmission of nerve impulse, neurotransmitter is released from presynaptic vesicles into synaptic cleft by
exocytosis to stimulate postsynaptic membrane of the distal neuron.
Synaptic Cleft
It is the gap measuring 20–30 nm between pre and postsynaptic membranes. It contains interstitial fluid rich in
polysaccharides. Through the process of exocytosis neurotransmitters are released across the presynaptic
membrane into synaptic cleft.
Postsynaptic Membrane
This is the thickened plasma membrane of dendrite spine at the site of synapse. This membrane shows
specialization known as receptors which are to uptake neurotransmitters passing across the synaptic cleft. The
dense cytoplasm beneath postsynaptic membrane is segmented and known as synaptic web which contains a
network of filame-ntous structure.
Fig. 1.13 Structure of a typical synapse

Impulse Transmitted Across the Synapse
Nerve impulse transmitted through presynaptic neuron causes release of neurotransmitter from presynaptic
vesicles. Neurotransmitter passing across the synaptic cleft act as chemical impulse to stimulate receptors of
postsynaptics membrane. Chemical impulse reaching synaptic web beneath postsynaptic membrane is again
converted into nerve impulse to stimulate postsynaptic neuron.
14 Neurotransmitters
There are varieties of chemical substances acting as neurotransmitter. Mostly found neurotransmitters are
Acetylcholine and Norepinephrine. Acetylcholine is liberated as neurotransmitter in many synapses of central
and peripheral nervous system including those of parasympathetic nervous system. Norepinephrine is released
in most of the synapses of sympathetic nervous system. Glycine is the neurotransmitter discharged in the
synapses of spinal cord. Dopamine is the transmitter found in basal ganglia and substantia nigra. Serotonin and
Gumma-amino-butyric acid (GABA) are other examples of commonly known neurotransmitters.
Deactivation or cessation of action of neurotransmitters
After desired effect, influence of neurotransmitters is withdrawn in either of two different ways. In case of
Acetylcholine, it is broken down by the enzyme Acetylcholinesterase at synaptic cleft. But in case of transmitters
like norepinephrine, its effect is restricted by its reuptake back through presynaptic membrane.
Neuromodulators
These are the chemical substances which enhance, prolong, restrict or inhibit the effect of the neurotransmitter
on postsynaptic membrane. They are stored in separate presynaptic vesicles.
NEUROGLIA
Broadly, the neuroglia can be defined as group of cells of nervous system which are other than the neurons. So
the cells of this family do not posses two basic characteristics of neurons, i.e. irritability and conductivity. That is
why none of them can generate and conduct the nerve impulse. Both in central as well as peripheral nervous
system fundamentally they act as intercellular (interneuronal) supportive material. In addition, each type of
neuroglia is characterized by its independent specific function.
Size of neuroglia is much smaller than neurons, but their number is far more proportionately, may be as many as
50 times the number of neurons. When the number of neurons are fixed after birth, the neuroglia can multiply
throughout life. In case of injury or disease of nervous tissue, area of damaged or dead neurons, are occupied by
multiplying neuroglia. This process is known as replacement gliosis.
Types of Neuroglia
In central nervous system

1. Ependymal cell
2. Macroglia – a) Astrocytes b) Oligodendrocytes 3. Microglia.
In peripheral nervous system 1. Schwann cells.

2. Satellite cells.
Ependymal cell (Fig. 1.14A)
These are single-layered cubical or columnar cells lining the cavities (ventricles and central canal) of central
nervous system (brain and spinal cord). They represent the original cells lining the neural tube of embryonic life.
The free surface of the cells present ultramicroscopic finger-like prolongations which are nonmotile in nature.
These are known as stereocilia. Functions:
1. Stereocilia of free surface of ependymal cells increase surface area, so help in absorption of cerebrospinal
fluid circulated in cavity of central nervous system.
2. Specialized area of ependymal lining of ventricles is also concerned with formation of cerebrospinal fluid
(CSF).
Astrocytes
These cells are so-called because they are star-shaped with radiating cytoplasmic processes. Astrocytes are of
following two types.
Protoplasmic astrocytes (Fig. 1.14B)
The radiating processes of these types of astrocytes are thicker containing more amount of cytoplasm inside.
Stereocilia (Nonmotile microvilli)
Fig. 1.14A Ependymal cells

Capillary
Protoplasmic astrocyte found in gray matter
Fig. 1.14B Protoplasmic astrocyte
They are related in relation to cell bodies of neuron (in gray matter of central nervous system). Terminal ends of
the processes present foot-like expansions known as end-feet. These types of astrocytes are intermediate in
position between cell bodies of neuron and blood capillary. End-feet come in contact in one side with neuronal cell
body and in another side with wall of capillary, thus helping in selective transport of substance like nutritive
substance or metabolites from blood capillary to neuron. This media may prevent transport of some unwanted or
toxic materials, for which it is known as ‘blood brain barrier’, some drugs having action on central nervous
system posses the ability to cross this blood brain barrier.
Fibrous astrocytes (Fig. 1.14C )
The cell bodies of these types of astrocytes are smaller with thinner and more branching processes. They are
predominantly distributed inbetween pro-cesses of nerve cells (in white matter of central nervous system).
15
Functions:
1. Astrocytes posses supportive function acting as
packing material of central nervous system.
2. Astrocytes transport nutritive materials from blood capillaries to neurons.
3. It forms the ‘blood brain barrier’.
Oligodendrocytes (Fig. 1.15A)
These are smaller round or spherical cells with lesser number of processes. They are found in white matter of
central nervous system where expanded end of their processes wrap around the length of nerve fibers. This
wrapping (ensheathment) or insulation of nerve fibers is known as Myelination. The myelination prevent the
nerve impulse to be dissociated to the surrounding tissue and thus facilitate the full conduction of impulse
towards the destination.
Functions:
1. Oligodendrocytes primarily provide supportive functions around neurons of central nervous system.
2. They form myelin sheath around nerve fibers (processes of neurons) inside central nervous system.
Neuron
Fibrous astrocytes
Nerve fibers of CNS forming white matter

Fig. 1.14C Fibrous astrocytes
16
Nerve
fiber
Cell body of oligodendrocyte
Process of oligodendrocyte Myelin sheath
Fig. 1.15A Multiple processes of one oligodendrocyte form myelin sheath (for insulation) of many nerve fibers in central nervous system
Microglia (Fig. 1.15B)

Microglia are so-called because they are smaller in size. The cells present finer tortuous processes. Microglia are
identified by following three characters which are related to the letter ‘M’.
1. MicrogliaareMesodermalinoriginwhichdevelops from circulating Monocytes of fetal blood.
2. MicrogliafunctionasMacrophagesofcentralner- vous system to engulf toxic substances, micro- organism

and damaged CNS tissue debris.
3. Forphagocyticfunction,microgliaareMigratoryin nature. Many microglia, acting as scavenger cells are
localized at the site of damaged or degenerated nerve tissue and may fuse together to form a
Multinucleated giant cell of central nervous system.
Function: Microglia, as already stated above, are phagocytic in nature to act as scavenger cells or
macrophages of central nervous system.
Fig. 1.15B Microglia– Macrophage of CNS– Surrounding damaged tissue for scavenging. Migrating in nature– Mesodermal in origin
Schwann cells (Fig. 1.16)
These are the neuroglial cells found in peripheral nervous system, related to peripheral nerve fibers. The cells
are flattened with adequate amount of cytoplasm surrounding nucleus. The surface of the cell is invaginated by
processes of neuron. The nerve fiber, following invagination, undergoes spiral movement to be finally wrapped by
layers of Schwann cells which finally acts as myelin sheath.
Function:ManySchwanncellsinarow,takepart in formation of myelin sheath of peripheral nerves outside

central nervous system.
Schwann cells
Schwann cells
Mesoaxon
Nerve fiber
Nerve fiber
Nerve fiber
Figs 1.16A and B Schwann cells– the glial (supporting) cells of peripheral nervous system
A. A Schwann cell is invaginated by a single nerve fiber to form myelin sheath
B. A Schwann cell is invaginated by many nerve fibers, so attempt for myelin sheath formation fails
Satellite cells (Fig. 1.17)
These are another variety of glial cells related to peripheral nervous system. These cells are related to surface of
cell body of the neurons which are present outside the central nervous system, e.g. neurons of posterior root
ganglia of spinal nerves and neurons of sympathetic ganglia. The satellite cells are flattened in shape and small
in size. A good number of these cells form an encapsulation around the surface of the above mentioned neurons
present outside the central nervous system.
Function: Satellite cells are also known as capsular cells as they form a covering around the cell bodies of
neurons of peripheral nervous system.
Developmental Source of Neuroglial Cells
1. Ependymal cells: These represent the original parent lining cells of primitive neural tube (ectodermal).
2. Macroglia (Astrocytes and oligodendrocytes): from the spongioblasts of mantle zone of neural tube
(ectodermal).
3. Microglia:Fromthecirculatingmonocytesoffetal life (mesodermal).

17
4. Schwann cells and satellite cells: From cells of neural crest (ectodermal).
MYELIN SHEATH (FIGS 1.15A, 1.16 AND 1.18)
A nerve fiber, either in peripheral or in central nervous system carries nerve impulse towards destination. This
impulse must reach the destination to the full extent with full velocity without being dissociated in the
surrounding tissue. For this, the nerve fiber needs insulation (nonconductive coating). This insulation is formed
by formation of sheath around the fiber, known as myelin sheath. In the nervous system, only the supporting
cells are available to form this myelin sheath. In peripheral nervous system, the Schwann cells and in central
nervous system, the oligodendrocytes take part in formation of myelin sheath.
Nerve fiber
Layers of plasma membrane of Schwann cell made up of lipid-protein
Nerve fiber
Capsular (Satellite) cells
Posterior root ganglion cell
Fig. 1.17 Capsular or satellite cells surrounding cell body of posterior root ganglion neuron
Nucleus of Schwann cell
Nerve fiber
Nerve fiber
Nucleus of Schwann cell
Myelin sheath Internode
Node of Ranvier
Fig. 1.18 Myelin sheath of peripheral nerves
So a tumor in nervous system cannot originate from neuron. Tumors formed due to abnormal proliferation or
multiplication of neuroglia and cells of connective tissue of meninges and cells of wall of blood vessels are known as
Glioma, Meningioma and Angioma respectively.
Neuronal Damage or Injury
Injury may affect neuronal cell body and /or processes. Initially it leads to loss of function. But ultimate effect will
depend upon serverity of the injury and duration of action of injurious agents. It is important to note at this stage
that if neuronal death occurs quickly, within a few minutes, no morphological changes are found. But if the neuron
manages to survive for 6–12 hours, morphological changes are characterized by swelling of cell cytoplasm and
nucleus, and displacement of Nissl granules to the periphery. This is followed by recovery of the neuron.
When a nerve cell process (axon) is a cut or injured, it will lead to change in nerve cell which is known as axonal
reaction or axonal degeneration. This change is noticed within 24–48 hours. The change is more rapid if axon is
injured close to cell body. Axonal injury in peripheral nervous system is followed by an attempt for repair in cell
body. In central nervous system, degeneration is not followed by regeneration.
Activities of Neuroglia Following Neuronal Damage
Neurons show some stage of cell death. Initially they are characterized by dark stained cytoplasm with ill- defined
nucleus. But the neurons finally get dissolved passing through a stage of appearance of vacuoles in cytoplasm and
disintegration of cell organelles. By this time microglia, being migratory in nature, rush to the site of lesion to act as
scavenger with their phagocytic activity. Monocytes from the neighboring bloodstream also join with the microglia to
help in scavenging activity. It is now the astrocytes which undergo hyperplasia and hypertrophy to occupy the space
of disintegrated neurons. This procedure is known as replacement gliosis.
Spread of Some Viral Infection Through Neuronal Process
Rabies is a viral disease which causes acute attack on central nervous system. The virus is transmitted through the
bite of rabied dog or some other wild animal. From the site of bite virus spread centrally towards central nervous
system through retrograde direction (retrograde axonal transport) via axoplasm. Therefore, it is clear that onset of
the disease will be quicker if the site of the wound (due to bite) is more
CLINICAL ANATOMY
Tumors of Central Nervous System
A tumor is formed as a result of abnormal cell division (mitosis) of a tissue. It is important to note at this stage that
nervous system is composed of neurons, neuroglia as well as blood vessels and meninges (covering of central nervous
system made up of connective tissue). Among these, only the neurons are fixed in number as they do not multiply
after birth.
18
In peripheral nervous system, many Schwann cells come in relation to the length of a single nerve fiber in a row.
These many Schwann cells are invaginated by a single nerve fiber. Due to invagination, Schwann cell give rise to
formation of mesoaxon (Fig. 1.16A). Now the Schwann cell rotates around axon in a spiral fashion. The mesoaxon
turn around several times around the fiber, thus squeezing out the cytoplasm at the periphery of Schwann cell. The
turns of cell membrane of Schwann cell around nerve fiber form the myelin sheath (Fig. 1.18A). The multiple
layered membranous sheath is white in color due to presence of white lipid– protein. More peripherally rim of
cytoplasm of Schwann cell form an additional sheath which is known as Schwann cell sheath or neurilemmal
sheath. Intermittent gap between the segments of myelin sheath formed by adjacent Schwann cells is known as
nodes of Ranvier (Fig. 1.18B). An unit of sheath formed by a single Schwann cell, in between nodes of Ranvier is
known as internode.
Myelin sheath of central nervous system is formed by oligodendrocytes. But it is important to note following
important points at this stage (Fig. 1.15A).
1. It is not the whole cell, but only the processes of
oligodendrocyte take part in formation of myelin
sheath.
2. Many processes of one oligodendrocyte take part
in the formation of myelin sheath of many nerve
fibers.
3. Again processes of many oligodendrocytes take
part in formation of myelin sheath of single nerve

fiber.
Functions:
1. Myelin sheath helps in conduction of impulse
through nerve fiber to the full extent and with full
velocity to the destination.
2. Thusmyelinsheathpreventsdissociationofimpu-
lse to the surrounding tissue.
3. It acts as a support to the nerve fiber.

4. It prevents ionic interchange between the cyto-
plasm of nerve fiber and the surrounding tissue.
19
close to central nervous system (i.e. in trunk or head and neck) than if it is away (e.g. in distal part of limbs).
Axonal transport also play important role in spread of some other viral diseases affecting nervous system, e.g.
poliomyelitis, and herpes simplex and herpes zoster.
Chemical Agents Acting on Synaptic Transmission
Neurotransmitters jumping through synaptic cleft from presynaptic neuron to postsynaptic neuron are
responsible for conduction of nerve impulse through chain of neurons to the destination. Chemical agents acting
on autonomic ganglia may interfare with neurotransmission is either of two ways. Some agents like procaine,
simply inhibit release of Acetylcholine (neurotransmitter) from presynaptic neuron. The other group, like
nicotine, hexamethonium do not give chance to Acetylcholine to act on postsynaptic membrane, because these
drugs occupy the receptor site of postsynaptic membrane. Some drugs which can cross the blood brain barrier,
like atropine,
scopolamine, are able to act on synapses of central nervous system. In myasthenia gravis there is a profuse
deficiency of synaptic transmission due to absence of Acetylcholine in synaptic cleft.
Caffeine present in tea or coffee act as neuro- modulator which enhance the activity of neurotransmitters
stimulating central nervous system.
Multiple Sclerosis – A Disease Causing Demyelination
Multiple sclerosis is a degenerative disease of central nervous system. Exact cause of the disease is not known.
Probable cause is the imbalance between some viral infection and immune response of the individual. Young
adults between the age of 20–40 years are most commonly affected. Fibers of optic nerve, spinal cord and
cerebellum are affected usually. The myelin sheath of nerve fibers are degenerated during active phase of the
disease. The myelins are scavenged by microglia with subsequent formation of replacement gliosis. The disease is
sometimes typically characterized by exacerbations and remissions.
Nervous System in Brief*
*(This chapter should not be ignored but is to be read thoroughly. If the reader goes thoroughly, all the subsequent chapters will be
better understood)
CENTRAL NERVOUS SYSTEM
Central Nervous System is made up of – (Fig. 2.1)

1. Brain:Proximalexpandedpartsituatedinsidethe
cranial cavity.
2. Spinalcord:Distal,narrow,tubularandelongated
part situated in upper two-third of vertebral canal.
Fundamental Subdivisions of Brain (Fig. 2.1)
Morphologically, the brain is composed of three comp-
onents which are further subdivided. Each of these parts is having Latin names which are of clinical significance.
Forebrain (prosencephalon)
It is most expanded part having

i. Diencephalon: Central midline part having rig-
ht and left identical halves–It forms different components of thalamus.
Cerebrum
Cerebellum
Spinal nerves
Lower spinal nerve forming cauda equina
Filum terminale
Brain
Brainstem
Spinal cord
Midbrain Pons
Medulla oblongata
Fig. 2.1 Central nervous system
2
Brain
Nervous System in Brief
21
Tree
Stem
Brainstem
Fig. 2.2 Brainstem is like stem of a tree
ii. Telencephalon: Two (right and left) lateral extensions, each of which looks like half of a sphere, known as
cerebral hemisphere. Both the cerebral hemispheres are most expended parts of brain. They overhang the
diencephalon (thalamus) form both sides and together form a sphere known as cerebrum.
Midbrain (mesencephalon)
It is shortest and simplest out of the three components of brain.
Hindbrain (rhombencephalon)
It is subdivided into as many as 3 parts.

Proximal–(Metencephalon): Which is further subdivided into two parts:
1. Ventral – Pons 2. Dorsal – Cerebellum

Distal – (Myelencephalon)– 3. Medulla oblongata: Which is distal most cylindrical part of brain. It is
continuous with the spinal cord below.
Cerebral peduncle
Brainstem
It is the component like stem of a tree on which lies the main mass of brain (Fig. 2.2). It is made up of following
parts of brain.
1. Midbrain
2. Pons
3. Medulla
oblongata
} Two ventral components of hindbrain

Long-axis of brainstem is oblique vertical directed downwards and backwards (Fig. 2.3). 3 components of
brainstem namely midbrain, pons and medulla oblongata are connected to cerebellum by 3 pairs of compact
bundles of white matter known as cerebellar peduncles (Fig. 2.4)
Superior cerebellar peduncle: Connecting midb-
rain.
Middle cerebellar peduncle: Connecting pons.
Inferior cerebellar peduncle: Connecting medulla
oblongata.
Superior cerebellar peduncle Middle cerebellar peduncle
Inferior cerebellar peduncle
Fig. 2.3 Long-axis of brainstem passes downwards and backwards
22
Cerebral peduncle
Superior cerebellar Peduncle
Middle cerebellar peduncle
central nervous system starts very early at the stage of tri-laminar embryonic disk (plate). Midline ectoderm on
the dorsal aspect of embryonic disk (neuroectoderm) becomes thickened on 16th day of embryonic life which is
called neural plate (Fig. 2.5A). By 20th day, a cephalocaudal linear depression appears on neural plate. It is
called neural groove (Fig. 2.5B). Right and left lips of neural groove gradually become more and more elevated
and prominent which are called neural crest. On 25th day fusion of two neural crests starts from the middle of
neural groove and proceeds simultaneously towards both ends. Closure is almost complete leaving temporarily
openings at the cephalic and caudal ends (Fig. 2.5C) called anterior (cephalic) and posterior (caudal) neuropores.
As soon as the neuropores are closed, a closed tube so far lined by single layer of neuroectodermal cells is formed
by 30th day of intraembryonic life. It is called neural tube. Within the period of 35th day, proximal (cephalic)
dilated part of tube, which will form the brain, is differentiated from the distal, narrow, elongated part, the
future spinal cord (Fig. 2.5D). By 35th day of intrauterine life, the proximal dilated part is divided into three
sacculations known as Forebrain, Midbrain and Hindbrain Vesicles (Fig. 2.5D).
Fig. 2.4 Peduncles of brain • One cerebral peduncle

• Three cerebellar peduncles
Cerebral peduncle – Compact ventral part of midbrain connecting brainstem with cerebrum (Fig. 2.4).
Gray and White Matters of Central Nervous System with Embryological Background
Central nervous system so also the whole nervous system is developed from ectoderm with the exception of its
blood vessels and some neuroglial cells (microglia) which are mesodermal in origin. Development of
Ectoderm Mesoderm
Endoderm
Neural plate
Neural groove
FB MB
HB
Telencephalon
Diencephalon Mesen cephalon
Rhombencephalon
Anterior neuropore
Posterior neuropore
CD
Figs 2.5A to D Embryological background showing central nervous system develops from neural tube. A. Formation of neural plate on
ectodermal surface of 3 germ layered embroyonic disk, B. Formation of neural groove, C. Anterior and posterior neuropores, D. Formation 3
brain vesicles
Multiplication of Single Layered Cells of Neural Tube (Fig. 2.6)

23
A
A B Single layered neuroectodermal
Spongioblast
Ependyma Astrocytes
Oligodendrocyte
Ependyma
cells initially lining neural tube Neuroblast
Neurons
C Neuroblast Spongioblast D
Figs 2.6A to D Multiplication of single-layered neural tube cells. A. Single-layered neuroectodermal cells lining neural tube, B. Following
mitosis, newer cells pushed to the periphery are differentiated into neuroblast and spongioblast, C and D. Formation neuron and neuroglia
(astrocyte and oligodendrocyte) from neuroblast and spongioblast respectively
On 35th day, single layered neuroectoderm cells (Fig. 2.6A) lining the neural tube start mitotic cell division. The
newer cells (daughter cells) are pushed to the periphery (Fig. 2.6B). The original lining cells form the inner lining
of the cavity of neural tube called Ependymal cells. The daughter cells pushed to the periphery, are differentiated
into two types known as neuroblasts and spongioblasts (Fig. 2.6C) which will be transformed into Neurons and
Neuroglia (Astrocytes and oligodendrocytes) respectively (Fig. 2.6D). The microglia will be formed from the
monocytes of blood squeezed out through pores of capillaries. Outside the ependymal cell lining, the cell bodies of
neuron forms a zone called Mantle Zone (Figs 2.7 and 2.8). This zone also contains Astrocyte type of neuroglia.
Foot processes (end-feet) of astrocytes come in contact, on one side with neuronal cell bodies and on other side
with the fenestrated (pored) wall of capillaries. These astrocytes thus, help in nutritional transport from
capillaries to neurons. Besides, these
cells form a barrier between neuron and capillary allowing selective transport of substance and prev- enting
transport of unwanted substance (toxic materials) from capillary to neuron. This is known as Blood Brain
Barrier (Fig. 2.8). The processes of neurons situated in mantle layer are pushed outside forming another
peripheral zone known as Marginal Zone (Figs 2.7 and 2.8). Oligodendrocytes of neuroglial cells are present in
this zone which will ensheath (myelin sheath) the neuronal processes. Microglia of neuroglial cells are present in
both mantle as well as marginal zones (Fig. 2.8).
Initially relation of inner mantle zone and surrounding it, outer marginal zone exists althrough the length of
neural tube.
Gray and White Matters (Fig. 2.8)
Lipid material of myelin sheath of nerve cell process (called nerve fiber) present in marginal zone of developing
central nervous system gives a Whitish
24
Ependyma Mantle zone
Marginal zone
Fig. 2.7 Cell division of neural tube leads to formation of layer of ependymal cells, mantle zone and marginal zone
appearance. That is why this zone is called White matter of central nervous system. Inner mantle zone made up
of neuronal cell bodies presents grayish appearance for which it is called Gray matter.
Variations of relationship between gray matter and white matter
In spinal cord, throughout the whole length, gray matter presents its original central position surrounding the
central canal. White matter, containing bundles of nerve fibers is peripherally positioned.
In brainstem (midbrain, pons and medulla oblongata) there is no separately demarcated zones
of gray and white matters. Both components are
intermingled.
In parts of brain (cerebrum and cerebellum)
relationship of gray and white matter is reversed. Gray matter becomes peripheral forming the cortex and white
matter forms the central core.
This alteration is due to following reasons:
i. Due to elongation of neuronal processes the nerve cell bodies forming the gray matter is pushed to the
periphery (Fig. 2.9).
ii. Peripheralization of gray matter (cortex) of cerebrum and cerebellum is further caused due to need for increase
in surface area of gray matter through formation of foldings (gyrus).
Ependymal cell
Astrocyte Capillary
Microglia
Oligodendrocyte
Forming Myelin sheath
Neuron
Mantle zone forming gray matter
Marginal zone forming white matter
M
Fig. 2.8 Various cells of central nervous system with blood brain barrier (B) and formation of myelin sheath (M)
Gray matter
White matter
Spinal cord is made up of 31 segments which are regionally subdivided from above downwards as follows—
Cervical – 8
Thoracic – 12
Lumbar – 5
25
Sacral – 5
Coccygeal – 1
A pair of spinal nerve (right and left) comes out
from each of the segments of spinal cord which are numbered and named accordingly (Fig. 2.10). All the spinal
nerves are mixed nerve formed by union of ventral (motor) outgoing and dorsal (sensory), incoming nerve roots
which are attached separately to anterolateral and posterolateral aspects of each segment respectively.
Interior of spinal cord shows centrally situated ‘H’- shaped area of gray matter. The central connecting limb (gray
commissure) is traversed by central canal lined by ependymal cells and extensive throughout the whole length.
Each lateral half of gray matter of spinal cord presents a broader anterior horn and narrower posterior horn. All
the thoracic and upper two lumbar (T1 – L2) segments of spinal cord present additional lateral horn. Along the
length of spinal cord, respective horns are called anterior, posterior and lateral gray columns. Neurons of
anterior (ventral) horn are motor (efferent) or effector in nature. Their axons, coming out through ventral nerve
root, pass via spinal nerves and end in effector organs, like voluntary muscles (Fig. 2.11).
Again neurons of posterior (dorsal) horn are sensory (afferent) or receptor in nature. These receive sensory
informations (inputs) carried from peripheral sensory end organs through peripheral processes of pseudounipolar
nerve cells of posterior root ganglion of posterior roots of spinal nerves. These pseudounipolar neurons of
posterior root ganglia are developed from neural crest cells aggregated on dorsolateral aspect of neural tube. The
neurons of posterior horns (tract neurons) give out axons which are pushed out to the peripheral white matter in
the form of compact bundle (ascending or afferent tract) which carry sensory informations from periphery, via
posterior (dorsal) nerve root upwards to the higher sensory centers of brain (Fig. 2.11). The neurons of
intermediate or lateral gray horn (T1 – L2 segments only) form centers for sympathetic component of autonomic
nervous system. Peripheral white matter also contains descending (efferent) or motor tracts coming down as long
axons of neurons of motor area of brain (upper motor neurons) to relay on motor neuron of anterior horns of
spinal cord (lower motor neurons). Each half of peripheral white matter of spinal cord is divided into anterior,
lateral and
Fig. 2.9 Peripheralization of neuronal cell bodies due to elongation of neuronal process, for which gray matter becomes superficial to white
matter
Diencephalon (thalamus), the central, midline portion of forebrain is made up of only gray matter. Basal
ganglia are submerged collection of gray matter in the central core of white matter of
cerebrum.
Different Parts of Central Nervous System in Brief
Spinal cord is the caudal (distal), elongated, narrow, tubular part of central nervous system situated in upper
two-third of vertebral canal. It starts as a continuation of medulla oblongata at upper border of 1st cervical
vertebra and ends at the level of lower border of 1st lumbar vertebra. Sometimes it may extend upto 2nd lumbar
vertebra. It is 18 inches in length.
Dorsal nerve root
Ventral nerve root
Posterior root ganglion
Gray matter
Spinal nerve White matter

Fig. 2.10 A pair of spinal nerve arises from each of the segments of spinal cord
Tract neuron
Posterior root ganglia cells
Sensory nerve endings carry impulse from receptors
26
Ascending Efferent (motor) (sensory) tract
neuron
Motor nerve endings supply effector organ (skeletal muscle)
posterior white columns. They are known as anterior, lateral or posterior funiculus. (Pl- funiculi). Anterior and
lateral funiculi are composed of both ascending (afferent or sensory) as well as descending (efferent or motor)
tracts. But posterior funiculus is made up of only ascending (sensory) tracts.
Again in 2nd, 3rd and 4th sacral (S2, S3 and S4) segments of spinal cord, neurons of intermediate area (no lateral
horn present here) form center for parasympathetic component of antonomic nervous system.
Cerebral peduncle of midbrain
Cut surface of middle cerebellar peduncle
BRAINSTEM (FIGS 2.12 TO 2.14)
Brainstem is the short tubular stalk-like or pedu- ncular component of brain which is composed of following
parts of brain from above downwards—
1. Midbrain
2. Pons
} Ventral parts of 3. Medulla oblongata hindbrain
Cerebral peduncle is the ventral most part of midbrain composed of compact vertical bundle of nerve
Superior cut surface of midbrain
Midbrain Pons
Medulla oblongata
Fig. 2.11 Destination of ventral and dorsal roots of a spinal nerve

Fig. 2.12 Ventral (anterior) view of brainstem
27
Cerebral peduncle Midbrain
Pons
Medulla oblongata
Nervous System in Brief Aqueduct (central canal) of midbrain
Superior cerebellar peduncle Middle cerebellar peduncle
Fig. 2.13 Lateral view of brainstem
fibers by which brainstem is connected above to the cerebrum (Figs 2.12 and 2.13).
Cerebellum is connected to the three components of brainstem, i.e. midbrain, pons and medulla oblongata
through 3 compact bundle of fibers called Superior, Middle and Inferior Cerebellar Peduncles. Superior cerebellar
peduncle is thinnest whereas middle is the thickest. Again superior and inferior peduncles are composed of both
afferent as well as efferent fibers of cerebellum, but middle is made up of only afferent fibers to cerebellum (Fig.
2.13).
Medulla oblongata is narrower, cylindrical and most caudal part of brainstem which is continuous below with the
cylindrical spinal cord. Pons presents ventrally bilateral bulge known as basilar part. In the midline, it presents
a vertical sulcus known as basilar
Central canal (aqueduct) of midbrain
Fourth ventricle
Central canal of lower part of medulla oblongata
sulcus which lodges the basilar artery. Basilar part of pons is continuous laterally and horizontally with middle
cerebellar peduncle. Ventral part of midbrain presents compact cerebral peduncle. Dorsally midbrain presents
two pairs of round bulge, upper is known as superior colliculus and lower one is called inferior colliculus (pl-
colliculi).
Cavity of brainstem (Fig. 2.14) cavity of midbrain is narrow and slit-like which is known as aqueduct of
Sylvius. Cavity of the central nervous system opposite pons and medulla oblongata is dilated which is known as
4th ventricle of brain. It is related ventrally to the dorsal surface of pons and medulla and dorsally to cerebellum.
The 4th ventricle of brain, cavity of hindbrain is continuous below with central canal of spinal cord.
Inner white matter
Outer gray matter of cerebellum
Fig. 2.14 Cavity of brainstem through sagittal section
28
Cerebral peduncle
Midbrain
Pons
Medulla oblongata
Cerebellum
Superior cerebellar peduncle
Fig. 2.15 Cerebellum related to three components of brainstem
Gray and White Matter of Brainstem

Brainstem is the part of central nervous system which shows intermingling of white and gray matter. There is no
defined separate zones of white and gray matter as found in the other parts of central nervous system. White
matter:
1. Vertical fibers: These are present in the form of ascending and descending bundles. Ascending bundles
are afferent or sensory fibers connecting spinal cord or different centers of brainstem vertically upwards
to the higher centers of cerebellum or cerebrum. Descending bundles of fibers are efferent or motor
passing down from higher centers to the spinal cord.
2. Horizontalfibers:Theseareafferenttoorefferent form cerebellum passing through three cerebellar
peduncles.
Gray matter:
1. Specificcollectionofnervecellsinadifferentparts
of brainstem forming nuclei, e.g.

i. In midbrain: Substantia nigra, red nucleus,
tectum.
ii. In pons: Pontine nucleus.
iii. In medulla oblongata: Olivary nuclei, nucleus
gracilis, nucleus cuneatus, arcuate nucleus.
2. Reticular nucleus extends throughout whole len-
gth of brainstem.
3. Nuclei of cranial nerves: Nuclei (motor and sen-
sory) of lower 10 (ten) cranial nerves (3rd–12th) are present at different levels of 3 components of
brainstem.
CEREBELLUM (FIGS 2.14 TO 2.16)
Cerebellum, the ‘Little Brain’ is dorsal part of Hind- brain situated behind pons and medulla oblongata
from which it is separated by the cavity of hindbrain, the 4th ventricle of brain. It is connected to 3 parts of
brainstem by 3 pairs of cerebellar peduncles, superior, middle and inferior.
Phylogenetically cerebellum is divided into following 3 parts:
i. Archicerebellum — Oldest (Vestibulocerebellum) ii. Paleocerebellum — Intermediate (spinocerebel-
lum)
iii.Neocerebellum — Latest (Pontocerebellum).
Principle of Functions
Various sensory inputs are carried to cerebellum to be analyzed and to be coordinated or integrated to give
directions for:
i. Maintenance of equilibrium (by archicerebellum).

ii. Maintenance of muscle tone and postural adjustment of muscles (by paleocerebellum).
iii. Coordination of muscle movements (by neocerebellum).

Midbrain
Vermis
Cerebellar hemisphere
Fig. 2.16 Cerebellum viewed from above
Superior vermis
Fastigial nucleus
Globose nucleus
Emboliform interpositus nucleus
Dentate nucleus
29
the white matter of cerebellum. Central core of white matter contains collections of gray matter called cerebellar
nuclei which are following from lateral to medial (Fig. 2.17).

} Nucleus
Inferior vermis
Gross Anatomy
Cerebellum presents superior and inferior surfaces. Anteriorly, a notch is related forwards to the brainstem.
Cerebellum is divided grossly into –
a) A midline part: Vermis, so called because it looks like worm.
b) Two lateral extensions: Cerebellar hemispheres.

Surface of both vermis as well as cerebellar hemispheres show parallel fissures. Primary fissures divide
cerebellum into lobes. Secondary fissures divide lobes into smaller units called lobules. Almost all the lobules
have vermis as well as corresponding lateral extensions. Tertiary fissures in each lobule demarcate adjacent
narrow linear ‘leaf-like’ components known as Folia.
Fundamental Structure
Outer or peripheral portion of cerebellum is made up of gray matter known as cerebellar cortex. Cortical gray
matter is thrown into narrow, linear leaf-like parallel pleats called folia. Inner central portion is
Cerebral hemisphere
Thalamus Diencephalon
{
Hypothalamus
Fig. 2.17 Coronal section of cerebellum strowing cerebellar nuclei
i. Dentate nucleus
ii. Emboliform nucleus
}
iii. Globose nucleus iv. Fastigial nucleus
Nucleus Interpositions
Forebrain (prosencephalon) (Fig. 2.18)
It is the largest component of brain and subdivided into: 1. Telencephalon: It is right and left lateral extension.
Both jointly giving the appearance of a sphere called cerebrum. Each half, right or left half of sphere (cerebrum)
is hemispherical called
cerebral hemisphere.
2. Diencephalon: It is the central component of fore-
brain which forms 5 components of thalamus. Components of diencephalon is not visible in intact brain as it is
overhung from either side by cerebral hemispheres (Fig. 2.18). Diencephalon is the inferomedial portion of
forebrain.
Cerebral hemisphere
Two cerebral hemispheres form cerebrum (Telencephalon)

Fig. 2.18 Forebrain seen through coronal section
30
B
Superolateral surface
Medial surface
Inferior surface C
Figs 2.19A to C Three primary surfaces of cerebral hemisphere of left side
Cerebral hemisphere
Both the cerebral hemispheres present large number of convolutions (foldings) on the surfaces. These
convolutions are known as gyri (singular = gyrus), one gyrus is separated from adjacent gyrus by linear
depression called sulcus (Plural = sulci). Gyri on the surfaces of cerebral cortex (superficial layer of gray matter)
increase the surface area of cortical gray matter. In life, both the cerebral hemispheres are inseperable from each
other, as both are interconnected by thick, compact, transversely passing band of white matter called corpus
callosum.
Surfaces of cerebral hemispheres: Grossly, cerebral hemisphere presents three surfaces (Figs 2.19A to C):
i. Superolateral
ii. Medial
iii. Inferior.
Superolateral surface is convex, but medial and
2. Parietal lobe: Between central sulcus and parieto occipital sulcus.
3. Occipital lobe: Behind parietooccipital sulcus.

4. Temporal lobe: Below lateral sulcus.
5. Central lobe (Insula): At the bottom of lateral
sulcus (Fig. 2.20B).

Poles of cerebral hemisphere are 3 in number
1. Frontal pole – (anterior).

2. Occipital pole – (posterior).
3. Temporal pole – (anterior and inferior).
Structural components
Fundamentally cerebral hemisphere is made up of – A. Outer gray matter: This is known as cerebral cortex.
Gray matter presents foldings called gyri (gyrus – singular) which increase the surface area of cortex, so number
of neurons within limited capacity of cranial cavity (cavity of skull). Almost all the gyri are named and separated
from each other by furrows named sulci. Different gyri or cortical areas have different functions. Grossly the
different lobes of cerebral hemisphere posses
different functions as follows: 1. Frontal lobe:
i. Voluntary movements of skeletal muscles of opposite half of body.
inferior surfaces are flat.

Lobes and Poles (Fig. 2.20A): Three (3) sulci called primary sulci divide the cerebral hemispheres into five lobes.
The sulci are (Fig. 2.20) —
1. Lateral sulcus.
3. Parietooccipital sulcus.
Five lobes are the following:
1. Frontal lobe: Infront of central sulcus.
2. Central sulcus.
31
Central sulcus
Frontal lobe
Frontal pole
Temporal pole Temporal lobe

Parietal lobe
Parietooccipital sulcus Occipital lobe
Occipital pole Lateral sulcus
Insula
Inferomedial border
Inferolateral border
Figs 2.20A and B Lobes, poles, surfaces and borders of cerebral hemisphere A. Lobes and poles of cerebral hemisphere, B. Surfaces and
borders of cerebral hemisphere
ii. Emotional activities

iii. Awareness of individual iv. Motivation for any activity v. Aggression or anger.
2. Parietal lobe: Reception, recognition (perception) and evaluation of all superficial and deep (from muscles,
tendons, joints) sensations except vision, hearing and smell.
3. Occipital lobe: Reception, perception and inter- action of visual sensation.
4. Temporal lobe:
i. Reception, perception and evaluation of sense
of hearing.
ii. Reception, perception and evaluation of sense
of smell.
iii. Memory and intellect of an individual.
5. Limbic lobe: It is not a separate anatomical lobe. But it is a ring-shaped component of cerebral cortex situated
in the border line (limbus means border) between central cortex and diencephalons. Limbic lobe is concerned
with following functions.
i. Control on the activity for acquisition of food,
water and reproductive activity.
ii. Storage of short-term memory.
B. Inner white matter: It forms central core of cerebral hemisphere. It is also known as medullary
substance. It is white in appearance as it is made up of nerve fibers (processes of nerve cells) which are
myelinated. The white matter or medullary substance of cerebral hemisphere contain following—
i. Bundle of nerve fibers.

ii. Basal ganglia: Deep-seated masses of gray
matter within the core of white matter.

iii. Lateral ventricle: Cavity of telencephalon. Nerve fibers in the white matter are compact
bundles of fibers of following types –

􏱧􏱧 􏱧sso􏱧i􏱧􏱧io􏱧 fibers 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧􏱧: These fibers may
be shorter to interconnect areas of adjacent gyrus. Again they may be long enough to interconnect areas of two
different lobes. Association fibers lie in the same hemisphere.
􏱧􏱧 􏱧o􏱧􏱧issur􏱧l fibers 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧􏱧: These fibers connect identical areas of two hemispheres, so cross the
midline.
Both association fibers and commissure fibers do
not project to any center beyond cerebral hemisphere. 􏱧􏱧 􏱧ro􏱧e􏱧􏱧io􏱧 fibers 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧􏱧: These types of
fibers projects beyond cerebral cortex to the
subcortical centers of same side or opposite side.
32
A Association fibers
B Commissural fibers
C 􏱺ro􏱺ectionfibers
Figs 2.21A to C Fibers of white matter of cerebrum A. Association fibers, B. Commissural fibers, C. Projection fibers
Basal Ganglia (Fig. 2.22): These are collections of gray matter deeply-seated inside white core of cerebrum.
These masses of gray matter are traversed by fine myelinated nerve fibers which give a striated appearance.
That is why they are known as ‘Corpus Striatum’.
ii. Claustrum Medial part: Globus pallidus iii. Lentiform nucleus

iv. Caudate nucleus Lateral part: Putamen
Phylogenetically, corpus striatum (basal ganglia) are divided into—

i.
Basal ganglia are composed of followings: Amygdaloid nucleus
Corpus callosum
Lateral ventricle
Caudate nucleus Stria terminalis
Thalamostriate vein Third ventricle
Thalamus Hypothalamus
Amygdaloid body
i. ii.
Archistriatum: Amygdaloid nucleus and claustrum

Paleostriatum: Globus pallidus
Cortical gray matter

Corona radiata in central white matter
Caudate nucleus Claustrum
Insula (central lobe) Lentiform nucleus
Fig. 2.22 Coronal section of cerebral hemisphere showing– Telencephalon composed of – cortical gray matter central white matter, basal
ganglia and ventricles, with diencephalon
iii. Neostriatum: Putamen and caudate nucleus.
33
Different components of basal ganglia form a specific functioning system in brain called extrapyramidal system
which has following functions:
1. It has regulatory effect on tone of voluntary mu-
scles.
2. During a desired voluntary movements, extrapy-
ramidal system inhibits unwanted movements of voluntary muscles and improves quality of motor functions.
Cavity of cerebral hemisphere (Figs 2.23 and 2.24): Cavity of cerebral hemisphere (telencephalon) are wide and
usually bilaterally symmetrical. They are named lateral ventricle of brain. Right and left lateral ventricles being
the most proximal are considered as 1st and 2nd ventricles. Both these ventricles communicate through
aperture (interventricular foramen) with the midline cavity of diencephalon called third ventricle of brain.
It is the time now to notice that cavity of central nervous system is of different nature and different name in
different levels as follows (Fig. 2.24):
Interventricular foramen
Third ventricle Aqueduct of midbrain
Fourth ventricle
1. Forebrain:
2. Midbrain:
3. Hindbrain:
4. Spinal cord:
Diencephalon
2. Telencephalon– (cavity dilated)
Diencephalon– (cavity: Narrow midline cleft)
Cavity is a narrow– –linear slit
Cavity dilated–
Narrow slit throughout whole length of

spinal cord–
1st and 2nd ventricles

(Both called lateral ventricle) 3rd ventricle
Aqueduct of Sylvius
4th ventricle
Central Canal
Diencephalon is the central or midline component of forebrain. On both sides, from superolateral aspect,
diencephalon is overlapped and hidden by cerebral hemispheres (telencephalon).
Anterior horn Central part Posterior horn
}
Inferior horn
Central canal of spinal cord
Lateral ventricle
Third ventricle
Corpus callosum
Lateral ventricle
Fornix
Caudate nucleus
Stria terminalis Thalamostriate vein
Fig. 2.23 Cavities of cerebral hemisphere
of Lateral ventricle
Fig. 2.24 Cavities of central nervous system
34
Thalamus
Metathalamus Epithalamus
Midbrain
} Dorsal diencephalon
Hypothalamic sulcus
On either side of midline diencephalon presents right and left identical halves separated by a narrow midline
cleft, cavity of third ventricle of brain (Fig. 2.23). Two halves of diencephalon merge with each other below 3rd
ventricle of brain. This part of diencephalon (hypothalamus) is only visible when seen from inferior surface (base)
of the brain.
Subdivisions of Diencephalon (Fig. 2.25):
Dorsal Diencephalon:
1. The thalamus.
2. Metathalamus (meta: beyond) — composed of
i. Lateral geniculate body
ii. Medial geniculate body.
3. Epithalamus: composed of
i. Pineal gland
ii. Habenular nucleus.
Ventral Diencephalon:
4. Hypothalamus.
5. Subthalamus.
Thalamus
Thalami (pl) are two in number, right and left. These are ovoid mass of gray matter which is made up of different
cell groups called thalamic nuclei. These nuclei of thalamus are the relay stations below cerebral cortex where all
kinds of sensory pathway (except that for smell) relay before their final relay in respective sensory areas of
cerebral cortex.
3rd ventricle of brain is the cavity of diencephalon between medial surfaces of both thalami. It communicates on
either side with respective (right and left) lateral ventricles which are cavities of telencephalon (cerebral
hemisphere) (Fig. 2.23).
Functions of thalamus
Fig. 2.25 Components of diencephalon
Subthalamus
}
Ventral
Hypothalamus diencephalon
1. Thalamus is an important sensory relay station where all sensory inputs converge (except sense of smell)
before they finally end in respective sensory areas of cerebral cortex.
2. Thalamus is the center where sense of pain and temperature can be perceived, even before they reach cerebral
cortex.
3. Thalamus is the center, where inputs are received from cerebellum and basal ganglia. These inputs are then
integrated to send message to cerebral cortex through efferent pathway for motor functions.
4. Efferentpathwayfromthalamustolimbicsystem of forebrain regulates mood, behavior and intellect of an

individual.
Metathalamus (Fig. 2.25)

Metathalamus is made up of two small ovoid bulge which protrude from posteroinferior aspect of thalamus.
These are called lateral and medial geniculate bodies.
Lateral geniculate body is the diencephalic relay station of visual pathway.
Medial geniculate body is the diencephalic relay station of pathway for hearing (auditory pathway).
Epithalamus (Fig. 2.25)
Epithalamus is a small sessile projection from posterosuperior aspect of thalamus.
It is composed of
i. Pineal gland (pineal body). ii. Habenular nuclei.
Functions of epithalamus
i. Pineal gland of epithalamus secretes a hormone, called melatonin. Melatonin regulates onset of puberty.
Early onset of puberty is found to be related to reduced synthesis of melatonin. In general, pineal gland has 35
inhibitory effect on gonads.
ii. Habenular nucleus of epithalamus, through its connections with limbic system regulates emotional and
visceral activities on perception of specific odors.
Hypothalamus (Fig. 2.25)
It is the anterior part of ventral diencephalon lying below thalamus and infront of subthalamus. Hypotha- lamus
is the part of diencephalon which forms the lower part of lateral wall as well as the floor of 3rd ventricle of brain.
Its lowermost part is the only part of diencephalon which is visible from inferior surface or base of the brain.
Hypothalamus is a very small area of brain which contain various nuclei.
Functions
1. Autonomic: Anterior part of hypothalamus produces influence on parasympathetic part and posterior
part influences on sympathetic part of autonomic nervous system. Through this influence, hypothalamus
controls visceral activities.
2. Hormonal: Pituitary gland (hypophysis cerebri), being the bandmaster of endocrine symphony (fun-
ctions), is influenced by hypothalamus through hypothalamo hypophyseal tract. Through influence on
pituitary, hypothalamus controls activities of various other endocrine glands.
Subthalamus (Fig. 2.25)
It is the posterior part of ventral diencephalon lying ventral to thalamus, posterior to hypothalamus and above
midbrain. It contains small compact mass of gray matter called subthalamic nucleus.
Subthalamic nucleus is one of the centers of extrapyramidal system. It controls unwanted voluntary movements
and thus makes movements of voluntary muscles smooth.
Coverings (Meninges) of Central Nervous System and Cerebrospinal Fluid (CSF)
Both brain and spinal cord posses coverings which are called meninges. The meninges are of following 3 layers
from outside inwards –
1. Dura mater: It is outermost and thickest. It is made up of tough fibrous tissue containing plenty of collagen
fibers. This thick fibrous layer is opaque. Its main function is protective.
2. Arachnoid mater: It is thin, delicate and transparent layer. It is related more close to the surface of brain and
spinal cord but does not dip into the wall or bottom of sulci of brain.
3. Pia mater: It is thinnest and most delicate layer made up of thin layer of fibroareolar tissue in which lies fine
network of blood vessels. This layer is closely adherent to surface of brain and spinal cord. It dips into the walls
and bottom of sulci and fissures.
Dura mater is known as ‘Pachymeninges’ which develops from mesoderm surrounding the developing neural
tube. Arachnoid mater and pia mater are known as ‘Leptomeninges’ which are ectodermal in origin.
Space beneath arachnoid mater, i.e. between arachnoid and pia mater of brain and spinal cord is prominent. This
space is called subarachnoid space. Subarachnoid space contains thin watery fluid which is called Cerebrospinal
fluid (CSF). This fluid is also present inside the cavity of whole central nervous system. Cerebrospinal fluid is
liberated from tufts of capillaries related to wall of ventricles of brain, called Tela Choroidea. CSF of ventricular
system (cavity of CNS) and subarachnoid space freely communicate with each other through apertures on the
roof of 4th ventricle. In normal individual a balance is maintained between secretion and absorption of CSF. In
case of imbalance, that means either oversecretion or less absorption, accumulations of excess CSF leads to a
clinical condition called hydrocephalus.
PERIPHERAL NERVOUS SYSTEM
Peripheral nervous system is the outflow from central nervous system (brain and spinal cord). It is mainly
composed of peripheral nerves. It means that apart from peripheral nerves, there are other constituents of
peripheral nervous system.
Composition of Peripheral Nervous System
1. Peripheral nerves: Outflow from brain and spinal cord in the form of
a) 12 pairs of cranial nerves from brain.
b) 31 pairs of spinal nerves from spinal cord.
2. Collections of neurons outside the central nervous system: These are named Ganglia (singular – ganglion).
36
Cortical sensory neuron
Lemniscus
Thalamic nucleus
Ascending (afferent) tract

Sensory (tract) neuron
Spinal (lower) motor neuron
Pseudounipolar primary sensory neuron
A (mixed) spinal nerve
Efferent (motor) component of spinal nerve
Effector organ (muscle)
Skin
Sensory cortex
Thalamus
Spinal cord
Fig. 2.26A Destination of motor and sensory components of spinal nerve
Functional Components of Peripheral Nerves (Figs 2.26A and B)
Peripheral nerves are made up of axons of groups of neurons situated inside the central nervous system and/or
dendrites of 1st order of neurons in the sensory pathway. Axons carry impulse (direction) from the central
nervous system to the target organ (e.g. muscles) and form motor or efferent component of a peripheral nerve.
Dendrites carry impulse (informations) from peripheral end organs (receptors) towards the central nervous
system and form sensory or afferent component of a peripheral nerve.
Functional Types of Peripheral Nerve
A peripheral nerve (cranial or spinal) may be either of the following three functional types:
i. Motor nerve: When it contains only motor component.
ii. Sensory nerve: When it contains only sensory component.

iii. Mixed nerve: When it contains both motor and sensory components.
Fundamental comparison between cranial and spinal nerve
12 pairs of cranial nerves come out through the surface of brain.
37
Receptor

Cell body of sensory root
of cranial nerve is not pseudounipolar, unlike posterior root ganglia of spinal nerve
Sensory nucleus of cranial nerve
Motor nucleus of cranial nerve
A cranial nerve may be 1. A motor nerve
2. A sensory nerve or
3. A mixed nerve
Effector
Fig. 2.26B A cranial nerve may be motor, sensory or mixed unlike spinal nerve which is always mixed in composition
A pair of spinal nerve comes out through surface of each of 31 segments of spinal cord. So number of spinal
nerves are 31 pairs.
All spinal nerves are mixed nerve but not all the cranial nerves:
All the spinal nerves are mixed nerves as they are made up of both motor as well as sensory roots. Motor and
sensory roots of spinal nerve are attached to different sites of surface of spinal cord called anterolateral sulcus
and posterolateral sulcus respectively.
Out of 12 pair of cranial nerves some are sensory, some are motor whereas some of these are mixed nerves as
follows:
Cranial Nerves I, II, VIII — Sensory Cranial Nerves III, IV, VI, XI, XII— Motor
Cranial nerves V, VII, IX, X — Mixed
Again, Ist (olfactory) and IInd (optic) cranial nerves, carrying special sense of smell and vision respectively, are
attached to the forebrain, but other 10 pairs of cranial nerves come out from the surface of brainstem. Unlike the
spinal nerves, separate motor and sensory roots of some of mixed cranial nerves (V, VII) are attached close to
each other at the surface of brainstem.
Peripheral Nerve Forming Plexus (Networks) (Fig. 2.27)
Adjacent spinal nerves in different regions, except 3rd thoracic to 11th thoracic intercommunicate with each
other in different regions (upper cervical, lower
Cords
Divisions
Trunks
Nv. roots
BRAIN
Lateral cord
Posterior cord
Medial cord
Anterior division
Posterior divisions
Anterior division
C5 C6 C7
C8 T1
Fig. 2.27 Peripheral spinal nerves forming plexus. C5– C8 and T1 spinal nerves, through formation of brachial plexus, supply upper limb
(through various nerves derived from lateral, posterior and medial cords)
38
Ventral rami of spinal nerve
1 C1 to C4 nerves
2. C5 to T1(T2) nerves
Umbilicus
Overlapping of T11 dermatome in the area of T10 dermatome
T10 Dermatome T11 Dermatome

Fig. 2.28 Belt of skin (Dermatome) supplied by sensory component of peripheral nerve
cervical, lumbar, sacrococcygeal) and finally give named branches which are distributed peripherally.
Reasons for formation of nerve plexuses
1. A muscle developed by union of multiple mesodermal units (segments), will get supply of multiple
segmental motor nerve fibers by union of adjacent spinal nerve roots through plexus formation.
2. A belt of skin of body is innervated (supplied) by sensory fibers of one peripheral nerve. This is called
dermatome. There may be overlapping of nerve supply by adjacent peripheral nerve to adjacent
dermatome (Fig. 2.28).
Different nerve plexuses
Each of the spinal nerves divides into ventral and dorsal rami. Nerve plexuses at different regions of body are
formed by ventral rami. Ventral rami of 3rd thoracic (T3) to 11th thoracic (T11) spinal nerves are distributed to
the body wall. Ventral rami of other spinal nerves are distributed to following regions of body through formation
of different nerve plexus named below.
Contd...
Name of the plexus formed
Cervical plexus
Brachial plexus
Distribution area
Motor fibers — to Muscles of neck and to diaphragm. Sensory fibers — to Skin of neck
Motor fibers — to Muscles of upper limb

Sensory fibers — to Skin of upper limb
Contd...
Spinal nerves which do not form plexuses (T2 – T11) but supply the body wall or trunk (thorax and abdomen) are
distributed as follows:
T2 – T11 nerves — Distributed in thorax.
T7 – T11 nerves — Distributed in abdomen. T12 nerve also supplies wall of abdomen.
Constituents of a Peripheral Nerve (Fig. 2.29)
A peripheral nerve is covered by connective tissue sheath in different planes which are as follows:
1. Epineurium: It is the outermost connective tissue
sheath of a peripheral nerve. Structurally, it is made up of dense connective tissue which posseses protective
function. On the surface of epineurium lies very fine network of blood vessels.
2. Perineurium: A peripheral nerve is composed of bundles of nerve fibers. Many group of nerve fibers which are
called fasciculi (singular – fasciculus) are present in a nerve. Each fasciculus is enclosed by a sheath of
connective tissue which is smooth in nature but made up of finer collagen fibers. This is called perineurium.
Ventral rami of spinal nerve
3. T12 to L4 nerves
4. L4 to S5 nerves
Name of the plexus formed
Lumbar plexus
Sacral plexus
Distribution area
Motor fibers — to Muscles of front of Lower limb. Sensory fibers — to Skin of front of lower limb.
Motor fibers — to Muscles of back of Lower limb.

Sensory fibers — to Skin of back of lower limb.
Epineurium Perineurium
Endoneurium (interstitial connective tissue between nerve fibers􏱺
Fasciculi
Fig. 2.29 Connective tissue elements of a peripheral nerve

39
3. Endoneurium: It is not present in the form of sheath. A nerve fasciculus enclosed by perineurium is composed
of number of nerve fibers. Interstitial tissue inbetween nerve fibers inside a fasciculus is called endoneurium. It
is made up of very delicate loose connective tissue.
Apart from the connective tissue related to a peripheral nerve classified as above individual nerve fibers which
are myelinated are covered by myelin sheath.
Types of Nerve Fibers in a Peripheral Nerve
I. According to thickness so also velocity of conduction:
2. Somatic efferent (motor): These fibers carry impulse (command) from central nervous system (brain and
spinal cord) to the skeletal muscles (effector organs).
3. Visceral afferent (sensory): These fibers carry impulse (sensory inputs or information) from viscera, like
sense of pain, pressure, distension, stretch.
4. Visceral efferent (motor): These fibers carry impulse (command) from central nervous system (brain and
spinal cord) to–
i. Smooth (involuntary) muscles of viscera.
ii. Smooth (involuntary) muscles of cardiovascular channels.

iii. Arrectores pili muscles (involuntary) of skin. iv. Exocrine glands.
Out of the above mentioned fibers visceral afferent
and visceral efferent fibers are fibers of autonomic nervous system which are made up of sympathetic and
parasympathetic components.
Somatic afferent and visceral afferent fibers enter through the same route of sensory nerve (cranial as well as
spinal), but relay in different groups of neurons in central nervous system (brain and spinal cord).
Again somatic efferent and visceral efferent fibers come out through the same route of motor nerve (cranial and
spinal). But somatic efferent fibers end directly to the target organs (effector organs) which are voluntary
muscles, and visceral efferent fibers reach the target organs (involuntary muscles or exocrine glands) after a
relay in postganglionic neurons thus forming autonomic ganglion (singular — ganglia) (Fig. 2.30B).
Additional functional components of fibers in cranial nerves: During intrauterine life, six pairs of mesodermal
bars develop winding primitive pharynx from its dorsolateral aspect. These are called pharyngeal (branchial)
arches. 5th branchial arch gets degenerated finally. Some muscles in the region of head and neck are developed
from mesoderm of 5 (1st–4th and 6th) branchial arches. These muscles are voluntary muscles but not somatic
muscles. Some of cranial nerves contain fibers which supply these branchial arch muscle called branchial
efferent component. These
Thickness Velocity of
Type Example
(diameter) conduction
1. Type A (thickest,
i. Motor neurons supplying skeletal
(voluntary) muscles
fastest and myelinated) ii. Most of the sensory neurons.
2. Type B (medium in 1.5 – 22 microns 4 – 120 meters/sec Preganglionic autonomic nerve fibers
thickness and as well as conduction 1.5 – 3 microns 3 – 15 meters/sec i. Postganglionic automonic nerve fibers
speed and myelinated) ii. Autonomic afferent (sensory) fibers
0.1 – 2 microns 0.5 – 4 meters/sec from viscera
3. Type C (thinnest with
iii.Somatic
afferent (sensory) fibers from
minimum conduction speed and non-
skin and muscles
myelinated)
Type A—Fibers are further classified as follows: Type A—Motor fiber – Alpha, Beta and Gamma Type A—
Sensory fibers – Types I, II, III.
II. According to area distribution (Figs 2.30A and B) 1. Somatic afferent (sensory): These fibers carry impulse
(sensory inputs or informations) from
skin, muscles, tendons and joints.
40
Somatic receptor
Somatic
afferent fiber
Somatic effector
Somatic
efferent fiber
Visceral
afferent fiber
Autonomic effector
Autonomic receptor
Autonomic ganglion
Figs 2.30A and B Types of nerve fibers in peripheral nerve. A. Somatic fibers, B. Autonomic fibers
fibers of cranial nerves are also called special visceral efferent component. In this connection, it is to be noted
here that, some special senses like taste (gustatory sensation) is carried from viscera like tongue, part of
pharyngeal wall and soft palate. Sensory fibers of some cranial nerves carrying this (taste) sensation are called
special visceral afferent component.
So, in addition to the previously mentioned four components of a peripheral spinal nerve, some of cranial nerves
may contain following types of fibers.
5. Special visceral afferent: Fibers carrying taste sensation.
6. Specialvisceralefferent(branchialefferent): Fibers supplying (voluntary) muscles developed from

branchial arch mesoderm of 1st to 4th and 6th arches.
For more clear concept about functional components of peripheral nerve, reader is suggested to go through the
chapters of spinal cord and brainstem.
Visceral
efferent fiber
Peripheral Nerve Injury (Figs 2.31A and B)
When a peripheral nerve is injured and cut, nerve fiber (neuronal process) may be divided into two segments. 41
The two segments are as follows:
1. Proximal:Thisisconnectedtocellbodyofneuron,
known as proximal stump.

2. Distal: This is known as distal stump.
Following nerve injury, both the proximal as well as distal stump of nerve fibers undergo degeneration. The cell
body also gets degenerated along with proximal stump.
􏱽e􏱽enerati􏱽e c􏱽an􏱽es of ner􏱽e fi􏱽ers
of nerve fiber towards the cell body which also shows degenerative changes. This is known as Retrograde or
Wallerian degeneration. This so called after the name of Waller who first noticed the degenerative changes of
nerve fiber.
This degeneration process starts within 48 hours of nerve injury.
􏱽e􏱽enerati􏱽e c􏱽an􏱽es of fi􏱽ers of 􏱽ro􏱽i􏱽al stu􏱽􏱽
Disintegrated myelin sheath is converted into lipid droplets.
Degenerative changes in cell body
i. Cell body is swollen and rounded.

ii. Nucleus becomes eccentric (peripheral) in
1.
Degeneration of proximal stump – From the site of lesion (injury) degenerative process start in retrograde
direction through the proximal stump
position.
􏱺nflu􏱺 of macrophages
Nucleus becomes eccentric
Chromatolysis with disappearance of Nissl granules
Cell body is rounded
Endoneurium is torn
Schwann cells disintegrate into lipid droplets

A
All axonal sprouts except one disappear
Axonal process regrows
Schwann cells proliferate
Figs 2.31A and B Degeneration and regeneration of neuron. A. Process of degeneration, B. Process of regeneration
42
iii. Fragmentation of Nissl bodies – This is called chromatolysis.
iv. Neurofilaments are broken down.
Degenerative changes of distal stump

This is called anterograde degeneration. This occurs immediately after injury. The degenerative process is same
as that of proximal stump fibers.
􏱽e􏱽eneration of ner􏱽e fi􏱽er
During degeneration process of a nerve fiber, following peripheral nerve injury, myelin sheath gets
disintegrated. But the endoneurium and neurolem- mal sheath of proximal stump remain intact. That is why
chance of regeneration of proximal stump of nerve fiber with cell body remains alive. But in no case distal stump
gets regenerated, unless and until it is surgically connected with the proximal stump. In central nervous system,
nerve fibers do not regenerate, because they are devoid of endoneurium.
Steps of regeneration
1. Many Schwann cells undergo proliferation at the site of injury.

2. Some of the Schwann cells undergo changes to macrophages which take out the tissue debris as well as
lipid droplets formed by disintegration of myelin sheath.
3. Neuronal body return to its original nature and shape. Its nucleus again come back to the central
position.
4. Terminal end of proximal stump presents knob- like appearance from where number of sprouts come out.
5. One of the sprouts is elongated and others disappear.
6. The elongated sprouts it ensheathed by many of the proliferating Schwann cells which thus form new
myelin sheath.
Regeneration of nerve fiber occur at a speed of
1mm per day. Complete regeneration may need a period of 3–6 months.
Regeneration of a nerve fiber is arrested due to following reasons:

1. If endoneurium is not intact.
2. If the distance between the two cut segments of
nerve fibers is more than 3 cm.

3. If nerve growth factor does not act.
4. If the site of injury is infected. It is important to
note here that leprosy bacillus travels beneath the endoneurium in retrogate direction and damage the Schwann
cells, thus disintegrating myelin sheath causes infective nerve injury.
Cellular Components of Peripheral Nervous System (Figs 2.30A and B)
In the pathway of peripheral nervous system, apart from the peripheral nerves, there are groups or clusters of
neurons, which are called ganglia (singular ganglion).
There are two different types of ganglia. Though both are commonly termed ‘Ganglia’ structurally they are
different.
Sensory Root Ganglia
In peripheral nervous system, outside the central nervous system, these are collections of cell bodies of first order
of sensory neurons in the afferent (sensory) pathway which form sensory component of peripheral nerves (cranial
and spinal nerves).
Sensory root ganglia of sensory components of some cranial nerves
These are cell bodies of 1st order of neurons present in sensory components of cranial nerves (Fig. 2.26B) which
may be either purely sensory nerves or sensory component of a mixed nerves.
The ganglia are as follows:
No. and name of cranial nerves Type of nerve (mixed or sensory) Name of the ganglia
Vth – Trigeminal VIIth – Facial
Semilunar ganglia Geniculate ganglia
Mixed Mixed Sensory
VIIIth – Vestibu- locochlear
Spiral ganglia and vestibular ganglia Superior and inferior ganglia
IXth – Glosso- pharyngeal
Mixed Mixed
Superior and inferior ganglia
Xth – Vagus
Cells of these ganglia are mostly bipolar. Peripheral process carries impulse from peripherally situated sensory
end organs towards the cell body. The central process carries impulse from the cell body towards the central
nervous system (brainstem).
Posterior root ganglia of spinal nerves (Figs 2.26A and 2.30)
These are cell bodies of 1st order of neurons carrying sensory impulse towards the spinal cord. The ganglia are
attached to the dorsal (posterior) root of spinal nerve close to spinal cord. The neurons are pseudounipolar in
nature whose single process bifurcates in ‘T’–shaped manner into peripheral and central process. The peripheral
limb acting as ‘dendrite’ carries impulse from peripherally situated sensory end organs (receptors). The central
limb of ‘T’–shaped process carries impulse towards central nervous system.
43
It is important to note that these sensory neurons of both cranial as well as spinal nerves are of two types. Some
carry somatic sensations from skin, muscles, tendons, joints. Some of them carry visceral sensation forming
sensory component of autonomic nervous system.
The sensory ganglia are covered by connective tissue capsule. Inside the ganglia, cell body of each of the
neurons is enclosed by capsular or satellite cells all around. These cells protect the neurons and also provide
nutrition to them lying between neurons and blood capillaries.
Autonomic Ganglia (Fig. 2.30B)
In case of somatic neurons (cranial as well as spinal), motor fibers coming out of central nervous system end
directly to the target organs (voluntary muscles). In case of both sympathetic as well as parasympathetic
components of autonomic nervous system, motor (efferent) fibers, after coming out of central nervous
system end in a relay stations, from where another neuron (postganglionic) starts to reach the target organs
(involuntary muscles or exocrine glands). These synaptic junctions with postganglionic cell bodies are called
autonomic ganglia. These ganglia may be large and enclosed by connective tissue capsule. Again it may be small
and situated in the network of autonomic nerves.
These autonomic ganglia lying in the peripheral nervous system are, therefore, relay stations as well as
collections of cell bodies of second order (postganglionic) of autonomic neurons.
Between central nervous system and target organs, relative position of sympathetic and parasympathetic
autonomic ganglia vary. Sympathetic ganglia are more close to the central nervous system. Parasympathetic
ganglia are away from central nervous system, so more close to the target organs (involuntary muscles or
exocrine glands).
By this time it is well-understood that a peripheral nerve is composed of nerve fibers. These nerve fibers may be
motor or sensory in nature. Sensory fibers, forming a sensory nerve, carry informations (input) through its
peripheral or terminal endings from the periphery of body. The peripheral ends of these sensory nerve fibers present
specialized structure to receive sensory inputs due to change in the environment. Again a motor nerve is made up of
nerve fibers which carry impulse (directions or command) from central nervous system to the peripheral target
organs (muscles or exocrine glands) for an effect. So, peripheral or terminal ends of motor nerve fibers come in close
contact with target organs (muscles or exocrine glands). These sites of contact present specialized structures.
These specialized terminal endings of both sensory as well as motor nerve fibers are called end organs (Fig. 3.1).
End organs at the terminal ends of sensory nerve fibers which receive sensory informations or inputs are called
receptors.
End organs at terminal ends of motor nerve fibers which are to produce effect in the form of contraction of muscles
or secretion of exocrine glands, are called effectors.
RECEPTORS
Receptors are specialized structures at the terminal ends of sensory nerve fibers which are distributed peripherally
to receive sensory informations (inputs) due to change in the environment (stimulus).
􏱪nato􏱪ical Classification of 􏱪􏱪c􏱪􏱪to􏱪s

Fundamentally, receptors are classified as – Exteroceptors.
Proprioceptors.
Interoceptors.
Exteroceptors
These receptors are distributed superficiall􏲄 in the layers of skin and subcutaneous tissue. Exteroceptors are
stimulated by external stimulus like–touch, pressure, pain by mechanical or chemical trauma and alteration of
temperature. These receptors are more accurately called general exteroceptors.
Exteroceptors for perception of sense of smell (olfactory), vision (visual), hearing (acoustic) and taste (gustatory) are
called special exteroceptors.
Peripheral End Organs
Receptor Effector
Sensory nerve Motor nerve
Central nervous system Central nervous system
Fig. 3.1 Peripheral end organs (receptor and effector)

3
Proprioceptors
When a joint moves due to contraction of a muscle or a group of muscles, we can feel it. This is called sense of
movements. Again, due to contraction of muscle, when a part of body is stretched or adjusted, we can also feel it. 45
This is called sense of position. These feelings or perceptions are because of impulse that are carried through
chain of sensory neurons from concerned part of periphery of body to central nervous system. The informations
are carried from peripheral end organs located in muscles, tendons and joints. These sensory end organs are
called general proprioceptors.
Specialized receptors are located in specialized site of internal (innermost) ear, whose function is related to
perception and maintenance of balance or equilibrium of body. These are called special proprioceptors. Impulse is
carried through vestibular component of vestibulocochlear nerve (eighth cranial nerve).
Interoceptors
Both exteroceptors as well as proprioceptors, defined above, are related to endings of somatic sensory nerves,
thus carry sensations called somatic sensations.
There are various sensations carried from viscera. These are sense of pain (due to ischemia), stretch,

distension, compression, etc. These sensations are carried through autonomic sensory nerves. The sensory end
organs in the wall of viscera from where these sensations are carried, are called interoceptors.
So, receptors are classified through following table:
In this chapter, general receptors (general exteroceptors and general proprioceptors) are described. For special
receptors, the reader is to consult the chapters of respective sensory pathways.
General exteroceptors
These receptors located in skin and subcutaneous tissue are subdivided into two groups –
1. Nonencapsulated.
2. Encapsulated.
􏲄onencapsulated receptors 􏲄􏲄ig􏲄 􏲄􏲄􏲄􏲄
These receptors do not present any specialized structures made up of modified cells of the tissue. These are free
endings of sensory nerve fibers in different forms which directly come in contact with tissue-cell or intercellular
spaces.
􏲄􏲄pes of nonencapsulated receptors:

1. Free nerve endings: These nerve fibers may be
myelinated or nonmyelinated. But finally ends of the fibers loose myelin sheath. Apart from the
Name of receptor Location Type of sensations carried Type of sensory nerve through which carried
1. General Skin and subcutaneous
Touch, pressure, pain, temperature Somatic sensory
exteroceptor tissue
2. Special
Nose, eye, ear, tongue Smell, vision, hearing, taste Somatic sensory. Special Visceral sensory–for taste
exteroceptor
3. General Sense of movement and position of
Muscles, tendons, joints Somatic sensory
proprioceptor body
4. Special
Ear Sense of body balance or equilibrium Somatic sensory
proprioceptor
Sense of pain, stretch, distension, Autonomic sensory (both sympathetic and
5. Interoceptor Viscera
compression parasympathetic)
Epidermis
{
Dermis
{
Free nerve endings
Hair follicle receptor
Merkel disk
Fig. 3.2 Nonencapsulated sensory end organ
46
End bulb of krause
skin, these receptors are also located in cornea, periosteum of bone and root of teeth. In skin, these free nerve
endings come in contact with basal cells of epidermis or with collagen fibers of dermis. Mostly, they carry pain
sensation. But they may be
stimulated by touch, pressure as well as temperature. 2. Hair follicle receptors: These are also free nerve
endings, but in different forms. Terminal unmyelinated ends of nerve fibers form a spiral arrangement around
the root of hair follicles below
the position of sebaceous gland.
These receptors are stimulated initially when the hair is bent. But so long hair remains bent, the receptors
remain silent. When hair is released, a second burst of stimulation occurs.
3. Merkel disks: These are also called ‘Tactile Dis-
ks of Merkel’. In this cases free nerve endings present small disk-shaped endings which come in contact with
specialized dark cells in the basal or deeper part of epidermis of skin. These cells are called Merkel cells.
These receptors are located in nonhairy skin. Stimulation of these receptors makes a person aware of degree of
pressure exerted while touching an object.
􏲄ncapsulated receptors 􏲄􏲄ig􏲄 􏲄􏲄􏲄􏲄
These receptors present outer connective tissue capsule surrounding a central core inside which lies the free
nerve ending. They are found in different size and shape.
1. Meissner’s corpuscles: These are the receptors for touch and that is why called Tactile Corpuscles of
Meissner. They are present in dermal papillae of skin and are mostly found in the skin of those parts of body
which are very sensitive to touch,
for example palm of hand, sole of foot, external genitalia, nipple and eyelids.
Meissner’s corpuscles are oval in shape and pre-
sent a capsule surrounding a central core made up of modified Schwann cells. At the center of the corpuscle
schwann cells are intermingled with free nerve endings.
These receptors gives a special tactile power to the skin. Because of their function, a person is able to feel two
points of skin touched close to each other. This is called power of two point discrimination.
2. Pacinian corpuscles: Pacinian corpuscles are
largest in size, widely distributed in the body, oval in shape being about 2mm in measurement.
They lie in dermis of skin and subcutaneous tissue,
being most abundant in palm, sole, breast. Apart from the skin, these are also found in the structures related to
joints, e.g. capsules, ligaments, synovial membrane. Firm pressure stimulates these receptors.
The oval corpuscles are 2mm in length and 0.5mm in diameter. Structurally it is made up of:
i. Outermost capsule.
ii. Inside the capsule, the central core is formed
by concentric layers of flattened cells.

iii. A large myelinated sensory nerve fiber pierces one pole of the corpuscle, looses its myelin sheath. The naked
nerve fiber traverses the center of central core of flattened cells and end
in a small swollen terminal.

Though pacinian corpuscle is known as pressure
receptor, it is also sensitive to vibration.

3. End bulbs: These are so called because they are bulbous and, spherical or fusiform in appearance at the end
of nerve terminal. They are of following
types:
a􏲄 􏲄nd 􏲄ulb of Ruffini: They are fusiform in outline
and present in the dermis of skin. Capsule of
Meissner’s corpuscle Pacinian corpuscle
End bulb of
􏱺uffini
Fig. 3.3 Encapsulated sensory end organ
47
Sensory nerve
Neuromuscular spindle
􏱺􏱺ntrafusal fiber􏱺
Neurotendinous spindle (Golgi tendon organ)
Fig. 3.4 Proprioceptive sensory end organs in skeletal muscle and its tendon
these receptors is cellular in nature and central core is made up of fine collagen fibers. Each corpuscle presents
multiple large unmyelinated nerve fibers ending within the center of collagen fibers. They are stretch receptors
and stimulated when skin is stretched.
b􏲄 􏲄nd 􏲄ulb of 􏲄rause: These are spherical in outline. The capsule is made up of cells as well as fibers. The
nerve fiber, after piercing the capsule, presents a club-shaped appearance at the central core of the bulb.
Though these end organs are enlisted here, these are not universally accepted as receptors. These are considered
by many as degenerating or regenerating nerve terminal rather than a receptor.
General proprioceptors
These are deep-seated receptors present in the muscles, tendons and joints. These receptors are—
1. 􏲄uscle 􏲄pindle or 􏲄euromuscular 􏲄pindle: These
sensory end organs are present in muscles.

2. 􏲄olgi 􏲄endon 􏲄rgan or 􏲄eurotendinous 􏲄pindle:
The receptors are present in tendons.

3. 􏲄roprioception sensation is also carried from 􏲄oint structures li􏲄e: Capsule, ligaments and synovial
membrane. These receptors are Pacinian
corpuscles which have been already discussed.
􏲄euromuscular spindle 􏲄􏲄ig􏲄 􏲄􏲄􏲄􏲄
Neuromuscular spindles are also known as muscle spindles. These are sensory end organs present in voluntary
muscles. They are more abundant in number in the muscle close to its junction with tendons. These receptors, on
stimulation, send information to the central nervous system regarding state of contraction
and position of voluntary muscles. Central nervous system uses this information for control of activity of
voluntary muscles.
Neuromuscular spindle is a fusiform or spindle- shaped organ whose long-axis is parallel to the length of a
muscle. Length of this end organ varies from 1–4 mm. It is enclosed by a connective tissue capsule. Inside the
capsule of this fusiform organ, units of this sensory receptors are situated. These are specialized muscle fibers
called intrafusal fibers. In contrast to these intrafusal fibers (inside the spindle), usual muscle fibers (myocytes)
of voluntary muscle, outside the spindle, are called e􏲄trafusal fibers which are effector in nature (Fig. 3.5).
The intrafusal fibers of neuromuscular spindle are of following two types –

1. Nuclear bag fibers.
2. Nuclear chain fibers.
Both these types of fibers are specialized muscle fibers. Their long-axis are parallel to the length of the spindle.
Their number in a spindle varies from 6–14. Each of them presents a central part (equatorial part) and two
terminal ends. Fundamentally terminal ends of both these fibers present transverse striations of voluntary
muscles and are contractile in nature. Central or equatorial part lacks striation property and present
accumulation of many nuclei (Figs 3.6 and 3.7).
Nu􏱧le􏱧r b􏱧􏱧 fibers: Equatorial part of these fibers presents spherical sac which is filled up with nuclei.
Length of nuclear bag fiber is more. Their ends project beyond the capsule and are fixed through their
attachment to connective tissue of extrafusal fibers. Nu􏱧le􏱧r 􏱧􏱧􏱧i􏱧 fibers: Structurally these differ from
nuclear bag fibers. These are shorter in length
48
Nuclear bag fiber 􏱺ntrafusal fibers
{
Nuclear chain fiber
Central equatorial parts containing nuclei
Terminal striated contractile parts
􏱺􏱺trafusal fibers
Capsule of neuromascular spindle
Fig. 3.5 Neuromuscular spindle composed of intrafusal fibers, and its relation with extrafusal fibers
and uniform in breath althrough. But the equatorial part presents collection of nuclei in the form of rows or
chains.
􏲄ot􏲄 intrafusal fibers are receptor as 􏲄ell as effector organs – It is important to notice at this stage that, though
the neuromuscular spindle are
proprioceptive sensory end organs, intrafusal fibers inside the spindle act as both receptor as well as effector.
Equatorial or central noncontractile part acts as receptors and terminal cross striated, contractile parts act as
effectors, which receive sensory and motor nerve fibers respectively.
Higher centers
• 􏱺asal ganglia
• 􏱺eticular formation • Cerebellum
1. 􏱺escending fiber tracts relay to
gamma motor neuron
2. Axon of gamma neuron innervates terminal contractile parts of intrafusal fibers
3. Stretching of both ends of ‘nuclear bag’
type of intrafusal fiber stimulates central
noncontractile part
􏱺. 􏱺Annulospiral endings􏱺 of afferent nerve fiber carry impulse to
spinal cord to stimulate alpha motor neuron through synapse
5. Axon terminal of alpha neuron innervates
e􏱺trafusal fiber
Fig. 3.6 Illustration to explain mode of function of neuromuscular spindle (nuclear bag fiber)
Mode of function of neuromuscular spindle (Figs 3.6 and 3.7): It is understood that central (equatorial)
nonstriated as well as noncontractile part of both nuclear bag and nuclear chain type intrafusal fibers are
receptor of voluntary muscle. From receptors proprioceptive sensations are carried by sensory root of spinal
nerves to the spinal cord. The terminal contractile parts of both type of intrafusal fibers receive efferent (motor)
nerves which are axons of small-sized (less than 25 microns) gamma motor neurons of gray mattter of spinal
cord. Again extrafusal fibers, lying outside neuromuscular spindle, are supplied by axons of large sized (more
than 25 microns) alpha motor neurons of spinal cord gray matter.
It is very important as well as interesting to note at this stage that functions of the neuromuscular spindle
proprioceptors is interrelated to the function of contractile terminal parts of intrafusal fibers supplied by 49
gamma motor neurons as well as function of extrafusal fibers supplied by alpha motor neurons.
Even when a muscle is in a resting stage, in unnoticed (subconscious) state of an individual, motor impulse is
carried from higher centers (Figs 3.6 and 3.7) of brain, e.g. basal ganglion, cerebellum, reticular formations to the
gamma motor neurons of spinal cord through descending motor fiber tracts (Figs 3.6 and 3.7). Impulse pass via
axons of gamma neurons to both the contractile ends of intrafusal fibers. When both the ends are contracted,
central noncontractile receptor part (proprioceptor) gets stretched and so stimulated. Sensory impulse is carried
from here through afferent (sensory) roots of spinal nerve to the gray matter of spinal cord where it forms
synapse with alpha motor neurons. Stimulation of alpha neurons helps to keep the extrafusal fibers so the whole
voluntary muscle in a partially contracted stage (in resting condition) which maintains thus the tone of the
muscle.
Neuromuscular spindle acting for stretch re􏱧e􏱧: In reference to the above stages of functions, even if
the influence of higher centers of brain, e.g.
Higher centers
• 􏱺asal ganglia
• 􏱺eticular formation • Cerebellum
1.􏱺escending fiber tracts relay to

gamma motor neuron
2. Axon of gamma neuron innervates terminal
contractile parts of intrafusal fibers
3. Stretching of both ends of ‘nuclear chain’
type of intrafusal fiber stimulates central
noncontractile part
4.‘Flower-spray endings’ of afferent nerve
fiber carry impulse to spinal cord to
stimulate alpha motor neuron through synapse
5. Axon terminal of alpha neuron innervates
e􏱺trafusal fiber
Fig. 3.7 Illustration to explain mode of function of neuromuscular spindle (nuclear chain fiber)
basal ganglia, cerebellum or reticular formation is not there to stimulate gamma neuron so the intrafusal fibers,
stretching of the voluntary muscle, causing elongation of intrafusal fibers at their ends will stimulate the central
receptor part. Sensory impulse will be carried to the spinal cord via afferent nerve which will synapse with motor
neurons supplying extrafusal fibers at the spinal cord segement level. This is called stretch reflex.
􏲄eurotendinous spindles 􏲄􏲄olgi tendon organ􏲄 􏲄ig􏲄 􏲄􏲄􏲄
These are fusiform or spindle-shaped proprioceptive receptors present in the tendons of voluntary muscle. They
are situated in the muscle-tendon close to its junction with fleshy belly. These receptors send information to the
50 central nervous system to make an individual aware of the state of tension of a muscle- tendon.
Like neuromuscular spindle, neurotendinous spindles are also fusiform in outline and covered by a connective
tissue capsule. But it is filled with parallel bundles of collagen fibers along long axis of the spindle. Fibroblasts
are larger and more in number in between the bundles of collagen fibers. The myelinated nerve pierces the
capsule, looses its myelin sheath and divides into finer branches which end in knob-like endings in between the
collagen fibers. When these fibers are stretched due to tension of a tendon, these knob-like endings are squeezed
and thus carry the impulse.
Mode of Function of Neurotendinous Spindle (Fig. 3.8): A tendon is continuation of a muscle. A
Afferent fibers carried from
Golgi tendon organ
Golgi tendon organ
muscle presents neuromuscular spindle (intrafusal fibers) and also extrafusal fibers. A tendon contains Golgi
tendon organs or neurotendinous spindles. These are receptors present in tendon. Increase in tension of a muscle
also causes increase in tension of tendon which stimulates the neurotendinous spindles. Afferent (sensory)
impulse is carried through sensory nerve root of spinal nerve to reach the spinal cord. Afferent nerve form
synaptic reflex arc with alpha neuron through an intermediate (internuncial) neuron. Alpha neuron ends in
extrafusal fibers which remain in a contracted state through stimulation of alpha neurons. But when impulse is
carried through internuncial neurons to alpha neuron, these internuncial neuron produces inhibitory effect to
alpha neuron, being inhibitory in nature. Result is the release of tension of the muscle.
􏲄eneral proprioceptors in relation to 􏲄oints

These sensory end organs are situated in the substance of capsule, ligaments and synovial membranes of joints.
Sense of position of joints and sense of their movements are detected when these receptors are stimulated.
Moreover sense of stretch, pressure and pain are also carried due to stimulation of these receptors.
Types: These are of following four types—

􏲄􏲄pe 􏲄: These are nothing but Ruffini endings structurally. They carry sense of position and
movement of the joint.
Internuncial neuron
Axon of alpha motor neuron supplies
e􏱺trafusal muscle fibers
Fig. 3.8 Illustration explaining mode of action of neurotendinous spindle (Golgi tendon organ)
􏲄􏲄pe 􏲄􏲄: Structurally these are Pacinian corpuscles. They carry the sense of pressure.
􏲄􏲄pe 􏲄􏲄􏲄: These are neurotendinous organ or 􏲄olgi tendon organ. As found in tendons, these are present in
ligaments. Due to stretching of ligament these carry in􏲄ibitor􏲄 impulse through internuncial neurons of spinal
cord, these prevents excessive movements of voluntary muscle.
􏲄􏲄pe 􏲄V: These are free nerve endings which carry pain sensations from synovial membrane.
RECEPTORS – OTHER WAYS OF CLASSIFICATION

51
􏱪cco􏱪􏱪in􏱪 to 􏱪at􏱪􏱪􏱪 of 􏱪ti􏱪􏱪lation
1. Mechanoreceptors:Thesearestimulatedbymec- hanical deformation, i.e. Receptors which

carry sense of –
i. Touch, pressure and stretch
ii. Sense of hearing – Through sound waves
iii. Sense of body balance (equilibrium).
2. Thermoreceptors: These are stimulated by change of temperature in the environment

surround-
ing them.
i. Rise of temperature – Heat

ii. Fall of temperature – Cold.
3. Chemoreceptors:Thesearestimulatedbychem- ical change in their environment.
i. Receptors for taste
ii. Receptors for smell.
4. Nociceptors:Thesereceptorsarestimulateddue to injury or damage in the tissue. Due to
stimulation of these receptor, unpleasant sensations are felt like-pain, irritation or
discomfort.
5. Photoreceptors: They are stimulated only by light causing perception of vision. Example–
Receptors in retina of eyeball called rods and cones cells.

6. Osmoreceptors: They are stimulated by change of osmotic pressure in the tissue.
􏱪t􏱪􏱪ct􏱪􏱪al Classification 􏱪􏱪i􏱪􏱪 􏱪􏱪􏱪􏱪
In general we know that receptors are specialized cells present in the peripheral tissue from where start the
sensory neurons to carry the impulse.
These afferent (sensory) neurons carry impulse to the central nervous system. Variation in this usual structural
pattern divides receptors in three different types. In first variety the specialized cells are epithelial cell. So the
receptors are called epit􏲄elial receptors 􏲄􏲄􏲄. Majority of the receptors are examples of this type. Sometimes,
these specialized cells forming receptors are modified neurons which are present in the epithelial lining, as are
the bipolar neurons in the epithelial linings of nose, carrying sensation of smell (olfactory sensation). These are
called neuroepit􏲄elial receptors 􏲄􏲄􏲄. In third variety, no specialized cells are present to be defined as receptors.
In this case, free nerve endings of peripheral dendritic processes of first order of sensory neurons themselves act
as receptors. Examples are nonencapsulated exteroceptors (cutaneous receptors). These are named as neuronal
rece􏲄 ptors 􏲄􏲄􏲄.
MOTOR END ORGANS (EFFECTORS)
Effectors are the specialized junctional areas where terminal ends of motor nerve fibers come in contact with
effector organs. These effector organs are of following three types—
1. Somatic effectors: These are skeletal muscle fibers (myocytes) which receive terminal ends of somatic motor
nerve fibers. These specialized sites are known as somatic neuromuscular or myoneural junctions.
2. Visceral effectors: These are smooth muscle fibers (myocytes) which receive terminal ends of
1. Epithelial receptor 2. Neuroepithelial receptor 􏱺􏱺ipolar 3. Neuronal receptor (Free nerve (Pacinian corpuscles) cells of nasal mucosa) endings)
Fig. 3.9 Structural classification of receptors
autonomic motor nerve fibers (sympathetic or parasympathetic). These specialized junctional sites are known
as visceral neuromuscular or myoneural junctions.
3. Secretomotor effectors: These are specialized junctional areas between secretomotor autonomic nerve
endings and specialized contractile cells in the walls of alveoli (acini) of exocrine glands. These contractile cells
are known as myoepithelial cells.
52
􏱪o􏱪atic 􏱪􏱪􏱪􏱪o􏱪􏱪sc􏱪la􏱪 􏱪􏱪nction 􏱪􏱪􏱪on􏱪􏱪􏱪al 􏱪􏱪nction􏱪
Each of the somatic (skeletal) muscle fibers gets direct contact with endings of motor nerve fibers for innervation.
This site of contact is called neuromuscular junction or myoneural junction.
These muscle fibers are of two types—

i. 􏲄􏲄trafusal fibers: Which receive endings of
alpha neuron
ii. 􏲄ntrafusal fibers: Which receive endings of
gamma neuron. It has already been studied
Axon terminal
that both terminal contractile ends of intrafusal
fibers receive gamma motor nerve endings. Myoneural junctions, in relation to above two types of muscle fibers,
may show following variations. A. Motor end plates or ‘en plaque’ endings (Fig. 3.10): Most of the
myoneural junctions are of this variety. In these types, the axon terminal of a motor nerve comes to an oval
specialized area of a muscle fiber at its center. This specialized oval area at the surface of muscle fiber is called
sole plate. The junctional area between sole plate and axon terminal
is known as motor end plates.
B. ‘En Grappe’ endings (Fig. 3.11A): In this variety, axon terminal runs along the length of muscle fiber.
While running along, it divides, into series of short branches which end into ‘knob-like’ endings on the surface of
muscle fiber.
C. Trail endings (Fig. 3.11B): In this type, axon terminal run along the length of muscle fibers and end in
multiple finer endings.
‘En Grappe’ and trail endings are found in intrafusal fibers of muscle spindles.
Motor nerve fiber
S􏱺eletal muscle fiber
(myocyte)
Motor end plate (‘en- plaque’ ending)
Fig. 3.10 Motor end plate
Axon terminal
Axon of a motor neuron

53
A
‘En-grappe’ ending
Noncontractile
equatorial part containing nuclei
Striated contractile part of
muscle fiber
Axon terminal
Noncontractile equatorial part containing nuclei
Striated contractile part
Figs 3.11A and B Neuromuscular junction of intrafusal fibers. A. ‘En-grappe’ endings, B. Trail endings
MOTOR UNIT (FIGS 3.12A AND B)
A motor unit is defined as a single alpha motor neuron and number of skeletal muscle fibers (extrafusal fibers)
innervated by it. So composition of a motor unit is as follows:
i. A motor neuron cell body in central nervous system (alpha neuron).

ii. Its axonal process coming out as motor nerve fiber.
iii. Number of muscle fibers (myocytes) innervated by a single axon.
Depending upon the number of muscle fibers supplied by a single motor neuron, a motor unit may be of two
types—
1. Large: When one axonal process supplies more
number of muscle fibers, as many as(!) 500, as found in coarse muscle for gross movements, like Gluteus
maximus (muscle of buttock).
2. Small: When one axonal process supplies less number of muscle fibers (10 in number), as found in small
muscles of hand for finer movements.
􏱪􏱪􏱪􏱪o􏱪􏱪sc􏱪la􏱪 􏱪􏱪nction o􏱪 􏱪􏱪on􏱪􏱪􏱪al 􏱪􏱪nction
It is called motor end plate which is defined as specialized junction between terminal end of one of the
divisions of axon of a motor neuron (neural element) and a skeletal muscle fiber (muscular element).
A motor nerve enters inside a skeletal muscle along with its blood vessels for innervation through a point called
neurovascular hilum. Inside the muscle, the nerve divides further into number of axons. One axonal process
divides into number of branches. Each of these branches of axon presents a terminal knob- like endings
(telodendria). This terminal swelling comes in contact with a gutter or depression on middle of surface of a
single muscle fiber (myocyte).
54
A
Skeletal
muscle fiber
Motor end plate
Axon terminal

B
Skeletal
muscle fiber
Motor end plate
Axon terminal
Figs 3.12A and B Motor unit. A. Large motor unit, B. Small motor unit
This junctional area is called motor end plate (neuromuscular junction or myoneural junction).
Structure of motor end plate (Fig. 3.13)
Motor end plate presents structural characteristics similar to that of a typical synaptic junction between two
neurons. Structure of motor end plate shows following 3 components.
1. Neural element: It is the terminal, nonmyelinated, swollen end of the division of axon of motor neuron
(Telodendria). It is called s􏲄naptic knob.
2. Muscular element: It is the central, raised surface of a muscle fiber with a gutter which comes in contact
with synaptic knob. This is called sole plate.
3. Synaptic cleft: It is the gap between neural and muscular element measuring 􏲄􏲄􏲄􏲄􏲄 mili micron or
nanometer􏲄
Synaptic knob at the terminal end of division of axonal process is swollen because axoplasm is crowded here
with—
i. Many mitochondria.
ii. Large number of electron-dense, membrane
bound vesicles called pres􏲄naptic vesicles. These vesicles are filled with Acet􏲄lc􏲄oline which acts as
neurotransmitters.
At the site of motor end plate, sole plate is characterized by a surface elevation which is at the middle of the
muscle fiber. This elevation is due to condensation of sarcoplasm (cytoplasm of muscle fiber) which shows
granular appearance beneath the sarcolemma (cell membrane of muscle fiber). This area also presents
accumulation of more number of nuclei􏲄 mitoc􏲄ondria􏲄 􏲄olgi apparatus and endoplasmic reticulum.
The raised surface of sole plate presents a depression called primary cleft which is related to axon terminal. But,
as already mentioned, axolemma
55
Presynaptic vesicle Synaptic cleft
Sarcoplasm
Mitochondria Nucleus
(cell membrane of axon) at the site of axon terminal is separated by synaptic cleft from primary cleft of sole plate
covered by sarcolemma. Surface of primary cleft is thrown into number of foldings to increase the surface area.
These are called secondary cleft. Bottom (floor) of the secondary cleft presents specialized features called
receptors.
Mechanism of neuromuscular transmission
When the nerve impulse reaches axon terminal at the site of neuromuscular junction, Acetylcholine is released
from presynaptic vesicles into the synaptic cleft through a process called exocytosis. Rele- ased Acetylcholine
diffuses at a high speed through synaptic cleft and binds with the receptors at the secondary cleft of postsynaptic
membrane of sole plate. The receptors get activated. Activation of receptors causes depolarization of postsynaptic
membrane which results in muscular contraction due to generation of action potential.
Contraction of a muscle fiber (so also the whole muscle) is to be followed by relaxation. This becomes possible
because, as soon as depolarization occurs to cause contraction of muscle fiber, Acetylcholine is broken down
(hydrolyzed) by the enzyme cholin- esterase into choline and acetic acid. This enzyme is bound to both pre as well
as postsynaptic membrane. Choline is reutilized back into the axoplasm for re- synthesis of acetylcholine.
Axolemma Myelin sheath
Synaptic knob
Sole plate Sarcolemma
Receptor
Myofilaments
Fig. 3.13 Structure of motor end plate
muscle spasm, function of this drug can be utilized. It becomes possible because the drug binds with the
receptors at postsynaptic membrane, thus not allowing acetylcholine to come in contact with the receptors to
result depolarization for generation of action potential.
􏱪􏱪ast􏱪􏱪nia 􏱪􏱪a􏱪is 􏱪 an 􏱪􏱪toi􏱪􏱪􏱪n􏱪 􏱪is􏱪as􏱪
Myasthenia gravis is an autoimmune disease which is characterized by generalized muscular weakness and
muscular fatigue. Muscles of eye, face, respiration and swallowing are mostly affected. This disorder is due to
formation of an antibody. This antibody binds with many (not all) of the receptors which are thereby destroyed.
So acetylcholine finds less number of receptors at postsynaptic membrane to bind for generation of action
potential. This disorder can be compensated by administration of a drug named neo- stigmine which posseses
anticholinesterase activity which prevents breakdown of acetylcholine at the synaptic cleft.
Myoneural junction of smooth muscle
This does not show classical structure of neuromuscular junction or motor end plate. A􏲄on terminal does not
come in contact 􏲄it􏲄 surface of muscle fiber. Rather, there is considerable gap between the two. Terminal
segment of axon is nonmyelinated and may be covered by cytoplasm of Schwann cells. At the terminal end
axoplasm presents vesicles containing neurotransmitter. In case of parasympathetic nerve ending
neurotransmitter is acetylcholine, but in
􏱪􏱪􏱪􏱪o􏱪􏱪sc􏱪la􏱪 􏱪loc􏱪in􏱪 􏱪􏱪􏱪nt
Tubocurarine is a drug which blocks neuromuscular transmission. In clinical conditions causing violent
56
Secretomotor nerve axon
Fig. 3.14 Secretomotor nerve endings supplying myoepithelial cells related to acini of exocrine gland
Epithelium lining acini of exocrine gland
Myoepithelial cell
Axon terminal
case of sympathetic it is catecholamine (usually noradrenaline). In sympathetic system, monoamine oxidase is

the enzyme which destroys catecholamine. In relation to muscle fibers of gastrointestinal and urinary tract, some
autonomic nerve endings release another variety of neurotransmitter called adenosine triphosphate which is
inhibitory in nature.
NERVE ENDING RELATED TO EXOCRINE GLAND ACINI (FIG. 3.14)
Same as myoneural junction of smooth muscle, in case of nerve endings of secretomotor fibers to
glandular acini or alveoli, there is no specialized junctional area. Glandular alveoli are lined by single layer of
cells resting on basement membrane. Close to the basement membrane in the substance of loose fibroconnective
tissue there are some specialized cells which are contractile in nature. These are called m􏲄oepit􏲄elial cells.
Autonomic secretomotor axon terminals come in relation to these myoepithelial cells close to the basal surface of
acinar cells. Following release of neurotransmitter (acetylcholine), myoepithelial cells contract and squeeze the
acinar wall leading to discharge of glandular content through the duct.
DEFINITION AND SITUATION
Spinal cord is the distal, narrow, cylindrical and elongated part of central nervous system which is situated in upper
two-thirds of vertebral canal as a continuation of medulla oblongata of hindbrain (Fig. 4.1).
ROLE OF SPINAL CORD AS A PART OF CENTRAL NERVOUS SYSTEM
1. It provides innervation (nerve impulse) to the trunk and limbs through its peripheral outflow known as
spinal nerves.
2. Itreceivessensoryinformationfromthereceptors distributed peripherally in the trunk and limbs and transmits
to the brain.
3. It contains cell groups at some levels (not throughout whole length of spinal cord) which form spinal
autonomic centers (sympathetic and parasympathetic) to send impulses to the autonomic effector organs
(smooth muscles and exocrine glands) and to receive sensory information from the visceral wall.
4. It forms local circuit (at its segmental level) known as reflex arc which regulates some bodily functions at
unconscious level.
EXTENT
Beginning: Spinal cord begins as continuation of medulla oblongata beyond foramen magnum at the level of
upper border of 1st cervical vertebra (atlas).
Termination: Spinal cord terminates as a conical end known as conus medullaris at the level of intervertebral
disk between first and second lumbar vertebrae. A connective tissue filaments known as Fil- um terminale extends
from conus medullaris downwards to be attached to the back of first piece of coccyx.
IMPORTANT NOTES IN CONNECTION WITH TERMINATION
Upto third month of intrauterine life, rate of growth of body wall so also the vertebral column is coextensive with that
of spinal cord. Subsequently vertebral column with the trunk grows at a rapid rate than spinal cord, when appears
the disparity in length of the two. At birth spinal cord is found to extend upto lower border of body of third lumbar
vertebra.
In 40% cases of adult, spinal cord extends upto the level of lower border of second lumbar vertebra or the disk
between second and third lumbar vertebra. On rare occasions, spinal cord terminates at the level of lower border of
twelfth thoracic vertebra.
The knowledge of termination of spinal cord is important for the clinicians to avoid injury to the spinal cord during
lumbar puncture to take out cerebrospinal fluid.
PARAMETERS OF SPINAL CORD

Length: 45 cm Weight: 30 gm
Spinal Cord
4
58
Medulla oblongata Spinomedullary junction
Cervical part
Thoracic part
Lumbar part
Sacral part
1 Coccygeal segment
Conus medullaris
Filum terminale
Spinal nerve of left side seen from lateral view
Spinal cord
Cauda equina
Fig. 4.1 Spinal cord (lateral view)—the distal, narrow, elongated and tubular part of central nervous system
Segments: Spinal cord is made up of 31 numbers of units known as segments of spinal cord. Adjacent
segments cannot be demarcated on the surface. Each of the segments gives rise to one pair of spinal nerves (right
and left). Each of the spinal nerves shows surface attachment of one ventral (motor or efferent) and one dorsal
(sensory or afferent) nerve root. The two roots unite within the vertebral canal to form a mixed spinal nerve
which finally comes out through intervertebral foramen.
Therefore, an universal truth is learnt that ventral root of a spinal nerve is made up motor fibers and its dorsal
root is composed of sensory fibers only. This is known as Bell-Magendie’s law.
It is important to note at this stage that all the spinal nerve (31 pairs) are mixed in nature, composed of motor as
well as sensory components. But a cranial nerve (out of total 12 pairs) may be mixed, purely motor or purely
sensory.
REGIONAL CLASSIFICATION OF SPINAL CORD SEGMENTS (FIG. 4.1)
31 segments of spinal cord are regionally classified as follows:
Cervical – 8
Thoracic – 12
Lumbar – 5
Sacral – 5
Coccygeal – 1
It is to be noted here that number of cervical
vertebrae are 7 and coccygeal pieces are 4. But the numbers of thoracic (12), lumbar (5) and sacral (5) cord
segments correspond with the same number of respective regional vertebrae.
Each of the spinal cord segments gives rise to a pair of spinal nerve of corresponding name and number. Each
spinal nerve, as already mentioned is formed by a ventral motor (efferent) and a dorsal sensory
Spinal Cord
59
Anterolateral sulcus
Ventral root of spinal nerve coming out through anterolateral sulcus
Posterior root ganglion Posterolateral sulcus
Dorsal nerve root coming out through posterolateral sulcus
A spinal nerve
Fig. 4.2 Segments of spinal cord (left lateral view) showing ventral and dorsal roots of spinal nerves coming out through corresponding sulcus
(afferent) root. Attachment of ventral roots forms a fine and shallow anterolateral sulcus and similarly
posterolateral sulcus is defined along the line of attachment of dorsal nerve roots. Dorsal nerve roots, close to
the site of surface attachment present a small enlargement known as posterior root ganglion which contains the
cell bodies of first order of sensory neurons located outside the central nervous systems (Fig. 4.2).
EXIT OF SPINAL NERVES FROM VERTEBRAL FORAMEN
All the spinal nerves come out of vertebral canal through the corresponding intervertebral foramina except fifth
sacral nerve and coccygeal nerve which
come out through sacral hiatus. To adjust the disparity of numbers of cervical spinal cord segments (8) and
cervical vertebra (7), cervical spinal nerves (1st to 7th) come out above the pedicles of corresponding vertebra and
8th cervical nerve comes out below the pedicle of 7th cervical vertebra, through the intervertebral foramen
between 7th cervical and 1st thoracic vertebra.
As the spinal cord is shorter in length than the vertebral column, lower spinal nerves (lumbar, sacral and
coccygeal) are to descend through the vertebral canal in the form of a bunch to reach corresponding
intervertebral foramen. These bunch of nerves are known as cauda equina as they look like a horse’s tail (Fig.
4.3).
Lower end of spinal cord
Conus medullaris Filum terminale
Bunch of lower spinal nerves forming cauda equina before their exit through respective intervertebral foramina
Exit of vth sacral and coccygeal nerves through sacral hiatus

Fig. 4.3 Lower spinal nerves form cauda equina before they come out through corresponding intervertebral foramina at a lower level
60
Cervical enlargement (C3–T2 Segments)
Key to remember level of enlargement
Lumbosacral enlargement (L1–S3 Segments)

13
Fig. 4.4 Enlargements of spinal cord
Key to remember level of enlargement
CORRELATION OF SPINAL CORD SEGMENTS WITH VERTEBRAL LEVEL
More lower is the segment of spinal cord, its distance from corresponding intervertebral foramen so also the
corresponding vertebra is more. Interrelations of their levels are as follows:
ENLARGEMENT (FIG. 4.4)
The spinal cord is almost cylindrical althrough its length. However, it presents two expansions as enlargements.
These are at the cervicothoracic (C3 – T2 segments) and lumbosacral (L1–S3 segments) levels (Fig. 4.4). These
enlargements appear in fetal life with the formation of upper and lower limb buds, because of more amount of
motor neurons in these segments to supply limb musculature and stretching of nerve fibers arising from the
plexuses for upper and lower limbs.
SURFACE FEATURES (FIG. 4.5)
Linear depression along the anterior and posterior median line of spinal cord are known as anterior median
fissure and posterior median sulcus respectively. Anterior (ventral) median fissure is 3mm deep, but posterior
(dorsal) median sulcus is comparatively shallower. Besides, linear depressions along the lines of attachment of
ventral (motor) and dorsal (sensory) nerve roots are respectively known as anterolateral and posterolateral
sulcus. Spinal arteries and venous tributaries run along the sulci and fissure. Single unpaired anterior spinal
artery
Spinal cord
Vertebral level
segments
same level = C3 - 1 = C6
- 2 = T3
- 3 = T5
Upper cervical Lower carnival Upper thoracic Lower thoracic Lumbar (upper) C3 C7 T5 T8 L3 L5 S1
Lumbar (lower) Sacral /coccygeal S5  - 4/5 = T11
 - 4/5 = T12 - 6/10 = T12 -
6/10 = L1
Clinical Importance of Correlation of Levels
In case of spinal injury, fracture dislocation of vertebra may cause lesion of spinal cord segment of the same level.
A clinician will be able to judge of level of spinal segment affected in spinal injury from the above mentioned
guidelines. Level of fracture dislocation of vertebra is counted through identi- fication of vertebral landmark.
61
Midline posterior spinal vein in posterior median sulcus
Spinal nerve
Lateral anterior spinal vein
Anterior spinal artery with corresponding vein in anterior median fissure
runs down along anterior median fissure, whereas paired bilateral posterior spinal arteries descend along
posterolateral sulci. Each of the fissure and sulci are occupied by one of six (3 anterior and 3 post-
erior) spinal veins.
COVERINGS (MENINGES) AND SPACES AROUND THE SPINAL CORD (FIG. 4.6)
Coverings (meninges) of spinal cord are the following from outside inwards.
1. Dura mater
Subarachnoid space containing CSF

Dura mater
Meninges
{ Arachnoid
Spinal Cord
Posterior median sulcus
Posterolateral sulcus with entry of posterior root of spinal nerve and presence of posterior spinal artery and vein
Anterolateral sulcus with exit of anterior root of spinal nerve and presence of anterior spinal vein
of spinal cord
mater Pia mater
These superimposed coverings are either in close contact to each other (dura and arachnoid) or separated by a
space (arachnoid and pia).
Dura Mater
This is tough and dense fibrous membrane made up of connective tissue which contains abundant collagen fibers.
It encloses spinal cord as well as cauda equina. Proximally dura mater of spinal cord extends upto
Subarachnoid septum Wall of vertebral canal
Subarachnoid sheath Spinal nerve
Intervertebral foramen
Ligamentum denticulatum
Linea splendens
Fig. 4.5 Surface features of spinal cord
2. Arachnoid mater 3. Pia mater.

Epidural space
Epidural (internal vertebral) venous plexus in epidural space
Fig. 4.6 Coverings (meninges) and spaces around spinal cord
62
foramen magnum of cranium above which it is continuous with inner (meningeal) layer of dura mater
of brain. Below, dura mater extends upto lower border of body of second sacral vertebra beyond lower end of
spinal cord to enclose cauda equina and upper larger part of filum terminale. Beyond that level, dura mater is
continued downward enwrapping external part of filum terminale to blend with periosteum of first piece of
coccyx. At the level of each segment of spinal cord dura mater is prolonged outwards around the spinal nerve to
be attached to the margin of intervertebral foramen. Inner surface of spinal dura is in close contact with
arachnoid mater. But outer surface of dura is separated from vertebral canal by a space known as epidural space.
This space contains loose areolar tissue containing fat in semiliquid state. The epidural space also contains
plexus of veins known as epidural venous plexus or internal vertebral venous plexus.
Arachnoid Mater
Arachnoid mater is a thin transparent membrane covering the spinal cord. It extends upwards beyond foramen
magnum to be continuous with arachnoid of brain and below extends like dura mater up to second sacral
vertebra. Unlike dura mater, arachnoid is prolonged for a short distance around spinal nerves beyond
intervertebral foramen. Arachnoid is separated from pia mater with spinal cord by a space known as
subarachnoid space, which is continuous above with the same space around brain. The subarachnoid space (of
spinal cord as well as brain) contains a thin watery fluid known as cerebrospinal fluid. Subarachnoid space
containing cerebrospinal fluid is more prominent below lower end of spinal cord (L 2–S2).
Spinal Subarachnoid Space and Clinical Anatomy of Lumbar Puncture (Fig. 4.7)
Spinal subarachnoid space is the space beneath the arachnoid mater covering the spinal cord. It is continuous
with the subarachnoid space over the brain and contains cerebrospinal fluid. The subarachnoid space around the
spinal cord becomes more spacious below the termination of spinal cord (L 2) upto its lower limit (S2), which
contains cerebrospinal fluid of considerable amount and is known as lumbar cistern.
Clinical Importance of Epidural (Internal- vertebral) Venous Plexus
This venous plexus extends throughout whole length of vertebral canal and it is proximally connected to the
veins of skull. In the vertebral canal it receives basivertebral veins and also veins from the viscera (e.g. prostate).
These communications may be hazar- dous to cause spread of cancer cells (metastasis) from viscera like prostate
to vertebral bodies and even cranial bones.
Lumbar vertebrae
Sacrum
Coccyx
L1
L2
L3
L4 L5
Conus medullaris of spinal cord
Subarachnoid space
Lumbar puncture needle inserted between L3 and L4 spine
Interspinous and supraspinous ligaments
Dura and arachnoid ending at the level of lower border of S2 vertebra
Filum terminale attached to back of 1st piece of coccyx
S1
S2
S3
S4 S5
Fig. 4.7 Distal part of vertebral canal in sagittal section and prominent spinal subarachnoid space with illustration for site of lumbar
puncture
63
Lumbar Puncture (Spinal Tap)
Various diseases of spinal cord so also whole central nervous system may cause abnormal increase in normally
freely flowing quantity of cerebrospinal fluid or may cause change of physical, biochemical or microscopical
characteristics of cerebrospinal fluid. In these cases for diagnosis and treatment of the disease, cerebrospinal
fluid (CSF) may be required to be drawn out from lumbar cistern below the termination of spinal cord. Again
some drugs may be required to be injected into the spinal subarachnoid space (lumbar cistern) for treatment of
some neurological disease or for induction of (spinal) anesthesia. This procedure is known as lumbar puncture
(spinal tap).
Anatomical Guidelines for Lumbar Puncture (Fig. 4.7)
Site: Puncture (introduction of needle cannula to draw fluid) is done through the interspinous space of
vertebral column.
Level: Spinal cord normally extends upto the level of intervertebral disk between 1st and 2nd lumbar
vertebrae. On rare occasion it may extend lower down upto 2nd lumbar vertebra. Ideal level for puncture is the
space between 3rd and 4th lumbar spines.
How to locate the levels of lumbar spines: Trans- cristal line is the line passing through the level of highest
point of both iliac crests. It passes through the level of 4th lumbar spine which will help to locate the
interspinous space between 3rd and 4th lumbar spines.
Position of body: Trunk of the body so also the vertebral column must be ventrally flexed either in lateral
lying down position in bed or in sitting position to achieve two advantages.
i. Interspinous space becomes wider.

ii. Lower end of spinal cord is raised slightly
upwards.
Knowledge of Planes of Puncture
During introduction of the needle-cannula, gentle and uniform (sustained) pressure is to be applied. After
supraspinous and interspinous ligaments, and tough layer of dura mater are penetrated, suddenly a loss of
resistance is felt. It confirms that needle has reached the subarachnoid space. At this stage patient may feel
tingling root pain as nerve of cauda equina is touched by the tip of needle. But it is just for a while as it floats
away in the cerebrospinal fluid.
Pia Mater
Pia mater is a thin delicate membrane which closely invests the surface of spinal cord. It is made up of fine
Spinal Cord
layer of fibroreticular tissue into which is embedded network of fine blood vessels. Spinal pia mater presents
following special features.
Filum terminale: It is a thin, white, delicate and shining thread-like structure which extends vertically
downwards from conus medullaris of spinal cord. Its lower end is attached to the dorsal aspect of first piece of
coccyx.
Length – 20cm
Structural composition: It is mainly composed of nonnervous pial connective tissue. But its upper end also
contains nervous element. It is supposed to be rudiments of 2nd, 3rd and 4th coccygeal nerve.
Central canal of spinal cord extends beyond conus medullaris for about 5mm in the upper end of filum terminale,
which is called terminal ventricle.
Parts: Spinal dura and arachnoid end at the level of 2nd sacral vertebra. But filum terminale extends from L 1/L2
vertebra to 1st piece of coccyx. That is why it is divided into following two parts.
1. Filum terminale internum: It is proximal 15cm lying inside subarachnoid space.
2. Filumterminaleexternum:Itisdistal5mmwhich is beyond S2 vertebra.
Linea splendens: It is condensation of pia mater along the anterior median line of spinal cord, where it dips
into anterior median fissure.
Subarachnoid septum: It is a thin fenestrated pial septum along the posterior median line of spinal cord
extending from posterior median sulcus to deep surface of arachnoid mater.
Ligamentum denticulatum: This is a bilateral pial septum extending throughout whole length of spinal
cord in between lines of attachment of ventral and dorsal nerve roots. Lateral margin of ligamentum
denticulatum is ragged and presents 21 tooth like pointed projections. First pair is situated above the margin of
foramen magnum of skull. Last pair is longer and oblique. It is attached at the level of conus medullaris and
descends obliquerly downwards and laterally between twelfth thoracic and first lumbar nerves.
INTERNAL STRUCTURE OF SPINAL CORD
Embryological background: Knowledge of internal structure of spinal cord is based on fundamental

concept of its embryological background. Spinal cord is developed from caudal elongated narrow tubular portion
of neural tube which is ectodermal in origin. At 4th week of intrauterine life surface ectoderm along the midline
gets condensed anteroposteriorly known as neural plate (Fig. 4.8). Neural plate lies dorsal to notocord which is
related on either side to
64 Ectoderm
Mesoderm Endoderm
Neural plate
Notochord
Neural groove
B
Neural crest
Surface ectoderm
Ependyma
Neural tube
Neural crest cells
Proliferating cells
􏱰􏱰
Figs 4.8A to F Illustrating development of spinal cord. A. Embryonic disk (Sectional view), B. Formation of neural plate, C. Formation of
neural groove, D. Formation of neural crest, E. Neural tube lined by single layer neuroectodermal cells, F. Proliferation of neural tube cells
secondary mesoderm. The neural plate gradually becomes grooved or folded cephalocaudally along its long axis to
form neural groove. This causes elevation of two parallel ridges known as neural crests. It is followed by two
changes. Some cells of neural crest get detached and migrate ventrally on either side of midline beneath surface
ectoderm. These are named neural crest cells. Secondly, the neural groove gradually deepens more and more
with prominence of both sided neural crests which finally fuse to form neural tube. Fusion starts from the middle
and proceed toward both cephalic and caudal ends. Just before 6th week of intrauterine life, when closed neural
tube is formed, cephalic and caudal ends present openings known as anterior and posterior neuropores. Cephalic
end of neural tube shows three dilatations known as forebrain, midbrain and hindbrain vesicles which will from
brain. Caudal narrow, elongated tubular part of neural tube forms spinal cord.
FORMATION OF DIFFERENT ZONES OF SPINAL CORD (FIG. 4.9A)
The whole neural tube is initially lined by single layer of ectodermal cells known as neuroectoderm. Part of the
tube giving rise to spinal cord, shows proliferation of cells same as proximal part. The canal of neural tube
becomes a narrow cleft and shows thickening of lateral wall. Its thin dorsal and ventral walls are known as roof
plate and floor plate. The original inner lining is known as ependymal layer or matrix cell layer. This layer of
cells ultimately forms columnar epithelium lining the central canal of spinal cord known as ependymal cells. Free
surface of these cells shows presence of ultramicroscopic finger-like, nonmotile processes known as stereocillia.
Proliferated daughter cells, pushed to the periphery, form mantle layer. Cells of this layer shows differentiation
into two types which are called neuroblasts and spongioblasts. Neuroblasts
Spinal Cord
65
Alar lamina
Mantle
{ layer
Basal lamina
Sensory neurons developed in alar lamina
Motor neurons developed in basal lamina
Neural crest cells Ependyma
Mantle zone
Marginal zone
(zone)
will form neurons of spinal cord whose processes will be elongated to be pushed to the periphery to form more
peripheral marginal zone. Spongioblasts will form supporting cells (neuroglia) of larger size known as macroglia
(astrocytes and oligodendrocytes). The most of the glial cells are pushed to the peripheral marginal zone. Cells
bodies of neurons present in the mantle zone showing grayish appearance will form central gray matter of spinal
cord. Processes of neurons (nerve fibers) located in peripheral marginal zone will be myelinated by
oligodendrocyte group of cells of macroglia. This myelination will give whitish appearance of marginal zone of
spinal cord for which it is called white matter.
FORMATION OF DIFFERENT FUNCTIONAL CELL GROUPS (FIG. 4.9B)
1. Cells of ependymal (matrix) layer: As already stated, these are original cell layer lining central canal of
spinal cord called ependymal cells. The cells lined by stereocilia posses absorptive function.
2. Cells of mantle zone: On either side of midline the neurons developed from neuroblasts are
divided into dorsal and ventral groups by two parallel cephalocaudal linear grooves on lateral wall of ependymal
lining called sulcus limitans. Ventral and dorsal groups of neurons are known as Basal and Alar lamina
respectively. Neurons of basal lamina will be motor neurons and those of alar lamina will form sensory
neurons. Alar laminae of both sides are apposed towards each other so obliterating dorsal part of central canal of
spinal cord. Two basal laminae diverge ventrolaterally forming future ventral median fissure of spinal cord.
The neurons of basal lamina from two different cell columns as –
i. Somatic efferent (motor): Medial and close to floor plate. The processes of these neurons will supply voluntary
(skeletal) muscles after leaving the spinal cord through ventral root of spinal nerve.
ii. Visceral efferent (motor): Lateral to and away from floor plate. Their processes leave spinal cord also through
ventral root of spinal nerve as preganglionic fibers for involuntary (smooth) muscles and exocrine glands.
Fig. 4.9A Differentiation of mantle and marginal zones
Fig. 4.9B Formation of different fundamental cells of spinal cord
Posterior root ganglion cells
Spinal nerve

The neurons of alar lamina form the following cell columns.
i. Somatic afferent (Sensory): This cell column is medial and close to roof plate. Neurons of this column receive
connections from the sensory cells outside central nervous system (posterior root ganglia cells) carrying somatic
sensation from peripheral receptors.
ii. Visceral afferent (Sensory): These neurons form cell column which is lateral to somatic afferent column and
away from roof plate. They receive sensory impulse from the wall of viscera via posterior root ganglia cells.
Somatic efferent and somatic afferent cell columns of gray matter of spinal cord extend throughout whole length
66 of spinal cord to be present in all 31 segments of spinal cord. Visceral efferent and visceral afferent cell columns
being close to each other in the intermediate and lateral area of gray matter form spinal center of autonomic
nervous system. But these cell groups, unlike somatic centers do not extend throughout all the segments of
spinal cord. Neuronal groups of these columns extending from 1st thoracic (T1) to 2nd lumbar (L2) segments of
spinal cord form sympathetic center and those of second, third and fourth sacral (S2, S3 and S4) segments form
parasympathetic center of spinal autonomic nervous system.
Beside the above four groups of neurons developed in the mantle zone (gray matter) of spinal cord, some cells are
known as interneurons or internuncial neurons which are functionally connecting neurons. 3. Cell of marginal
zone–(Marcoglia): They are
supporting cells called marcoglia group of neuroglia which are astrocytes and oligodendrocytes. Some glial cells
are also present in mantle zone. Astro- cytes form connecting link between neurons and capillaries for selective
transport of nutritive substances from capillaries to neurons and prev- enting entry of toxic materials (blood
neuron barrier).
4. Migratedcellsfrombloodstream(Microglia): Microglia are characterized by letter M. It is mesodermal in

origin, derived from, monocytes and migratory in nature to act as macrophages.
PERIPHERAL OUTFLOW OF SPINAL CORD
Spinal Nerves
Spinal cord is made up of 31 segments. These segments are numbered regionally as Cervical-8, Thoracic-12,
Lumbar-5, Sacral-5 and Coccygeal-1. A pair of nerve (right and left) is attached to the surface of each of
the segments of spinal cord by two roots known as anterior (ventral) and posterior (dorsal) roots. Along the
length of spinal cord anterior and posterior roots are attached along the lines of anterolateral sulcus and
posterolateral sulcus respectively. Anterior or ventral roots of spinal nerve are outgoing (efferent) fibers of spinal
nerve which go to the peripheral target organs, e.g. muscles or glands. They are called motor or efferent fibers.
Posterior or dorsal roots of spinal nerve are the incoming (afferent) fibers of spinal nerve which carry
informations from peripheral sensory end organs known as receptors. They are called sensory or afferent fibers.
All spinal nerves are mixed nerve: It is very clear from the above that each of the spinal nerves, either right or
left, is composed of outgoing or efferent (motor) and incoming or afferent (sensory) fibers. So all of them are
considered as mixed nerve.
It is to be remembered at this stage that, out of 12 pair of cranial nerve, some are mixed like spinal nerve,
whereas others are either motor or sensory.
INTERNAL STRUCTURE OF SPINAL CORD
Internal structure of spinal cord can be understood through the study of its cross section (Fig. 4.10).
Cross section of spinal cord shows fundamentally following two components.

1. Central gray matter: This is so called due to
grayish color of cell bodies of neurons. Central zones of gray matter looks like ‘butterfly’ on cross section. Roughly
it resembles the capital letter ‘H’. Intermediate bar of ‘H’ represents the body, whereas wings of butterfly are
represented by two limbs of the letter.
Basic components of spinal gray matter: Inter- mediate part of spinal gray matter is traversed centrally be
central canal of spinal cord throughout its whole length.
Central canal of spinal cord is lined by ependymal cells. The gray matter anterior and posterior to central canal
are known as anterior and posterior gray commissures respectively.
Each side of spinal cord gray matter is composed of following components:

a) Anterior known as anterior horn
b) Intermediate area
c) Posterior known as posterior horn.
When considered the whole length of spinal cord, anterior gray horn forms the anterior gray column and
posterior gray horn forms the posterior gray column.
In addition to the above mentioned three components, first thoracic to second lumbar segments (T 1 – L2) of
spinal cord gray matter show a lateral
67
Posterior funiculus
Lateral funiculus
Anterior white commissure
Anterior funiculus
Spinal Cord
Posterior median septum
Posterior gray commissure
Posterior gray horn
Intermediolateral gray horn
Anterior gray horn
Anterior gray commissure
Anterior median
fissure
Fig. 4.10 Fundamental components of internal structure of spinal cord
projection of intermediate area, which is known as intermediolateral cell column. Neurons of this area constitute
sympathetic center of autonomic nervous system. It is important to note at this stage that spinal center of
parasympathetic nervous system is formed by neurons of intermediate area of second, third and fourth (S2, S3 and
S4) sacral segments of spinal cord.
The different components so also the entire gray matter of spinal cord show variations in appearance in different
regions of spinal cord, because it depends upon the relative amount of nerve cells. Basically gray matter is
proportionately broader in lower cervical and lumbosacral regions of spinal cord.
2. Peripheral white matter: This is mainly made
up of compact bundles of nerve fibers running vertically either in ascending or in descending direction.
These fibers in the bundles are myelinated. The
lipid-protein substance of myelin sheath of nerve fibers is white in color for which this peripheral zone of spinal
cord is called white matter.
The bundles of ascending fibers carry sensory informations to the centers of brain above the level of spinal cord.
The descending bundles carry impulse from higher motor centers of brain (above spinal cord) to the motor
neurons situated in anterior horn of spinal cord.
On either side of midline, the white matter is composed of following three components called Funiculi (Singular –
Funiculus).
a) Anterior funiculus: It is the part of white matter between anterior median fissure and anterolateral sulcus
presenting outgoing fibers of ventral nerve root. Anterior funiculi of two sides are bridged by a thin midline
strip
of white matter known as anterior white
commissure.
b) Lateral funiculus: It is the part of white mat-
ter demarcated between outgoing fibers of ventral root and incoming fibers of dorsal root of spinal nerve.
c) Posterior funiculus: It is the part of white matter between posterior median sulcus and incoming fibers of
dorsal root of spinal nerve attached to the posterolateral sulcus. Posterior funiculi of both sides are separated
incompletely or even completely by posterior median septum.
The bundles of fibers either ascending (sensory or afferent) or descending (motor or efferent) are called tracts or
fasciculi (Singular-Fasciculus).
It is interesting to note at this stage that posterior funiculus is composed of only ascending tracts whereas
anterior and lateral funiculi are composed of both ascending as well as descending tracts.
Fundamental cell groups of spinal gray matter: All neurons of spinal cord are multipolar.
Fundamentally the three different zones of spinal
gray matter are made up of following four different neuronal groups.

1. Posterior horn: Sensory (afferent ) or tract neurons 2. Anterior horn: Motor (efferent) neurons.
3. Intermediate area:
i. Interconnecting neurons (interneurons), and ii. Parasympathetic neurons at S , S and S
234
segments only. 4. Intermediolateral area: Sympathetic neurons
(only T1 – L2 segmetns).
Both the sympathetic as well as parasympathetic areas are composed of motor and sensory neurons.

Internuncial neuron Sensory neuron
68
Somatic afferent neuron
Visceral afferent neuron
Tract neurons
Primary sensory neurons
Carrying somatic sensation
Carrying visceral sensation
Supplying smooth muscles, exocrine glands
Supplying voluntary muscles
Visceral efferent neuron Somatic efferent neuron

Skin
Voluntary muscle Motor neuron
Fig. 4.11 Fundamental types of neurons of spinal gray matter
􏱧u􏱧􏱧􏱧io􏱧􏱧l 􏱧l􏱧ssifi􏱧􏱧􏱧io􏱧 o􏱧 􏱧euro􏱧s o􏱧 s􏱧i􏱧􏱧l gray matter (Fig. 4.11):

A. Tract neurons: These are sensory or afferent neurons present in posterior horn.
They are so called because their axons form compact bundles of ascending (sensory) tracts to relay in higher
centers in brain.
They receive synaptic connections from central process of pseudounipolar neurons of posterior root ganglion
which collect sensory informations from peripheral sensory end organs (receptors).
It is important to note at this stage that axons of tract cells may ascend in the same side or may cross the
midline and then ascend along opposite side of spinal cord to form uncrossed (ipsilateral) or crossed
(contralateral) tracts respectively.
B. Motor neurons (efferent neurons): The neurons of anterior horn are motor neurons. Their axons, leaving
spinal cord through ventral root, end in voluntary muscles via spinal nerve.
These motor neurons of spinal cord are called lower motor neurons on which relay the axons of nerve cells
situated at higher centers (brain) which are called upper motor neurons.
Motor neurons of anterior horn of spinal cord sending axons to voluntary muscles are of two types:
i. Alpha motor neurons: Their cell bodies are more than 25 microns in size and their axon
terminate in extrafusal fibers of voluntary muscles, stimulation of which results in muscular contraction.
ii. Gamma motor neurons: Cell bodies of these neurons are less than 25 microns in size and their axons terminate
in intrafusal fibers of voluntary muscles, stimulation of which is concerned with increase in muscle tone.
C. Interneurons (internuncial neurons): These are example of short axoned Golgi type II neurons.
Their axon as well as dendrite are shorter being confined in the gray matter of spinal cord.
Functionally they are interconnecting in nature forming synaptic link between sensory and motor neuron which
together form a local reflex arc (Fig. 4.11).
Internuncial neuron also leads to an advantage by connecting one first order of neuron, through its multiple axon
collateral, to the multiple third order of neurons.
􏲄urt􏲄er classification of motor and sensor􏲄 neurons (Fig. 4.11):
It is already understood from the knowledge of embryological background that, mantle zone of developing spinal
cord forming gray matter forms four column of cells which are as follows from ventral to dorsal aspect.
1. Somatic motor (efferent)
2. Visceral motor (efferent)
3. Visceral sensory (afferent)

4. Somatic sensory (afferent). 69
Among above four cell groups somatic efferent
and somatic afferent cell groups extend over all the 31 segments of spinal cord in anterior and posterior gray
columns (horns) respectively. Somatic efferent neurons of anterior horn send axons to voluntary or skeletal
(somatic) muscles. Somatic afferent neurons of posterior horn from tract neurons whose axons form ascending
tracts.
Visceral efferent and visceral afferent neurons do not extend throughout whole length of spinal cord, but are
present in two levels as follows:
1. a) T1 – L2 segments of spinal cord: Here both the motor and sensory cell groups form additional horns
called intermediolateral horn, where visceral efferent and visceral afferent cell groups form motor and
sensory centers of sympathetic part of autonomic nervous system respectively.
2. b) S2, S3 and S4 segments of spinal cord: Here the cell groups are present in intermediate area of gray
matter without forming any additional lateral horn. Visceral efferent and visceral afferent neurons in
these cell groups form motor and sensory centers of parasympathetic part of autonomic nervous system
respectively.
INTERNAL STRUCTURE OF SPINAL GRAY MATTER
Gray matter of spinal cord, as mentioned earlier, is so called because of grayish coloration of cell bodies of
neurons. But apart from the neuronal cell bodies, spinal gray matter is composed of neuronal processes, neuronal
junctions (synapses), neuroglia and blood vessels.
Nucleus marginalis
Substantia gelatinosa of Rolando
Nucleus proprius
Visceral afferent column Intermediolateral cell column

(Spinal symp center)
Retrodorsolateral group Dorsolateral group
Ventrolateral group
Spinal Cord
VARIOUS CELL GROUPS OF SPINAL GRAY MATTER (FIG. 4.12A)
Throughout the length of spinal cord, different neuronal groups are present in the form of linear columns.
Following two fundamental points are to be noted before individual cell groups are studied.
1. Someofthecellcolumnsextendthroughoutwhole length of spinal cord, but some cover part of its length.
2. Cellgroupsareprimarilysubdividedintofollowing areas.
Posterior gray column: Tract (sensory) neurons.

Intermediate area: Autonomic neurons and inte-
rneurons.
Anterior gray column: Motor neurons.
CELL GROUPS IN POSTERIOR GRAY COLUMN (FIG. 4.12A)
From apex towards the base they are as follows:

1. Nucleus marginalis: It is ill-defined, thin strip of gray matter extending throughout whole length of spinal
cord. It contains neurons of varying size
with intermingling reticulum of fibers.

2. Substantia gelatinosa of Rolando: It is a narrow area extending throughout the whole length of spinal
cord. Afferent fibers, entering through posterior nerve root which carry pain and temperature sensations from
synaptic connection with these neurons. Axons of these neurons cross midline and ascend through contralateral
lateral white column of spinal cord to form lateral
spinothalamic tract.
3. Nucleusproprius:Itisthemainbulkofneurons
in posterior horn and extend throughout whole

Clarke’s column (nucl. dorsalis)
Intermediomedial cell column (spinal parasympathetic center)
Substantia gelatinosa centralis
Central group Dorsomedial group Ventromedial group
Fig. 4.12A Cell groups spinal cord gray matter
70
length of spinal cord. Nucleus proprius consists of following neurons.
i. Some of these cells receive incoming posterior
nerve root fibers which carry sensations of crude touch and pressure. However it is told these days that
crude touch and pressure fibers end in many cell group of posterior horn.
ii. Axons of some of cells of nucleus proprius link adjacent segments of spinal cord for intraspinal
coordination.
4. Nucleus dorsalis (Clarke’s column): It is also called nucleus thoracis. It extends from eighth cervical to
third or fourth lumbar segments of spinal cord. Nucleus dorsalis or Clarke’s column of cells are situated on
medial side of base of dorsal gray horn and show a projection on posterior white column of spinal cord. Neurons
of this column of varying size and shape are of following two varieties.
i. Neurons which receive incoming afferent fibers via nerve root carrying unconscious proprioceptive sensation
from muscle spindle and Golgi tendon organs. These neurons send axons which ascend through marginal strip
of lateral white column forming dorsal as well as anterior spinocerebellar tract.
ii. Interneurons of Golgi type II characterized by short dendrites as well as short axons.
5. Visceral afferent cell column: These cell groups are situated lateral to Clarke’s column of cells at the base
of dorsal gray horn. But it exists in following two levels of spinal cord.
i. T1 to L1/L2 segments of spinal cord: The cell groups receive sympathetic afferent fibers which enter the spinal
cord through posterior root of spinal nerve. It receives sensations from wall of viscera.
ii. S2, S3 and S4 segments of spinal cord: These cell groups receive parasympathetic afferent fibers which also
enter the spinal cord through posterior root of spinal nerve. It receives parasympathetic sensation from the wall
of the viscera wherefrom carried via pelvic splanchnic nerve.
CELL GROUPS IN INTERMEDIATE AREA OF SPI- NAL GRAY MATTER (FIG. 4.12A)
Cells are fundamentally classified in two groups.

Interneurons: These interneurons link between sensory neuron of dorsal horn and motor neuron of ventral
horn, so form a local circuit of reflex arc. Autonomic motor neurons: Having following two components,
which are not coexistant in a
spinal segment.
i. Intermediolateral: These cell groups extend from C8/T1 to L2/L3 segments of spinal cord and form an outward
projection called intermediolateral cell column. These cells form motor center for sympathetic part of autonomic
nervous system and send out axons which leave the spinal cord through ventral nerve root.
ii. Intermediomedial: These functional cell groups are present only in S2, S3 and S4 segments of spinal cord. But
their existance does not show any outward projection in intermediate gray column of spinal cord. These cells
form spinal center for parasympathetic component of autonomic nervous system. Their axons also pass out
through ventral nerve root of corresponding sacral nerve.
CELL GROUPS IN ANTERIOR GRAY COLUMN (FIG. 4.12A)
Cells of these groups are variable in size and are either motor neurons or interneurons.
Neurons, whose cell body size is more than 25 microns, are known as alpha motor neurons. Their axons leave
spinal cord via ventral nerve root and supply extrafusal fibers of voluntary muscle, stimulation of which is
responsible for initiation of movements of voluntary muscle.
Neurons, whose cell body size in between 15 to 25 microns are either interneurons or gamma motor neurons.
Gamma motor neurons, through their outgoing axons passing through the ventral root of spinal nerve, supply
intrafusal fibers of muscle spindle stimulation of which is responsible for maintenance of muscle tone.
Motor neurons of anterior gray column of spinal cord are divided into three groups – Medial, lateral and central.
These groups extend for varying level in spinal cord.
Medial group extends throughout whole length of spinal cord. It may be deficient in fifth lumbar and first sacral
segment. In thoracic and upper lumbar level medial group of anterior horn cells is divided into ventromedial and
dorsomedial parts. Neurons of medial column are concerned with innervation of axial musculature, i.e. muscles
of trunk.
Lateral group exists only in the segments of lower cervical and lumbosacral enlargements of spinal cord, as cells
of this group innervate musculature of upper and lower limb respectively.
Cell group of lateral column is divided into ventrolateral, dorsolateral and retrodorsolateral components.
Nucleus of Onuf: These are cells of ventrolateral group at first and second sacral segments which supply perineal
striated muscles.
Central group of neurons form independent column in cervical and lumbosacral segments only.
In cervical segments central group forms following two nuclei.
Phrenic nerve nucleus: It extends from C3–C5 segments of spinal cord. Their axons, forming independent
phrenic nerve, supply musculature of diaphragm which is very important respiratory muscles. Recent study
shows phrenic nerve nucleus extends up to C7 segments.
Nucleus of spinal accessory nerve: It is formed by central group of anterior horn cells from C 1–C5 segment of
71
spinal cord. Axons of these cells form spinal root of accessory nerve which supplies sternomastoid and trapezius
muscles.
Though existance of lumbosacral segments of central group is established, their function is not yet clear.
CELL GROUPS AROUND CENTRAL CANAL (FIG. 4.12A)
This is the area which forms anterior and posterior gray commissures. It extends throughout whole length of
spinal cord. This area is populated by neuroglia and nonspecific neurons. This area is called substantia
gelatinosa centralis.
REXED’S LAMINATION OF SPINAL GRAY MATTER (FIG. 4.12B)
On cross-section of spinal cord, cells of various columns of spinal gray matter represent a strip-like appearance
which is called Rexed lamination. These
Lamina I
Lamina II Lamina III
Lamina IV Lamina V
Lamina VI Lamina VII
Lamina VIII
Lamina IX (lateral)
Spinal Cord
laminae are ten in number, which are sequentially numbered from the dorsal horn side towards ventral horn, as
per Roman numerals.
The cells of these laminae are classified according to shape, size, density and cytological characteristics. These
laminae corresponds more or less to the different cell-groups stated earlier.
Lamina I: It is also called lamina marginalis. It is a very thin layer on the tip of dorsal horn. This lamina is
composed of cells of different size and shape with intermingling fibers giving a reticular appearance.
Lamina II: It is made up of densely packed and darkly stained cells with nonmyelinated fibers. It is a part of
substantia gelatinosa.
Lamina III: It is made up of loosely packed and large sized cells with myelinated fibers. This lamina is made
up of cells of nucleus proprius and some cells of substantia gelatinosa.
Lamina IV: It is thick and homogeneous lamina forming nucleus proprius.
Lamina V and VI: These two laminae constitute base of posterior horn. Cells of this laminae receive,

i. Afferent fibers carrying proprioceptive sensations and sensation from viscera.
ii. Projections from corticospinal tracts which suggests that they are concerned with regulation of movement.
Lamina VII: It contains following cell group –

i. Intermediolateral cell group: Cells of sympat-
hetic center of autonomic nervous system.

ii. Intermediomedial cell group: Cell forming spinal parasympathetic center of autonomic
nervous system.
iii. Clarke’s column of cells.
Lamina X
Lamina IX (medial)
Fig. 4.12B Rexed lamination of spinal cord gray matter
Lamina VIII: It is made up of interneurons which receive terminals from –
i. Cells of adjacent laminae of same side

ii. Cells of lamina VIII of opposite side through
gray commissures.
72 Lamina IX: This lamina presents lateral and medial strips which are made up of –
i. Alpha and gamma motor neurons
ii. Interneurons.
Lamina X: These are the nonspecific cells of anterior and posterior gray commissures encircling central
canal.
INTERNAL STRUCTURE OF SPINAL WHITE MATTER
Each of the funiculi (Singular–funiculus) of white matter of spinal cord is mostly made up of vertically running
fibers, parallel to the length of spinal cord. These fibers posses following characteristics.
1. The fibers vary in caliber having the range from 1–10 mm.
2. They are either myelinated or nonmyelinated.
3. The fibers are grouped in bundles. Those of one particular bundle have common origin and common
destination. These bundles are tracts
which are mostly of following two types.
Ascending Tracts: They carry sensory information from the level of spinal cord to the higher sensory areas
of central nervous system ultimately to reach sensory area of cerebral cortex.
Descending Tracts: These are axons of upper motor neurons (UMN) located in supraspinal centers
Third order neuron (thalamic nuclei)
Second order neuron above spinal cord
Long primary sensory neuron
Short primary sensory neuron
which are motor area of cerebral cortex or other subcortical centers. Fibers of the descending tracts relay in
lower motor neurons (LMN) located in anterior horn of spinal gray matter to give command for motor activities.
Some fibers of spinal white matter ascend or descend for a few segments and localized entirely in spinal cord for
intersegmental coordination. These are called propriospinal tract.
Ascending Tracts
Ascending tract is a part of sensory pathway. Sensory pathway transmits sensory inputs (impulse) from
peripheral receptors to concerned sensory areas of brain through chain of neurons. Mostly the chain is made up
of three neurons called neurons of first, second and third orders (Fig. 4.13).
First order neuron is called primary sensory neuron. Its cell body is situated in posterior root ganglion of spinal
nerve. Peripheral process of this neuron carries sensory impulse from receptors or sensory end organs. Its central
process or axon, entering the spinal cord, will have either of the follo-wing two fates:
i. ii.
It terminates in different laminae of posterior gray horn of spinal cord to relay in the tract neuron. These are
short primary sensory neurons.
Axons of some primary sensory neuron (called long primary sensory neurons) run vertically upwards through
white matter of spinal cord to relay in some cell groups or nuclei above the
Ascending tract
Second order neuron in spinal cord (Tract cell)
Fig. 4.13 Principle of formation of ascending tract as a part of sensory pathway made up of three orders of neuron
73
level of spinal cord, e.g. nucleus gracilis and
nucleus cuneatus of medulla oblongata.

Axons of tract neurons of spinal cord and axons of long primary sensory neuron, as compact bundles, carrying
one specific type of sensation (exteroceptive or proprioceptive), ascend through different funiculi
of spinal cord to form ascending tracts.

Second order neurons are therefore tract neurons
of spinal cord, or some nuclei above spinal cord, where long primary sensory neurons relay.
Third order neuron is present in the thalamus in the form of different nuclei receiving inputs for different
sensations. Axons of third order of neurons finally send projection fibers to sensory areas of cerebral cortex.
At this stage, it is important to repeat that ascending tract and sensory pathways are not synonymous term. It is
already understood that ascending tract is a part of sensory pathway. It is further important to note that, some
of sensory pathway is made up of less than three neuronal chain, e.g. pathway for spinocerebellar tract. Again,
some are composed of more than three orders of neurons, e.g. visual pathway.
􏲄lassification of ascending tracts on functional basis:
A tract, as classified below, may carry either exteroceptive or proprioceptive sensation. Again one may transmit
sensations of both these kinds.
Spinal Cord
Before further study of ascending tracts, it is important to note following points.
1. Only major ascending tracts from above table are
described below.
2. All ascending tracts (so also descending tract) are
bilateral, and symmetrical in position in both side.
3. Fibersofadjacenttractsmaypresentoverlapping.
4. Some of the tracts are uncrossed (ipsilateral) and
some are crossed (contralateral). Decussation (crossing) occurs mostly at the level of spinal cord. Some
cross in supraspinal level. For example, ventral (anterior) spinocerebellar tract crosses at the level of
midbrain.
5. Ascendingtractsaredescribedbelowonlyuptothe level of their primary destination beyond spinal cord.

Their further course has been mentioned while studied cross section (internal structure) of different
levels of brainstem and forebrain.
Dorsal column (Fig. 4.14)
Note: Reader must consult the figure while reading. This is the ascending tract passing through dorsal white
column of spinal cord for which it is so called. Dorsal white column or posterior funiculus is made up
of this ascending tract which is ipsilateral in nature. Dorsal column transmits following sensory infor-
mations.
1. Exteroceptive: Discrimination touch with the
help of ability to localize two points touched very
closely on the body surface.

2. Proprioceptive:Senseofpositionandmovements
from muscles and joints, and vibration sense.
Discriminative touch (and pressure also) sensation is carried from peripheral receptors to the spinal cord through
its posterior nerve root. Primary sensory neurons carrying this exteroceptive sensation are called long primary
sensory neurons because their axons, i.e. central process of the posterior root ganglia cells, do not form synaptic
connection with spinal sensory neurons. They pass vertically upwards through the posterior funiculus to form
the dorsal column tract.
Short primary sensory neurons carrying vibration sense and sense of position and movements from muscles and
joints relay in tract cell in Clerke’s column and other cell group of laminae IV to VI. Axons of these second order
neuron ascend through posterior column to take part in formation of dorsal column tract along with axons of long
primary sensory neurons carrying discriminative touch (and also pressure to some extent).
So, it is clear from above description that, dorsal column tract is formed by axons of two different kinds as
follows.
Type of sensation Name of tract

Discriminative touch, i.e. ability to localize two points touched very close to each other on
Tracts of posterior funiculus, called dorsal column
skin, fine touch or light touch, sense of vibration, sense of position and move- -ments
(fasciculus gracilis and fasciculus cuneatus).
carried from muscles and joints.
Pain and thermal sensation (heat or cold). Lateral spinothalamic tract.
Crude touch and pressure. Anterior spinothalamic tract.
Unconscious information (unconscious proprioceptive) from muscles, tendons, joints and Dorsal (posterior) and ventral (anterior)
even from subcutaneous tissue for automatic, stereotyped postural adjustment of body. spinocerebellar tract.
Pain, thermal and tactile information to the midbrain level for reflex visual response Spinotectal tract to superior colliculus of tectum
through pathway for spinovisual reflex. of midbrain.
Impulse from skin, muscles and joints to reticular nuclei of brainstem for awakefulness. Spinoreticular tract
Spinoolivary tract (part of spinoolivocerebellar
An alternative and indirect pathway of spinocerebellar tract.
tract).
Nucleus gracilis Nucleus cuneatus
Fasciculus cuneatus
Central canal Fasciculus gracilis
Cross section of lower half of medulla oblongata
Fasciculus cuneatus
Fasciculus gracilis
}= Dorsal column
74 Posterointermediate
septum demarcating fasciculus gracilis from fasciculus cuneatus
Fasciculus gracilis
Midthoracic level
Tract neuron in lamina IV to VI

Short primary afferent neuron carrying sense of position, movement and vibration from upper half of body
Long primary afferent neuron carrying cutaneous sensation of discriminative touch from upper half of body
Midthoracic level
Short primary afferent neuron carrying sense of position, movement and vibration from lower half of body
Long primary afferent neuron carrying cutaneous sensation of discriminative touch from lower half of body
1. Axons of long primary sensory neurons carrying sensory impulse for discriminative touch and pressure.
2. Axons of tract neurons from Clarke’s column and other sensory neurons of lamina IV to VI carrying
impulse for sense of position and movements and also vibration sense.
Fiber tracts of dorsal column carrying sensory
impulse from lower half of body (below midthoracic level), entering through lower group of spinal nerves, are
placed in the medial part of posterior funiculus. It is called fasciculus gracilis. It is superadded by similar kind
of fiber bundle which enter the spinal cord carrying similar sensation from upper half of body (above midthoracic
level). These fiber bundles of dorsal column ascend through lateral part of posterior funiculus lateral to medially
placed fasciculus gracilis. It is called fasciculus cuneatus. It is demarcated from fasciculus gracilis by
intermediolateral septum.
Both kinds of fibers of fasciculus gracilis and fasciculus cuneatus, i.e. axons of long primary sensory neurons as
well as those of tract neurons of lamina IV to VI, relay in nucleus gracilis and nucleus cuneatus in posterior part
of lower half of medulla oblongata. Posterior surface of lower half of medulla oblongata presents two round bulge
known as gracile tubercle and cuneate tubercle beneath which lies corresponding nucleus.
Spinocerebellar tracts
General consideration: These tracts are two in number, called ventral (anterior) and dorsal (posterior)
spinocerebellar tracts.
Instead of going upto sensory area of cerebral cortex via thalamus, they terminate in cerebellar cortex.
Functions of spinocerebellar tracts are concerned wih coordination of movements.
Fig. 4.14 Dorsal column (fasciculus gracilis and fasciculus cuneatus)
75
Impulse is carried from neuromuscular spindle (muscle spindle), neurotendinous spindle (Golgi tendon organ)
and joint receptors.
End organs are stimulated due to stretching of muscles and tendons, and movements of the joints.
Both the spinocerebellar tracts are situated in the form of narrow strip covering the peripheral part of lateral
funiculus, being anteroposteriorly related.
Both the tracts are ipsilateral. But it is important to note that fibers for ventral spinocerebellar tract cross at the
level of corresponding spinal cord segments. But for the second time the tract crosses as a whole at the level of
midbrain.
Both the tracts are made of myelinated fibers of large diameter. Ventral spinocerebellar tract also contains some
thin calibered fibers.
Individual characteristics of either of the tracts will be clear from their description below.
Dorsal spinocerebellar tract (Fig. 4.15)
It is formed by axons of Clerke’s column of cells. Therefore this tract start formation and so also starts ascending
from second or third lumbar segment of spinal cord. It is also not difficult to understand that dorsal
spinocerebellar tract gets formed from L2 / L3
Spinal Cord
segment to T1 segment. It receives therefore input from the trunk through T 1–L2 / L3 segmental spinal nerve. It is
interesting to note that it also receives inputs from lower limb. Proprioceptive impulse from neuromuscular
spindle, neurotendinous spindle and joints of lower limbs are carried by dorsal column (fasciculus gracilis).
Reaching upto L2 / L3 segments, collaterals are given from dorsal column to relay in Clarke’s column of cells of
L2/L3 segments.
These collateral are given by the fibers of dorsal column carrying impulse from the lower limb through spinal
segment, as they reach the level of L2/L3 segments. Again above T1 segment, proprioceptive sensations from
neuromuscular spindle, neurotendinous spindle and joint receptors ascends through fasciculus cuneatus to relay
also in accessory cuneate nucleus which is a smaller oval bulge superolateral to nucleus cuneates. Fibers from
this nucleus reach the cerebellum via cuneocerebellar tract.
Ventral spinocerebellar tract (Fig. 4.16)
Ventral (anterior) spinocerebellar tract is formed by axons of tract neurons of lamina V to VII of spinal cord in
addition to Clarke’s column of cells.
Fasciculus gracilis
Collaterals from fasciculus gracilis conveys inputs from lower limb proprioceptors to Clarke’s column of cells axons of which form dorsal
spinocerebellar tract
Fasciculus gracilis
1. Fasciculus gracilis
2. Fasciculus cuneatus
3. Dorsal spinocerebellar tract
Dorsal spinocerebellar tract-formed by axons of Clarke’s column of cells
Impulse from muscle, tendon and joint receptors carried through posterior spinal nerve roots (T1–L2 segments) relay in Clarke’s column of cells
Proprioceptive sensation from neuromuscular and neurotendinous spindles and joint receptor from lower limb enter spinal cord to form fasciculus
gracilis
12
Fig. 4.15 Formation of dorsal spinocerebellar tract
76
Ventral spinocerebellar tract
Dorsal spinocerebellar tract (ipsilateral)
Ventral spinocerebellar tract (contralateral)
Fasciculus cuneatus (ipsilateral)
Fasciculus gracilis (ipsilateral)
Primary sensory neuron carrying proprioceptive sensation as well as cutaneous sensation from skin and subcutaneous tissue
Tract cells of lamina V to VII send axons which cross midline to form ventral spinocerebellar tract which carries proprioceptive sensations from
muscles, tendons and joints and also exteroceptive sensation from skin and sup. fascia
These second order neurons, receives information from muscle, tendon and joint receptors via the first order
neurons, which are primary sensory neurons of posterior root ganglia. In addition, ventral spinocerebellar tract
carries sensory information from skin and subcutaneous tissue also.
These sensation are carried via ventral spinocerebellar tract from trunk as well as upper and lower limb.
Before the tract is being formed by the axons of lamina V to VII and also Clarke’s column of cells, majority of
fibers cross the midline along ventral white commissure of spinal cord, while the minority of fibers remain in
same side. Fibers take the position over a narrow strip of anterior peripheral part of lateral funiculus to ascend
upwards in front of dorsal spinocerebellar tract. Fibers of ventral spinocerebellar tract run upwards carrying
contralateral fibers, through the brainstem beyond spinal cord. Reaching the level of midbrain, fibers cross the
midline for second time to reach cerebellar hemisphere of the same side through superior cerebellar peduncle.
Spinothalamic tracts
These are two in number, known as lateral and anterior (ventral) spinothalamic tracts passing through lateral
and anterior white columns of spinal cord respectively. Lateral spinothalamic tract conducts pain and
temperature sensations, whereas through anterior spinothalamic tract pass sensations of coarse
(nondiscriminative) touch and pressure. In cases of
both the spinothalamic tracts, concerned sensory impulse pass from respective receptors through primary
sensory neurons or first order neurons, which are posterior root ganglia cells. Their central process enter spinal
cord to relay in second order neurons.
Lateral spinothalamic tract (Fig. 4.17)
This tract is positioned in lateral funiculus, medial to anterior spinocerebellar tract and lateral to anterior gray
horn and emerging fibers of anterior nerve root.
It is formed by axons of tract neurons which are second order neuron situated in substantia gelatinosa of
posterior gray horn. The fibers cross the midline and ascend upwards through lateral funiculus, carrying
therefore sensation from opposite side of body. This tract carries pain and temperature sensations.
Anterior (ventral) spinothalamic tract (Fig. 4.18)
It is so called because it ascends through anterior white column of spinal cord. It is placed medial to emerging
fibers of ventral root of spinal nerve.
This tract is formed by axons of tract neurons of all the sensory laminae of posterior gray horn. Before the tract is
formed, the fibers cross the midline, thereby carrying sensation from opposite side of body.
This tract carries coarse (nondiscriminative) touch and pressure sensations.
Positions of the important ascending tracts, discussed above are shows in both sides of spinal cord are shown in
Figure 4.19.
Fig. 4.16 Formation of ventral spinocerebellar tract

Lateral spinothalamic tract
Axons of tract neurons of substantia gelatinosa cross the midline to form lateral spinothalamic tract at lateral funiculus
Primary sensory neuron carries pain and temperature sensation to relay in tract neurons of substantia gelatinosa of posterior horn
Tract neuron of all laminae of posterior gray horn crosses midline to form anterior spinothalamic tract
Primary sensory neuron carries coarse touch and pressure sensations to relay in tract neurons of all laminae of posterior gray horn
Lateral spinothalamic tract formed at lateral funiculus of opposite side lateral to emerging ventral nerve root 77
Anterior spinothalamic tract
Fig. 4.17 Formation of lateral spinothalamic tract
Spinal Cord
Anterior spinothalamic tract formed at anterior funiculus medial to emerging fibers of ventral nerve root
Ipsilateral (uncrossed) 2. Fasciculus
{
Fig. 4.18 Formation of anterior spinothalamic tract 1. Fasciculus gracilis
tract
cuneatus
4. Ventral spinocerebellar tract
5. Lateral
Contralateral
{ spinothalamic
(crossed) tract
tract
6. Ventral (anterior) spinothalamic tract
Fig. 4.19 Positions of important ascending tracts of spinal cord
78
What is Dorsolateral Spinothalamic Tract?
Existence of this tract is established in animals. It is formed by axons of lamina I. The tract carries noxious,
mechanical and thermal sensations from skin. It is a crossed tract and passes through dorsolateral funiculus
which is the small area of white matter between dorsal and lateral white columns. It is proved that in case of
man, this tract is concerned with transmission of clinicopathological pain from which a patient gets relief after
dorsolateral cordotomy.
Descending Tracts
Descendingtractsofspinalcordpassdownthrough lateral and anterior white columns of spinal cord.

Descending tracts are axons of neurons of various supraspinal centers which include motor centers in cerebral
cortex and brainstem.
The neurons of supraspinal centers are known as upper motor neurons which finally project on motor neurons
of anterior horn cells of spinal cord called lower motor neurons.
Descending tract is a part of motor pathway which is usually made up of three order of neurons. The first
order neurons are neurons of supraspinal centers. Second order neurons are internuncial neurons situated in
anterior gray column of spinal cord. Third order neurons are alpha and gamma motor neurons of spinal cord.
Axons of these neurons reach the effector organs (voluntary muscles) via the anterior root of spinal nerve which
is known as final common pathway of Sherrington.
Descending tract discharges constantly impulse on lower motor neuron to exert following functions.
1. It controls movements, muscle tone and posture.

2. It modulates spinal reflex mechanism.
3. It also modulates transmission of afferent information to higher centers.
4. It exerts influence on visceral activities through its control on spinal autonomic motor neurons.
􏲄roadclassification:Descendingtractsarebroadly
classified into following groups—

1. From motor areas of cerebral cortex
Corticospinal tracts
Corticobulbar (corticonuclear) tracts: Projecting to
motor nuclei of cranial nerves situated in brainstem, which do not extend low down upto spinal cord.
2. From different subcortical centers to the spinal cord:
Noncorticospinal tracts.
Corticospinal and corticobulbar tracts
Two tracts having common origin and different destination: Corticospinal as well as corticobulbar
(corticonuclear) tracts arise from cerebral cortex. The fibers of both the tracts arise from:
1. Primary motor cortex (area 4) = 30%

2. Premotor cortex (area 6) = 30%
3. Postcentralgyrus(area3,1,2)andadjacentpari-
etal cortex (area 5) = 40%.
Initially corticospinal and corticobulbar (cortico-
nuclear) tract fibers run down in association with each other through subcortical white matter to the level of
brainstem where corticobulbar (corticonuclear) fibers terminate in contralateral motor nuclei of different cranial
nerves. Corticospinal tract fibers descend alone further through the spinal cord.
Corticospinal tract is also called Pyramidal tract: While passing through the medulla oblongata to approach
spinal cord, fibers of corticospinal tract arising from pyramidal cells of cerebral cortex passes beneath the
paramedian ventral bulge looking like a pyramid with its narrower end directed downwards. That is why
corticospinal tract is called pyramidal tract (Fig. 4.20).
Fibers of Pyramidal tract (Corticospinal tract)

􏲄umber of fibers: Pyramidal tract of each side contains 1 million fibers.
Fibers mostly myelinated: 70􏲠 fibers are myelinated.
Fibers are of varying caliber—
90% = 1 – 4 mm in diameter
9% = 5 – 10 mm
1% = 11 – 22 mm, which are the axons of giant
pyramidal cells of Betz situated in primary motor cortex (area 4).
Two corticospinal tracts – lateral (crossed) and anterior (uncrossed) – (Fig. 4.20)
Just proximal to spinomedullary junction, i.e. at the lower end of pyramid of medulla oblongata, 75􏲠 to 90􏲠
fibers of corticospinal tract cross the midline from either side forming a decussation beneath the anterior median
fissure of medulla. The majority crossed fibers descend vertically through the lateral white column (lateral
funiculus) of spinal cord to form lateral corticospinal tract. This tract is positioned medial to dorsal
spinocerebellar tract and ventrolateral to posterior gray column. The remaining uncrossed fibers (10􏲠–25􏲠)
descend through anterior white column (anterior funiculus) of same side to form anterior corticospinal tract
which is an uncrossed tract.
Spinal Cord
79
Motor area of cerebral cortex
Medulla oblongata
7􏱺􏱺90􏱺 of fibers cross
midline at the level of lower part of medulla to form lateral corticospinal tract
Corticospinal tract is called pyramidal tract as it passes through pyramid of medulla oblongata
Pyramid of medulla oblongata
10􏱺2􏱺􏱺 of fibers descend
uncrossed to form anterior corticospinal tract
Fig. 4.20 Corticospinal tract– Originating from different areas of motor cortex
Termination of corticospinal tract (Figs 4.21A and B)
While descending through respective funiculus, in every segment of spinal cord successively, fibers of both the
tracts (axons of upper motor neuron) relay in both alpha and gamma motor neurons (lower motor neurons) of
anterior gray column. As the lateral corticospinal tract is a crossed tract, it is very clear to understand that, it
possesses influence on anterior horn cell of contralateral side (Fig. 4.21A and B).
Medulla oblongata
Anterior corticospinal tract (uncrossed)
Lateral corticospinal tract (crossed)
But it is very important to notice at this stage that, though anterior corticospinal tract is an uncrossed
(ipsilateral) one, in every segment of spinal cord fibers for the respective segment cross the midline through
anterior white commissure and relay in opposite sided motor neurons of spinal cord (Fig. 4.21A and B). So it is
not difficult to understand that, ipsilateral anterior corticospinal tract also possesses influence on contralateral
lower motor neurons.
Olive Pyramid
Lateral corticospinal tract in lateral funiculus
Anterior corticospinal tract in anterior funiculus
Fig. 4.21A Both lateral (crossed) and anterior (uncrossed) corticospinal tracts beyond medulla oblongata, and their position in lateral and
anterior white columns of spinal cord respectively
80
Anterior corticospinal tract
Lateral corticospinal tract
In each segment of spinal
cord, fibers from uncrossed
anterior corticospinal tract cross midline through anterior white commissure to relay in opposite sided lower motor neurons
Ventral root of spinal nerve

In each segment of spinal cord, lateral corticospinal tract which is already crossed at medullary level, gives fibers to relay in lower motor neurons of
same side
Fig. 4.21B Corticospinal tracts. Lateral corticospinal tract— A crossed (contralateral) tract which descends through lateral funiculus.
Anterior corticospinal tract— An uncrossed (ipsilateral) tract which descends through anterior funiculus
Corticospinal tracts terminates indirectly through interneurons –
Most of the fibers of corticospinal tracts terminate contralaterally on interneurons of laminae V to VII, which
finally relay in alpha as well as gamma motor neurons of lamina IX. Direct termination on motor neurons are
mostly found in segments of cervicothoracic and lumbosacral enlargements of spinal cord.
Variations of corticospinal tract
1. Corticospinal fibers may be totally crossed.

2. All the fibers may remain uncrossed in very rare
occasion.
Principle of functions of corticospinal tract
1. Fibers arising from primary motor cortex and premotor cortex (area 4 and 6 respectively), through their
influence on both alpha and gamma motor neurons of spinal cord, facilitate activities of extensor group of
muscles. They are concerned with pre􏲠cised and skillful movements, particularly, of distal part of limbs. It is
proved by lesions of the tract, which very commonly occurs due to ‘cerebrovascular accident’. It affects mostly
the movements of distal part of limbs with fingers and toes.
2. Fibers arising from parietal cortex, i.e. postcentral gyrus (area 3, 1, 2) and adjacent parietal area (area 5),
projecting on neurons of posterior gray horn, modulate spinal reflex activities and transmission of afferent
informations to higher sensory centers.
Noncorticospinal tract
These are the descending tracts which originate from various centers of brainstem, below the level of cerebral
cortex, which are considered as subcortical centers.
Like corticospinal tracts, cell of these centers are upper motor neurons which project on lower motor neurons, i.e.
alpha and gamma motor neurons of spinal cord.
These tracts are described below in reference to the following points:

Origin
Nature, i.e. extent and, crossed or uncrossed
Localization in spinal cord
Termination
Function.
RUBROSPINAL TRACT
Origin: Central core (tegmentum) of upper half of midbrain (at the level of superior colliculus)
Rostral
parvocellular part
] Red
nucleus Caudal magno-
cellular part
Rubrospinal tract
Fig. 4.22A Rubrospinal tract originates from caudal magnocellular part of red nucleus
presents a reddish gray colored ovoid mass of nerve cells, called red nucleus which is divided into rostral
parvocellular part made up of smaller neurons and caudal magnocellular part made up of larger neurons.
Rubrospinal tract originates from caudal magnocellular part of red nucleus which contains 150–200 neurons
(Fig. 4.22A).
Morphology: In man, rubrospinal tract is rudimentary and poorly defined. In animals, it extends upto
lumbosacral segments of spinal cord.
Nature: Rubrospinal tract is a crossed tract. Fibers of this tract cross horizontally, just after their origin from 81
red nucleus. It is called ventral tegmental decussation. After decussation fibers descend through central core
(tegmentum) of brainstem to reach spinal cord (Fig. 4.22B).
Localization: Fibers of rubrospinal tract are localized in the lateral white column of spinal cord, just in front
of lateral corticospinal tract with which its fibers are intermingled (Fig. 4.23).
Termination: Rubrospinal tract extends upto only upper three cervical segments of spinal cord.
Aqueduct of midbrain
Red nucleus
Ventral tegmental decussation
Rubrospinal tract
Fig. 4.22B Fibers of rubrospinal tract originating from red nucleus cross midline at midbrain to form ventral tegmental decussation
Before terminating into alpha and gamma motor neurons of spinal cord, fibers from polysynaptic connection via
interneurons of laminae V to VII.
Functions: Functions of rubrospinal tract are similar to those of corticospinal tract.
TECTOSPINAL TRACT
Origin: Dorsal part of midbrain, which is behind aqueduct (central canal) of midbrain, is called Tectum.
When viewed from behind, tectum is seen to be made up of one upper and one lower pair of bulges called superior
and inferior colliculi (Singular-colliculus). These colliculi are made up of clusters of nerve cells which are
arranged in the form of superficial, intermediate and deep layers.
Tectospinal tract originates from intermediate and deep layers of cells of superior colliculus of both sides at the
upper half of midbrain.
Nature: Tectospinal tract is crossed tract like rubrospinal tract. Fibers of this tract also cross
Spinal Cord
Fasciculus gracilis Fasciculus cuneatus
Dorsal spinocerebellar tract
Ventral spinocerebellar tract Lateral spinothalamic tract
Ascending tract
Crossed
Uncrossed
Crossed
Lateral corticospinal tract
Rubrospinal tract Lateral reticulospinal tract
Medial reticulospinal tract Anterior corticospinal tract
Olivospinal tract
Vestibulospinal tract Tectospinal tract

Descending tract Uncrossed
Fig. 4.23 Cross-section of spinal cord showing ascending (afferent) and descending (effercent) tracts
horizontally in front of aqueduct of midbrain, in a more posterior plane, just after their origin from tectum. It is
called dorsal tegmental decussation. After decussation, fibers of this tract descend through central core
(tegmentum) of brainstem to reach the level of spinal cord.
82 Localization: Tectospinal tract is localized in anterior white column of spinal cord, in front of anterior
corticospinal tract, just by the side of ventral part of anterior median fissure (Fig. 4.23).
Termination: Tectospinal tract extends only upto upper cervical segments of spinal cord.
Before terminating into alpha and gamma motor neurons of spinal cord, fibers form polysynaptic connection via
interneurons of laminae VI to VIII.
Functions: Before the function of tectospinal tract is understood, it is to be noted that, this tract forms
efferent component of a reflex pathway known as spinovisual reflex. Activity of this pathway is manifested by
turning neck with head away when a powerful light falls on retina of eyeball.
5 components of this reflex pathway are following:

1. Receptor: Rod and cone cells of retina (photoreceptors)— which are stimulated by light falling
on retina.
2. Afferent path: Visual pathway from retina - optic
nerve – optic chiasma – optic tract – lateral
geniculate body – superior brachium.

3. Center: Superior colliculus of midbrain which receives collaterals from lateral geniculate body
through superior brachium.
4. Efferent path: Tectospinal tract.

5. Effector: Voluntary muscles of neck.
VESTIBULOSPINAL TRACTS
They are two in number known as lateral and medial vestibulospinal tracts.
Though called lateral and medial, both are present in anterior white column of spinal cord, but latero-
medially positioned.
These tracts arise from vestibular nuclear complex situated at the lateral angle of floor of fourth ventricle at
pontomedullary junction (Fig. 4.24A).
Origin (Fig. 4.24B):

Lateral vestibulospinal tract– from lateral vestib-
ular nucleus.
Medial vestibulospinal tract– from
i. Medial and inferior vestibular nuclei ii. Some fibers – From lateral nucleus.
Nature:
Lateral – uncrossed (ipsilateral)
Medial– crossed (contralateral) as well as uncros-
sed (ipsilateral).
Fibers of medial vestibulospinal tract extend upto
midthoracic level.
Localization: Both the tracts are located in ventral marginal part of anterior white column (Fig. 4.23).
Termination: Both vestibulospinal tracts terminate in alpha as well as gamma motor neurons of spinal
cord via interneurons of laminae VII and VIII. Function: Lateral vestibulospinal tract is excitatory to the
spinal motor neurons which supply extensor
Superior colliculus Inferior colliculus
Superior cerebellar peduncle Vestibular triangle
Floor of 4th ventricle
Cuneate tubercle Gracile tubercle

Fig. 4.24A Vestibulospinal tract arises from vestibular nuclear complex lying beneath vestibular triangle of floor of 4th ventricle at
pontomedullary junction
Lateral vestibular nucleus
Inferior vestibular nucleus
Lateral vestibulospinal tract originates from lateral vestibular nucleus
83
Spinal Cord
Superior vestibular nucleus Medial vestibular nucleus
Medial vestibulospinal tract originates from medial and inferior vestibular nuclei
Fig. 4.24B Origin of lateral and medial vestibulospinal tracts
muscles of neck, back and limbs. It is inhibitory to neurons which supply flexor muscles of limbs.
Medial vestibulospinal tract inhibit spinal motor neurons which supply muscles of neck and upper part of back.
RETICULOSPINAL TRACT
Reticulospinal tracts are two— Medial and lateral. These tracts project from reticular nuclei of brainstem (upper
motor neurons) to alpha and gamma motor neurons (lower motor neurons) of spinal cord either directly or
through interneurons of laminae VII and VIII. Upper motor neurons for these tract are called reticular nuclei
because the cells are intermingled with network (reticulum) of fibers.
Origin:
Medial: From reticular nuclei of pons and medulla
oblongata.
Lateral: From reticular nuclei of medulla oblongata.
Nature:
Medial: Crossed as well as uncrossed. Lateral: Uncrossed.
Localization (Fig. 4.23):

Medial: Located in anterior white column, medial
to base of anterior horn.

Lateral: Located in lateral white column, lateral
to base of anterior horn, close to lateral corticospinal tract and rubrospinal tract.
Termination: Both the tracts terminate in alpha as well as gamma neurons of anterior horn cells (Lamina
IX) of spinal cord either directly or through interneurons of laminae VII and VIII.
Function:
Medial reticulospinal tract: It is concerned with i. Postural adjustment
ii. Steering of head and trunk movement in response to external stimulus.
iii. Stereotyped movement of muscles of limbs.
Lateral reticulospinal tract: It is involved in regulation of:
i. Motor function
ii. Perception of pain sensation.
OLIVOSPINAL TRACT
There is doubt in existence of this tract in man nowadays. It was thought that this tract originates from inferior
olivary nucleus and project on motor neurons of spinal cord. It was thought to be localized in lateral white
column of spinal cord.
HYPOTHALAMOSPINAL TRACT
It is better to be called hypothalamospinal fibers rather than tract as the fibers do not form compact bundle.
Origin: From paraventricular (and some other) nuclei of anterior and posterior half of hypothalamus.
Nature: Uncrossed (ipsilateral)

Localization: Lateral funiculus of spinal cord. Termination:
i. Sympathetic neurons of intermediolateral cell
column of T1 to L2 segments of spinal cord.
ii. Parasympathetic neurons of intermediate area
of S2, S3 and S4 segments of spinal cord.

Function: Supraspinal control of sympathetic and parasympathetic visceral function.
SOLITARIOSPINAL TRACT
Origin: Nucleus tractus solitarius of medulla oblongata. It is a composite special visceral sensory
fe through the posterolateral part of cord to cut descending (motor) tracts which are posterior to the plane of
ligamentum denticulatum.
Knowledge of Termination of Spinal Cord in Clinical Practice
Upto 3rd month of fetal life, rate of growth of vertebral column and that of spinal cord are co-extensive. After 3rd
month vertebral column grows more rapidly than spinal cord. That is why, at birth spinal cord is found to end at the
level of lower border of body of 3rd lumbar vertebra. This status remains in infancy. But finally, spinal cord is found
to end at the level of lower border of body of 1st lumbar vertebra. Sometimes, it may extend upto 2nd lumbar
vertebra in case of adults.
But arachnoid and dura maters extend upto lower border of body of 2nd sacral vertebra. So subarachnoid space
below the level of termination of spinal cord (L 1/ L2), and above S2 level, is prominent which is filled with
cerebrospinal fluid where float the fibers of cauda equina. This area of prominent spinal subarachniod space is
approached from outside through a procedure called spinal tap or lumbar puncture which helps in diagnosis and
management of some central nervous system diseases.
Lumbar Puncture (Spinal Tap) (Fig. 4.7)
It is the clinical procedure to approach spinal subarachnoid space below the level of termination of spinal cord for
following two purposes.
1. Diagnostic: For the purpose of diagnosis of some
diseases of nervous system which is related to alteration of character of cerebrospinal fluid, this procedure is
adopted to take out the sample of fluid for its physical, chemical/biochemical, microscopic and bacteriological
examination.
2. Therapeutic: Instead of withdrawal of cerebrospinal fluid, some drugs are injected for the following two purposes:
i. Some drugs in the form of anesthetics are
injected for induction of spinal anesthesia before performing surgical operations. There are some indications where
surgeons prefer spinal anesthesia to general anesthesia.
ii. Some drugs are injected through this route for treatment of some diseases of central nervous system.
Where to Perform Lumbar Puncture?
Lumbar puncture needle, specially designed, is introduced through interspinous space in the back between 3rd and
4th lumbar spine.
CLINICAL ANATOMY OF SPINAL CORD
Protection of Spinal Cord
Spinal cord, which is part of central nervous system and, made up of delicate and sensitive nervous tissue, is well-
protected by:
1. Vertebral column – Inside which, in vertebral
canal, it is lodged.
2. Spinal meninges – Dura, arachnoid and pia
maters, mainly dura mater which is toughest,
outermost fibrous membrane.

3. 􏲄us􏲄ion of cerebrospinal 􏲄uid – Inside subarac-
hnoid space.
Factors Holding Spinal Cord in Position
1. Spinalnerves(31pairs),formedbyunionofventral and dorsal roots, come out through intervertebral foramen.

Dural sheath of spinal nerves is attached at the margin of intervertebral foramen.
2. Ligamentum denticulatum – One on either side, with 21 pairs of tooth-like pial projections bind lateral
surface of spinal cord to the inner surface of arachnoid mater.
3. Filumterminale–Itisthenonnervousfilamentous band which ties conus medullaris of spinal cord below to the
back of 1st piece of coccyx.
Ligamentum Denticulatum – A Guide for Selective Cordotomy
Anterolateral cordotomy is done to relieve excrutiating pain. Surgeon passes his knife through anterolateral
part of cord to cut ascending (sensory) tracts which are anterior to the plane of ligamentum denticulatum.
Posterolateral cordotomy is done to relieve abnormal muscular spasm. Surgeon passes his kni-
84
nucleus having parts for VIIth, IXth and Xth cranial nerves. It receives sensory fibers of these cranial nerves
carrying taste sensation from tongue and soft palate.
Nature: Mostly crossed Localization:
i. Anterior funiculus and
ii. Anterior part of lateral funiculus. Termination:
i. Anterior horn cells of C3, C4 and C5 segment of spinal cord supplying diaphragm.
ii. Anterior horn cells of thoracic segments of spinal cord supplying intercostal muscles.
Function: Reflex movements of intercostal muscles and diaphragm on stimulation of nucleus tractus solitarius.
How to Locate L3/L4 Interspinous Space?
It is the space just above L4 spine. To find out the space, L4 spine is located. L4 spine is at the level of a horizontal
plane which passes through highest point of two iliac crests (transcristal plane).
How to Perform Lumbar Puncture?
After taking proper aseptic measures, patient is placed in lateral position in bed or upright sitting position and
vertebral column is flexed. Two advantages are enjoyed in flexed position of spine. Interspinous space becomes
wider and lower end of spinal cord is further elevated above lower border of body of L 1 vertebra.
85
Lumbar puncture needle is introduced through midline interspinous space between L3 and L4 spines. The tip of
the stellate followed by needle is directed horizontally with slight upward inclination. A sustained resistance is
felt till the needle crosses supraspinous and interspinous ligament and finally it passes through dura mater with
arachnoid mater. Queckenstedt sign: Normal CSF pressure is 60–150 mm of water. Pressure applied over
internal jugular vein leads to cerebral venous congestion causing rise of subarachnoid CSF pressure as a result of
less absorption of CSF through arachnoid granulations. In case of expanding tumor of spinal cord (glioma) or
meninges (meningioma), due to blockade of subarachnoid space, even rise of cerebral
Pedicle
Intervertebral disk Zygapophyseal (facet) joint
Spinal nerve emerging through intervertebral foramen
Fig. 4.25A Spinal nerve is predisposed for compression at intervertebral foramen which may cause ‘root canal pressure’
Torn annulus fibrosus
Herniated nucleus pulposus Compressed spinal nerve
Spinal Cord
Fig. 4.25B Disruption of annulus fibrosus squeezes out nucleus pulposus of intervertebral disk to press over spinal nerve roots
venous pressure by application of pressure over internal jugular vein does not cause rise of CSF pressure. This is
called positive Queckenstedt sign.
Lesion of Spinal Nerve Emerging Through Intervertebral Foramen
Intervertebral foramen is bounded above and below by the pedicles of two adjacent vertebrae. The foramen is
bounded anteriorly by intervertebral disk and posteriorly by zygapophyseal joint or facet joint of articular
processes. This foramen transmits spinal nerve root formed by union of ventral and dorsal rami. At this site the
spinal nerve may be lesioned due to stretching, pressure or edema resulting from –
i. Fracture dislocation of vertebra

ii. Osteoarthritis due to inflammation of facet
joint or
iii. Herniation of intervertebral disk. Compression of spinal nerve root in the interv-
ertebral foramen due to above reasons leads to a clinical condition known as ‘root canal pressure’ (Fig. 4.25A).
Herniation of intervertebral disk causing root canal pressure is not midline but posterolateral. Disruption or tear
of annulus fibrosus squeezes out the nucleus pulposus to press over spinal nerve root (Fig. 4.25B). Common sites
of herniation are cervicothoracic and lumbosacral junction of vertebral column where mobile part of vertebral
column changes into immobile part.

Effect of root canal pressure: Spinal nerve, being mixed nerve, when compressed or irritated, gives rise to
motor as well as sensory manifestations. Motor effect will be painful muscular spasm with weakness of the
muscles. Involvement of sensory fibers ranging from irritation to compression leads to variable effects like
altered sensation (paresthesia) to exaggerated sensation (hyperesthesia) with tingling pain over the belt of skin
(dermatome) supplied by the corresponding segmental nerve.
Pyramidal and extrapyramidal tracts – two reciprocal components of descending (motor)

pathway: Efferent (motor) descending pathway originating from different areas of cerebral cortex, e.g. primary
motor area (area 4), premotor area (area 6) and even primary sensory area (area 3, 1, 2) project to motor neurons
(alpha as well as gamma motor neurons) of spinal cord. Thereby this tract is called corticospinal tract. Before
86
crossing the midline in lower medulla to relay in lower motor neurons of spinal cord, this tract passes through
the bulge of pyramid of medulla oblongata. That is why it is called pyramidal tract. Other types of descending
tracts originating from subcortical centers, various nuclei of brainstem are called noncorticospinal tracts. As
these tracts are not passing through pyramid of medulla oblongata, they are called extrapyramidal tracts.
Two basic motor activities, namely voluntary movements following contraction of skeletal muscles and
maintenance of muscle tone are the result of balanced combined activity of pyramidal (corticospinal) and
extrapyramidal (noncorticospinal) tracts.
Voluntary Movements
Execution of voluntary movements resulting from contraction of group of muscles is the effect of stimulation of
alpha motor neurons of anterior gray column of spinal cord by pyramidal (corticospinal) as well as
extrapyramidal (noncorticospinal) tracts.
Cortical as well as subcortical motor centers receives the information from sensory system, eyes, ears and even
the stored information from memory. Then these centers (UMN) give command to the alpha motor neurons
(LMN) of spinal cord through their descending axons (descending tracts). Axons of alpha motor neurons of spinal
cord leave through spinal nerve to stimulate extrafusal fibers of voluntary muscles which causes muscular
contraction resulting voluntary movements.
But basic difference between corticospinal and noncorticospinal tracts are as follows. Corticospinal tract
regulates prime mover muscles, particularly
those muscles which are concerned for skilful voluntary movements of distal part of limbs. Non- corticospinal
tracts control gross, basic voluntary movements resulting easy and rapid movements of the joints for
maintenance of posture.
Muscle Tone
Muscle tone is defined as a state of continuous partial contraction of a muscle which is obviously the result of
continuous stimulation of e􏲄trafusal fibers. But it is interesting to note that, this effect depends, beforehand on
impulse received by gamma motor neurons at intrafusal fibers through corticospinal (facilitatory) and
noncorticospinal (inhibitory) tracts. This impulse (facilitatory and inhibitory) from intrafusal fibers is carried
back to spinal cord by proprioceptive reflex arc with alpha motor neurons which supply extrafusal fibers.
It is interesting to note the following points at this stage:
Normal muscle tone is maintained by balanced facilitatory effect of corticospinal tract and inhibitory effect of
noncorticospinal tract on intrafusal fibers of muscle spindle through gamma motor neurons.
In case of lesions of upper motor neurons or descending tracts, patient presents manifestations which are the
effect of combined damage to pyramidal and extrapyramidal tracts.
Lesions of extrapyramidal (noncorticospinal) tract leads to release (withdrawal) of inhibitory effect on gamma
motor neurons, which thereby causes spasticity due to increase of muscle tone.
Upper Motor Neurons Lesions
It is the combined lesion of both pyramidal (corticospinal) and extrapyramidal (noncorticospinal) tracts.
Corticospinal tract originates from different areas of cerebral cortex. Noncorticospinal tract originates from
different motor centers of brainstem. But these centers are also influenced by some descending cortical fibers. It
means therefore, even in case of lesion of upper motor neuron anywhere above brainstem, patient will present
effect of combined lesion of corticospinal as well as noncorticospinal tracts.
Lesion of Corticospinal Tract (Pyramidal Tract)
1. It results in loss of fine, skilled voluntary movements. It affects particularly distal part of limbs. This
manifestation is due to loss of command of corticospinal tract over alpha motor neurons of
spinal gray matter whose axons innervate extra-
fusal fibers of skeletal muscle.
2. Lossoffunctionofefferentcomponent(corticospinal
tract􏲄 of some re􏲄e􏲄 pat􏲄􏲄a􏲄
It is well-known that a reflex pathway is composed of 5 components— i) receptor ii) afferent path iii) center iv)
efferent path and, v) effector organ. Corticospinal tract forms efferent component of some reflex pathway which
are, not horizontally, but vertically oriented. So when corticospinal tract is lesioned, these reflexes are abolished
or lost.
􏱧l􏱧􏱧􏱧􏱧r re􏱧e􏱧 – Its 5 components are—

i. Receptor – At skin of lateral border of sole of
foot.
ii. Afferent component – Sensory nerves from
lateral border of sole of foot, ascending tract of
spinal cord which reaches upto cerebral cortex. iii. Center – Motor area of cerebral cortex.
iv. Efferentcomponent–Corticospinal(pyramidal)
tract, motor (efferent) nerve of lower limb
supplying plantar muscles.

v. Effector organ – Plantar muscles.
Due to integrity of this reflex pathway, scratching
of lateral border of sole of foot causes plantar flexion of foot normally. Therefore, in case of lesion of corticospinal
tract, there becomes interruption of the circuit of reflex pathway, which results in – 87
a) Abolition of plantar reflex

b) In addition, withdrawal phenomenon of limbs
occurs by dorsiflexion of the great toe with fanning (abduction) of other toes. This is called positive Babinski sign.
In case of infants, myelination of corticospinal tract is completed at the age of 2 years. So upto age of 2 years,
nonmyelinated corticospinal tract is characterized by loss of velocity of action potential, which makes it
nonfunctioning. So in an attempt to elicit plantar reflex, it will show positive Babinski sign.
􏱧u􏱧erfi􏱧i􏱧l 􏱧b􏱧o􏱧i􏱧􏱧l re􏱧e􏱧
Components
1. Receptors: Stretch receptors under the skin of anterior abdominal wall.

2. Afferentcomponent:Sensoryfibersoflowerinter- costals nerve carrying sensation to the spinal cord –
Ascending tracts of the spinal cord reaching finally to cerebral cortex.
3. Center: Motor area of cerebral cortex.
4. Efferentcomponent:Corticospinaltract–anterior horn cells of spinal cord – motor fibers of lower
intercostal nerve.
5. Effectororgan:Flatmusclesofanteriorabdominal
wall.
In normal individual, scratching of skin of anterior

abdominal wall causes brisk visible contraction of
Spinal Cord
muscles of anterior abdominal wall. In lesion of corticospinal tract, which is part of efferent component of reflex
pathway, superficial abdominal reflex is found to be absent.
􏱧re􏱧es􏱧eri􏱧 re􏱧e􏱧 Components
1. Receptors: Stretch receptors beneath the skin of medial side of front of thigh below groin.
2. Afferent component: Femoral branch of genitofemoral nerve (L1 L2) – Ascending tract from L1/ L2 level of
spinal cord to end finally to cerebral cortex.
3. Center: Motor area of cerebral cortex.
4. Efferentcomponent–Corticospinaltract–Genital
branch of Genitofemoral nerve (L1, L2)
5. Effector:Cremestermuscleinmalesothisreflexis
elicited only in male patients.
In normal individual, scratching of skin of front
of thigh below groin causes contraction of cremesteric muscle leading to slight upward pull to testis which is
visible through skin of scrotum. In case of lesion of corticospinal tract, which is efferent component of the reflex
pathway, cremesteric reflex is absent.
Lesion of Noncorticospinal Tracts (Extrapyramidal tracts)
1. Widespread paralysis of voluntary muscles which are concerned with gross movements.
2. Hypertonicity: Muscle tone is increased because, inhibitory effect of extrapyramidal tract on gamma
motor neurons is cut off. As the muscles are paralyzed, it gives rise to spasticity. So paralysis is called
spastic paralysis.
3. 􏲄􏲄aggeratedtendonre􏲄e􏲄es:Innormalindividual, tapping of tendon of quadriceps femoris (ligamentum
patellae) causes brisk jerky extension movement of knee. This is due to integrity of local reflex arc at
the spinal cord level. In case of lesion of extrapyramidal (noncorticospinal) tracts, its inhibitory effect on
gamma motor neuron is cut off, which will cause exaggeration of tendon jerks.
Lower Motor Neurons Lesion
Motor neurons (both alpha as well as gamma) of anterior gray column of spinal cord are known as lower motor
neurons (LMN) which are governed by upper motor neurons (UMN) of all supraspinal centers. The axons of all
the lower motor neurons of spinal cord leave central nervous system to end in the target organs (voluntary
muscles) via ventral (motor) root of spinal nerve. That is why the ventral motor root is called ‘final common
pat􏲄􏲄a􏲄 of 􏲄􏲄errington’.
Depending upon the site, lesions may be subdivided as follows:
1. Extradural
2. Intradural: i) Extramedullary – lesion outside
spinal medulla (spinal cord) ii) Intramedullary – inside spinal medulla.
Spinal Cord Syndrome
Depending upon causes of spinal cord lesion, spinal cord may be compressed to a variable extent, i.e. completely or
partially leading to different types of clinical manifestations. These are as follows:
1. Complete cord transection syndrome

2. Anterior cord syndrome
3. Central cord syndrome
4. Cord hemisection syndrome or Brown-Se􏲠quard
syndrome.
It is important to note at this stage that, patient attacked with any of the above mentioned syndrome passes
initially and temporarily through an acute phase of shock, which is called spinal shock syndrome.
Spinal Shock Syndrome
It is the initial phase of ‘blackout’ faced by spinal cord following injury of any type causing damage to spinal cord.
Duration: In most of the cases, this phase lasts for 1 day (24 hours). In some cases, of course, it may extend upto
1 week to 1 month (4 weeks).
Clinical features: Fundamentally it is characterized by depression or loss of all cord functions (motor and
sensory) below the level of lesion. These are –
1. Flaccid paralysis
2. Hypotonia or atonia, i.e. loss of muscle tone
3. Loss of tendon jerks and reflexes
4. Loss of all sensation below the level of lesion
5. If the lesion is higher level, hypotension (fall
of blood pressure) due to loss of sympathetic
vasomotor control
6. Loss of bladder and bowel function.
Regeneration of function of cord –

After the phase of spinal shock is over, partial regeneration of cord function occurs because –
i. Neurons, which are not permanently damaged, get back the power of irritability and conductivity.
ii. Edema of the affected neural tissue subsides.
After the period of spinal shock is over, neurological impairment (clinically called neurodeficit) is categ- orized as
following syndromes.
1. Complete cord transection syndrome
2. Anterior cord syndrome
Same as upper motor neuron, lower motor neuron lesions may occur due to following causes.
1. Traumatic
2. Ischemic
3. Infective
4. Degenerative
5. Neoplastic.
Whatever the reason is, lower motor neuron lesion
results in damage to cell bodies of anterior gray horn and/or their axonal process emerging as ventral nerve root.
Effects or manifestations are as follows:
1. Flaccidparalysis:Itistheparalysisofvoluntary muscles supplied by the affected spinal segments

with loss of muscle tone because of lesion of gamma
with alpha motor neurons.
2. Atrophy of muscles following atonic paralysis.
􏱧􏱧 􏱧oss o􏱧 re􏱧e􏱧es related to affected muscles. It
explains abolition of tendon jerks (e.g. knee jerks)
depending upon the corresponding segment.

4. Contracture of muscles: It is the shortening of the muscles which occurs in antagonists, as they
are not opposed by the paralyzed muscles.
SPINAL CORD INJURIES
Incidence of spinal cord injuries (spinal injuries) is very common in modern days. These injuries are catastrophic as
there is very little or no chance of regeneration of damaged neural tissue. It leads to permanent disabilities.
Principles of Management
1. Decompression of spinal cord by realignment of vertebra fractured and/or dislocated.

2. Stabilization of injured area.
3. Rehabilitation.
4. Recently,useofcertaindrugs,e.g.GM1,Ganglioside
and methylprednisolone, soon after injury results in improvement of neurological deficit.
Causes of Spinal Cord Lesion
1. Traumatic: i) Fracture dislocation of vertebra ii) Penetrating injury – e.g. stab injury, gunshot injury.
2. Vascular: i) Arterial occlusion or compression – causes degeneration of nerve cells and fibers.
ii) Venous compression – causes edema of neural tissue.
3. Infective: Viral or bacterial.
4. Degenerative: Causing demyelination of nerve
fibers.
5. Neoplastic: By expanding tumor.
88
3. Central cord syndrome

4. Cord hemisection syndrome (Brown-Se􏲠quard
syndrome).
These syndromes differ from one another depending upon the area of the segment of spinal cord affected.
The clinical findings are combination of following fundamentally –

1. Lowermotorneuronlesionatthelevelofsegment
affected.
2. Uppermotorneuronlesionbelowtheleveloflesion.
3. Sensory loss below the level of lesion.
Combination of clinical manifestations in any of
the above syndromes will vary according to the level of spinal cord lesion.
Complete Cord Transection Syndrome (Fig. 4.26A) 89
Causes
1. Fracture dislocation of vertebral column (spinal injury).
2. Panetratinginjury–Stabinjuryorgunshotinjury. 3. Expanding tumor.
Effects
All motor and sensory impairments will be bilateral as follows –

1. Damageofanteriorhorncells(LMN)andemerging
motor nerve roots of the segment affected will cause bilateral lower motor neuron paralysis of the muscles
supplied by motor nerve roots arising from the particular segment.
This paralysis will ultimately will be followed by atrophy of the muscles affected.
2. Damageofbothsidedcorticospinalaswellasnon-
corticospinal tracts will cause following bilateral manifestations below the level of lesion.
i. Spastic paralysis
ii. Babinski sign positive
iii. Loss of abdominal and cremesteric reflexes.

3. Damage of all sensory tracts in anterior, lateral and posterior funiculi of both sides will cause bilateral loss of
all sensations (exteroceptive as
well as proprioceptive) below the level of lesion.
Spinal Cord
AB
CD
Figs 4.26A to D Various types of spinal cord syndrome. A. Complete cord transection syndrome, B. Anterior cord syndrome, C. Central cord
syndrome, D. Cord hemisection syndrome (Brown-Se􏲠quard syndrome)
4. Loss of voluntary control of bladder and bowel function due to damage of descending autonomic fibers.
90
Anterior Cord Syndrome (Fig. 4.26B)
Causes
1. Traumatic: i) Fracture dislocation of anterior component of vertebral column ii) Herniation of

intervertebral disk.
2. Ischemic: Occlusion or compression of anterior spinal artery which supplies anterior two-third of spinal
cord.
Effect
Effects are bilateral:

1. Damage of anterior horn cell and emerging ante-
rior nerve roots will cause lower motor neurons paralysis of the muscle supplied by the segment affected.
The paralysis of the muscle affected will be follo-
wed by muscular atrophy.
2. Bilateral spastic paralysis below the level of les-
ion due to damage of anterior corticospinal and
various noncorticospinal tracts.

3. Lesionofanteriorandlateralspinothalamictracts
will cause bilateral loss of pain, temperature (lateral spinothalamic tract) and pressure and light touch (anterior
spinothalamic tract) sensation. Touch is not affected as fine touch and discrim-
inative touch sensation is carried through dorsal white column (fasciculus gracilis and fasciculus cuneatus). Due
to same reason, sense of position and movements, and vibration sensation are also not lost.
Central Cord Syndrome (Fig. 4.26C)
Cause
Severe hyperextension of cervical part of vertebral column (called hyperextension injury) which occurs due to
violent force applied to the back of neck in automobile accident.
In this type of injury, central part of spinal cord is compressed by vertebral bodies and ligamentum flavum from
front and back respectively.
Effect
All the manifestations as explained below are bilateral. As this lesion occurs classically in cervical region, both
motor and sensory loss involve both upper and
lower parts of body.

1. Lesion of anterior horn cells causes lower motor
neuron lesion manifested by paralysis of the muscles which are innervated by that particular
segment of spinal cord. Paralysis will be followed
by atrophy of muscles.
2. Bilateral spastic paralysis with all features of
upper motor neuron lesion. It is due to damage to both corticospinal and noncorticospinal tracts. It affects
both upper and lower limbs as the lesion is in the cervical part of cord.
3. Bilateral loss of pain, temperature and pressure sensation as lateral and anterior spinothalamic tracts
are affected. The sensory loss is below the level of lesion, which in this type of injury is at cervical level.
Though the lesion of central cord syndrome is in cervical region, lower limb may remain unaffected for
somatomotor and somatosensory loss, because in both motor and sensory tracts, peripherally placed
sacral fibers are spared (Fig. 4.26C).
Though crude touch is affected fine touch is
preserved as peripheral parts of fasciculus gracilis (from lower half of body) and fasciculus cuneatus (from upper
half of body) remain undamaged. For the same reason, sense of position, movement and vibration is also not
affected.
Brown-Séquard Syndrome (Fig. 4.26D) (Cord hemisection syndrome)
Cause
Penetrating injury like gunshot injury or stab injury.
Effect
Fundamental difference of this spinal cord injury from above mentioned types is that it produces unilateral
effects which are as follows.
1. Ipsilateral lower motor neuron paralysis of the
muscles which are supplied by the lesioned spinal cord segment. It is caused due to injury to the anterior horn
cells and emerging anterior nerve root of the particular segment. The paralysis is followed by muscular atrophy.
2. Ipsilateral loss of all cutaneous sensations (anesthesia) over the dermatome supplied by the incoming
sensory nerve root of the affected segment. Initially this area of dermatome may present hyperesthesia
(exaggerated sensation) due to irritation of posterior nerve root.
3. Ipsilateral spastic paralysis due to lesion of same sided corticospinal and noncorticospinal tracts passing
through lateral and anterior white column. Paralysis is below the level of lesion. Depending upon the
level of lesion, clinical finding may include Babinski sign positive, loss of abdominal and cremesteric
reflexes, exaggerated tendon jerks.
4. Ipsilateral loss of fine as well as discriminative touch (exteroceptive sensation) and sense of
position, movement with vibration sensation (proprioceptive sensation) are manifested due to lesion of dorsal
white column tracts (fasciculus gracilis and fasciculus cuneatus). Sensory loss is below the level of lesion.
5. Contralaterallossofpainandtemperature(lateral spinothalamic tract) and pressure sensation (anterior
spinothalamic tract) is observed below the level of lesion.
Touch sensation is not affected as crude touch of the same side and fine touch of opposite side are preserved due
to noninvolvement of opposite half of spinal cord.
SELECTIVE LESIONS OF SPINAL CORD
The above mentioned spinal cord syndromes are the results of spinal cord lesions which are of traumatic,
Spinal Cord
91
A Tabes dorsalis
B Anterior poliomyelitis
D Multiple sclerosis
􏱰 Amyotrophic lateral sclerosis
C Syringomyelia
Figs 4.27A to E Various types of selective lesions of spinal cord. A. Tabes dorsalis, B. Anterior poliomyelitis, C. Syringomyelia, D. Multiple
sclerosis, E. Amyotrophic lateral sclerosis
ischemic or neoplastic origin. Various infective or degenerative causes may give rise to selective lesion of
different motor and/or sensory tracts, upper or lower motor neurons which are as follows.
Tabes Dorsalis – A Sensory Lesion (Fig. 4.27A)
It is a neurological disease caused by syphilis when central nervous system is affected (neurosyphilis). It
damages selectively the posterior white column (fasciculus gracilis and fasciculus cuneatus) and also posterior
nerve root fibers entering dorsal column. Commonly thoracic and lumbosacral segments are affected.
Effect
Due to lesion of dorsal column tracts (fasciculus gracilis and fasciculus cuneatus)—
1. Loss of sense of position and movement, and loss of vibration sensation.

2. As the patient is not aware of position of limbs while walking, the limbs strike against the ground
causing stumping gait. Patient tries to compensate this disability with the help of vision.
3. If visual help is withdrawn by closure of eyes, in standing position, due to loss of sense of position,
patient will have a tendency to fall. It is known as positive Romberg sign.
4. Lossofsensationoffullnessofurinarybladder,as this sensory pathway traverses dorsal column. 􏲄ue to
lesion of posterior nerve root fibers–
5. Lossofexteroceptivesensationoverthedermatome areas of skin opposite the segments of spinal cord
affected.
92 Due to irritation of dorsal nerve root ganglia–
6. Paresthesia (altered sensation) or hyperesthesia (exaggerated sensation) with stabbing pain sensation
of the dermatome areas corresponding to affected spinal cord segments.
Poliomyelitis – Acute Viral Infection of Spinal Motor Neurons (LMN) (Fig. 4.27B)
It is the neuronal disease caused by poliovirus which cause selective damage to the motor neurons of anterior
gray column of spinal cord and motor nuclei of cranial nerves supplying muscles of face, tongue, larynx and
pharynx.
Worldwide immunization program by poliovac- cine remarkably reduced the horror of incidence of the disease
among children.
The viral infection is characterized by edema of neural tissue with selective damage of anterior horn cells (LMN).
It causes paralysis with wasting of muscles. Lower limb is more affected than upper limb. If motor nuclei of
cranial nerves are affected, it causes paralysis of muscles of face, tongue, pharynx and larynx. In severe
poliomyelitis, respiratory muscles (diaphragm and intercostal muscles) may be paralyzed.
Patient recovers from disease when edema subsides and motor neurons regain power. Permanent death of some
neurons is characterized by residual paralysis.
Syringomyelia – A Lesion of Embryological Cause (Fig. 4.27C)
Syringomyelia is a degenerative lesion of spinal cord characterized by excavation (dilatation) of central canal of
some segments of spinal cord due to some developmental reason. Usually cervicothoracic (lower cervical and
upper thoracic) segments of spinal cord
are affected. At the site of lesion cavitation followed by gliosis gives rise to following clinical findings.
1. Before formation of lateral spinothalamic tract,
fibers carrying sensation from opposite side of body, decussate in front of central canal in the anterior
gray and white commissures of the segments commonly affected (lower cervical and upper thoracic).
Cavitation of central canal causes damage to these fibers causing loss of pain and temperature sensation
over skin of neck, upper limb and upper part of trunk. Area of anesthesia simulates area of body covered
by a jacket. That is why it is called ‘Jacket type of anesthesia’.
2. Dilatation of central canal (in lower cervical and upper thoracic segments) starts from C 8–T1 segments of
spinal cord and proceeds upwards as well as downwards. So initially dilatation is maximum at C8–T1
segments for which at these two segments lesion extends peripherally to damage anterior horn cell which
causes paralysis of small muscles of hand followed by muscular atrophy. Subsequently other muscle of
upper limb are also paralyzed.
3. If excavation of central canal progresses further laterally, it will damage corticospinal and noncort-
icospinal tracts leading to spastic paralysis with exaggerated tendon jerks of both lower limbs, i.e. below
the level of lesion.
Multiple Sclerosis – A Demyelinating Disease (Fig. 4.27D)
It is a degenerative disease of spinal cord caused by demyelination of both descending as well as ascending
tracts. Following are the cause alone or in combination –
1. Heredity
2. Autoimmunity
3. Infection.
Young adult age groups are affected. Because of
above mentioned predisposing factors, functioning of blood brain barrier looses it integrity. It will cause more
chance of infection which will lead to entry of leukocytes in central nervous system tissue. Inflammation will
cause loss of myelin sheath (demyelination) of tract fibers of spinal cord. Demyelination will cause initial
reduction and ultimate loss of velocity of action potential of tract fibers.
During active phase of the disease following demyelination, the patient present impaired sensation, weakness
of muscle at different levels depending upon level of spinal cord affected. There may be signs of ataxia as tracts of
the cerebellum is affected.
The disease is characterized by ‘Recovery and Recurrence’. Recovery is due to ‘remodeling’ of plasma membrane of
demyelinated axons which become able to regenerate velocity of action potential.
But in unfortunate cases of progressive type of the disease, instead of recovery, loss of myelin sheath is followed
by permanent damage of the axons.
Amyotrophic Lateral Sclerosis – A Progressive Degenerative Disease (Fig. 4.27E)
It is a progressive degenerative disease of unknown cause victimizing middle-aged people. It damages selectively
the corticospinal and noncorticospinal descending tracts causing spastic paralysis below
Spinal Cord
93
the level of lesion. It is associated with damage to anterior horn cells causing lower motor neuron lesion of the
muscles supplied by the affected segment.
The disease turns to a fatal state within 5 to 6 years.
Combined Degeneration of Spinal Cord – In Pernicious Anemia
Pernicious anemia, a type of megaloblastic anemia is caused due to vitamin B 12 deficiency. The disease is
associated with combined degeneration of descending (motor) and ascending (sensory) tracts of spinal cord due to
lesion of posterior and lateral white column. It is characterized by widespread motor and sensory less.
Brainstem is the tubular stalk-like part of the brain made up of midbrain, pons and medulla oblongata from above
downward (Fig. 5.1). It is so called because it is like stem of a tree. Main mass of the brain, cerebrum with
cerebellum rests on the brainstem and through it, is connected to spinal cord below. Long axis of brainstem is
oblique, directed downward and backward.
Extent: Above, upper end of brainstem (midbrain) is continuous with diencephalon of forebrain.
Below: Lower end of brainstem (medulla oblongata) passes out of cranial cavity through foramen magnum to
become continuous with spinal cord at the level of upper border of first cervical vertebra.
Relations of Brainstem
With cranial cavity: Brainstem lies in posterior cranial fossa of skull and rests on the slope of clivus
Midbrain
Pons Medulla oblongata
Fig. 5.1 Brainstem (lateral view)
which is formed by posterosuperior surface of basilar parts of sphenoid and occipital bones.
With tentorium cerebelli: Tentorium cerebelli is a crescentic horizontal shelf of dura mater of brain lying
between posterior part of cerebrum (occipital lobe) and cerebellum. It posseses peripheral convex border. In front of
concave anterior border (tentorial notch), brainstem passes downwards. Midbrain is the supratentorial part and,
pons with medulla oblongata is the infratentorial part of brainstem lying above and below the tentorium cerebelli
respectively (Fig. 5.2).
With cerebrum and cerebellum: Cerebrum with thalamus (diencephalon) is above and, cerebellum is behind
the brainstem. Ventral compact part
Brainstem
Supratentorial part of brainstem
Infratentorial part of brainstem
Tentorium cerebelli
Fig. 5.2 Tentorium cerebelli divides brainstem into supratentorial and infratentorial parts
5
Cerebral peduncle Cerebellum Middle cerebellar peduncle
Fig. 5.3 Cerebellum and peduncles (cerebral as well as cerebellar) related to brainstem
95
Brainstem
of midbrain, composed of bundle of descending fibers connects the brainstem (midbrain) above with cerebrum. It
is called cerebral peduncle having right and left identical halves. Cerebellum is connected to midbrain, pons and
medulla oblongata of brainstem by three pairs of compact bundle of white matter. These are called superior,
middle and inferior cerebellar peduncles respectively (Fig. 5.3).
Withfourthventricleofbrain:Fourthventricle is the cavity of hindbrain. It is related anteriorly to pons and

medulla oblongata and posteriorly to cerebellum (Fig. 5.4).
Cavity Related to Brainstem
Cavity related to brainstem is of different shapes and natures at different level as follows:
Midbrain–Anarrowlinearslitknownasaqueduct
of Sylvius.
Aqueduct of Sylvius
Fourth ventricle of brain
Central canal of lower end of medulla oblongata

Pons and upper part of medulla oblongata: A wide tent shaped space forming cavity of hindbrain called fourth
ventricle of brain.
Lower part of medulla oblongata: A narrow central canal of medulla continuous below with central canal of
spinal cord.
Structural and Functional Characteristics
Intermingling of gray matter and white matter
Brainstem is the part of central nervous system where gray matter and white matter are not demarcated into
two separate zones. Unlike spinal cord, it is not divided into central gray matter and peripheral white matter.
Again, unlike cerebrum and cerebellum it does not show superficial cortex and deeper medullary substance.
Brainstem presents intermingling of gray matter and white matter.
Fig. 5.4 Cavity related to brainstem
96
White Matter of Brainstem
Brainstem acts as a bridge, composed of compact vertical bundles of fibers in the form of ascending and
descending tracts connecting spinal cord with higher centers.
􏲠orizontal fibers from the three components of brainstem connect cerebellum through three pairs of cerebellar
peduncles.
Gray Matter of Brainstem
Gray matter inside the brainstem is present in the form of clusters of nerve cells called nuclei which are as
follows—
1. Cranial nerve nuclei: There are motor and
sensory nuclei of 3rd to 12th cranial nerves.
2. Other nuclear masses: In all the three components of brainstem, there are other nuclear
masses, for example red nucleus in midbrain, pontine nucleus in pons and olivary nucleus in
medulla oblongata.
3. Reticular nuclei: Throughout the whole length
of central core of brainstem, scattered collection of nerve cells are present. There are
intermingled with network (reticulum) of nerve fibers. These constitutes reticular formation
of brainstem. Scatt- ered nerve cells are known as reticular nuclei.
Special Functional Areas in Brainstem
1. Brainstemcontains‘VitalCenters’whichregulate the activities of cardiovascular and respiratory systems.

2. Brainstem contains center which controls autonomic reflex activities.
3. Brainstem reticular formation, which is defined above, regulates level of consciousness and alertness.
Aqueduct of Sylvius
Foramen cecum
Anterior median fissure
Posterolateral sulcus Anterolateral sulcus
External Features of Brainstem
In this connection, two important points are to be noted.

1. Externalfeaturesofthreecomponentsofbrainstem
are described here together.

2. External feature of brainstem are described in
following three points:

a) Surface features of brainstem
b) Surface attachments of roots of 3rd to 12th
cranial nerves.
c) Surface relations of brainstem with different
arteries.
Relative length
Midbrain– 2 cm
Pons – 2.5 cm
Medulla oblongata – 3 cm.
Surface Features of Brainstem
Ventral surface – (Fig. 5.5)
A. At the level of medulla oblongata
1. Along the midline of ventral surface of medulla oblongata a longitudinal fissure extends. It is called
ventral median fissure. Lower end of fissure is continuous below with ventral median fissure of spinal
cord. 􏲠pper end of fissure, at pontomedullary junction, ends in a small shallow depression called foramen
cecum.
2. On either side of ventral median fissure, there is a narrow linear elevation called pyramid with its
broader upper end and narrower lower end. Deep to it, passes a descending (motor) tract called
pyramidal tract (corticospinal tract). Some of the
Upper cut surface of midbrain
Cerebral peduncle Basilar sulcus
Basilar part of pons

Cut surface of middle cerebellar peduncle
Inferior cerebellar peduncle Olive
Pyramid
Fig. 5.5 External features of brainstem (ventral surface)

fibers of this tract decussate (cross) at the lower end of pyramid. Decussation of these fibers is visible at the lower
end of ventral median fissure.
3. Pyramid is demarcated laterally by anterolateral sulcus which is continuous below with same sulcus of
spinal cord.
4. Anovalelevation,withitslongaxisbeingvertical, is present lateral to upper end of anterolateral sulcus. It is
called olive. Deep to olive lies a mass of gray matter called inferior olivary nucleus.
5. Posterolateral to olive, a sulcus extends vertically which is parallel to anterolateral sulcus. This is called
posterolateral sulcus. It is continuous below with same sulcus of spinal cord.
6. Furtherposterolateral,acompactverticalbandof medulla, passes upwards, backwards and laterally to
cerebellum. It is called inferior cerebellar peduncle.
B. At the level of pons
1. Junction between pons and medulla oblongata presents a deep transverse sulcus. Midline of po-
ntomedullary junction presents a small blind depression called foramen cecum.
2. Along the midline of ventral surface of pons, a wide shallow sulcus extends vertically. It is known as
basilar sulcus. Basilar artery passes along this sulcus from below upwards.
3. Oneithersideofbasilarsulcus,ventralsurfaceof pons presents a bulge, called basilar part of pons.
4. Lateral to basilar part, pons presents thick compact band-like part which is horizontal in direction and
passes laterally and backwards to cerebellum. This is middle cerebellar peduncle.
Superior colliculus
Inferior colliculus Superior medullary velum
Floor of 4th ventricle Facial colliculus
Hypoglossal triangle
Vagal triangle 97
Dorsal surface of lower closed part of medulla oblongata
C. At the level of midbrain
Ventral surface of midbrain presents bilateral, compact, thick band-like structures separated by a midline
depression or broad sulcus. This is called cerebral peduncle. Upper cut surface of midbrain shows that cerebral
peduncle is the part of midbrain which is ventral to aqueduct of Sylvius. Anterior most part of the cerebral
peduncle is made up of compact bundle of descending (motor) fibers. This part is called crus cerebri.
Dorsal surface (Fig. 5.6)
For better understanding, surface feature of dorsal surface of brainstem is described in following three
components.
A. At the level of lower half of medulla oblongata.
B. At the level of upper half of medulla oblongata and pons.
C. At the level of midbrain.
A. At the level of lower half of medulla oblongata
1. Along the midline, a vertical sulcus runs. It is called median intermediate sulcus which is continuous below
with posterior median sulcus of spinal cord.
2. On either side of this sulcus, dorsal surface of lower half of medulla oblongata present a linear vertical
elevation.
3. Upper end of this elevation, on either side, presents a small elevation called gracile tubercle.
Cut upper surface of midbrain
Trochlear nerve
Cuneate tubercle Gracile tubercle
Median intermediate sulcus
Brainstem
Fig. 5.6 External features of brainstem (dorsal surface)
4. Superolateral to each gracile tubercle, another elevation is present. This is called cuneate tubercle. Beneath
the above two tubercles, lie nucleus gra-
cilis and nucleus cuneatus respectively.

5. Superolateral to cuneate tubercle, compact band-
like structure, called inferior cerebellar peduncle passes upwards and laterally to the cerebellum.
98
B. At the level of upper half of medulla oblongata and pons
Dorsal surface of this part of brainstem presents following characteristics.
i. This area form the floor of 􏲠th ventricle of brain.
ii. This area receives the opening of central canal of medulla oblongata below and the opening of aqueduct of
midbrain above.
Details of features of this area is described in the chapter of 4th ventricle of brain. Some important features are
as follows:
1. The total area is rhomboid in outline, so called
Rhomboid fossa.
2. It is divided into right and left symmetrical tria-
ngular halves by a vertical midline sulcus called
median sulcus.
3. On either side of median sulcus, there is a linear

elevation called medial eminence.
4. Medial eminence at the level of pons, presents a
round elevation called facial colliculus.
5. Atthelevelofmedullaoblongata,medialeminence area is divided by a small sulcus into two triangular

areas. The superomedial triangular area is called Hypoglossal triangle, and inferolateral one is
called vagal triangle.
6. The medial eminence is bounded laterally by a
sulcus, known as sulcus limitans.
7. Small depressions at upper and lower ends of
sulcus limitans area known as superior fovea and
inferior fovea respectively.
8. Area lateral to sulcus limitans is triangular which
is called vestibular triangle.
For further details, reader is suggested to go
through text of floor of 􏲠th vertricle of brain.
C. At the level of midbrain
1. Uppermost part of dorsal surface of midbrain presents two pairs round elevations. They are known as
superior and inferior colliculi or corpora quadrigemina (Singular–colliculus). Superior colliculi are
slightly larger than the inferior.
2. Four colliculi are separated from each other by a cruciform sulcus which presents a vertical and
a horizontal limb crossing each other at a right
angle.
3. Upper end of vertical limb presents a small
depression to lodge pineal gland.

4. From inferolateral aspect of inferior colliculus of
midbrain, a pair of compact band of white matter goes downwards, backwards and laterally to the cerebellum.
This is superior cerebellar peduncle.
5. Athinlaminaofwhitematterconnectsthemedial sides of two superior cerebellar peduncles, thus forming the

upper part of roof of 4th ventricle of brain. This is called superior medullary velum.
6. Lower end of vertical limb of cruciform sulcus is continued vertically downwards across the midline of superior
medullary velum in the form of a thin ridge. It is called frenulum veli.
7. On either side of frenulum veli, 4th cranial nerve (trochlear nerve) comes out of brainstem piercing superior
medullary velum.
It is to be noted at this stage that, out of last 10
pairs of cranial nerves (3rd–12th), only trochlear nerve comes out of brainstem from its dorsal surface. Finally,
trochlear nerve goes forwards curving
round the posterolateral aspect of superior cerebellar peduncle.

Exit of cranial nerves (3rd–12th) form brainstem (Figs 5.6 and 5.7):
All of last 10 pairs of cranial nerves (3rd–12th) except 4th (trochlear), come out of brainstem from ventral surface
(Fig. 5.7). Trochlear nerve comes out from dorsal surface (Fig.5.6).
Site of attachment of roots of these cranial nerves on the surface of the brainstem will be better understood and
remembered if noticed in reverse order (i.e. 12th –3rd) as follows:
12thcranialnerve(hypoglossal)comesoutthrough multiple rootlets, from anterolateral sulcus between pyramid
and olive.
9th (glossopharyngeal), 10th (vagus) and 11th (accessory) nerves comes out in vertical row from above
downwards through posterolateral sulcus between olive and inferior cerebellar peduncle.
From medial to lateral at pontomedullary junction, 6th (abducent), 7th (facial) and 8th (vestibulocochlear)
nerves comes out from the level of upper end of olive. Motor root of facial nerve (VII) is medial to its sensory root.
5th cranial nerve (trigeminal) comes out from midpontine level at the junction of basilar part of pons and
middle cerebellar peduncle. The nerve comes out in the form of superomedial motor root and inferolateral
sensory root.
4th cranial nerve (trochlear) is the exception which comes out from dorsal surface of brainstem. The nerve
comes out piercing superior medullary relum lateral to frenulum veli. Finally the nerve comes in
Brainstem
99
Glossopharyngeal nerve (IX)
Vagus nerve (X)
Accessory nerve (XI) Hypoglossal nerve (XII)
Oculomotor nerve (III) Trochlear nerve (IV)
Trigeminal nerve (V) Abducent nerve (VI)
Facial nerve (VII) Vestibulocochlear nerve (VIII)
Fig. 5.7 Exit of cranial nerves (III to XII) from brainstem
front winding round posterolateral aspect superior cerebellar peduncle (Fig. 5.6).
3rd cranial nerve (oculomotor) emerges from medial surface of crus cerebri of cerebral peduncle.
Arteries related to surface of brainstem (Fig. 5.8)

Arteries of vertebrobasilar system are related to ventral surface of brainstem.
Right and left vertebral arteries run vertically from below upwards winding round the posterolateral aspect of
medulla oblongata. In the midline of pontomedullary junction two vertebral arteries unite to form basilar artery.
Basilar artery
Posterior cerebral artery
Labyrinthine artery
Anterior inferior cerebellar artery
Two vertebral arteries unite to form basilar artery
run vertically upwards along the length of basilar sulcus.
At the upper end of pons, basilar artery bifurcates into right and left posterior cerebral arteries.
5 sets of branches from vertebral artery and 5 sets of branches from basilar artery are related to the ventral
surface of brainstem as seen in Figure 5.8.
5 sets of branches of vertebral artery:
1. Meningeal arteries
2. Medullary arteries
3. Anterior spinal artery
4. Posterior spinal artery
5. Posterior inferior cerebellar artery.
Superior cerebellar artery Pontine arteries
Posterior inferior cerebellar artery
Meningeal arteries Medullary arteries
Posterior spinal artery Anterior spinal artery
Fig. 5.8 Arteries related to ventral surface of brainstem

100
Diencephalon Telencephalon
Diencephalon Mesencephalon
Rhombencephalon
Spinal cord
Fig. 5.9 Components of neural tube 5 sets of branches of basilar artery:
1. Pontine arteries
2. Labyrinthine artery
3. Anterior inferior cerebellar artery 4. Superior cerebellar artery
5. Posterior cerebral artery.
Embryological Background of Brainstem
Internal structure of brainstem is not only important, it is very interesting. For its better understanding, a
reader must have a basic concept of embryological background of brainstem.
Three components of brainstem, midbrain, pons and mudulla oblongata develop from two of three brains
vesicles. These are midbrain vesicle (mesencephalon) and hindbrain vesicle (rhombencephalon) (Figs 5.9 and
5.10).
Rhombencephalon is further divided into proximal metencephalon and distal myelencephalon (Fig. 5.11).
Neuroectodermal lining Midbrain vesicle
Hindbrain vesicle
Spinal cord
Fig. 5.10 Caudal two components of 3 brain vesicles to from future brainstem
Mesencephalon Metencephalon
] Rhombencephalon Myelencephalon
Fig. 5.11 Differentiation of 3 components of developing brainstem
Pons is developed from ventral part of metencephalon, dorsal part forming cerebellum. Medulla oblongata is
developed from myelencephalon. Prox- imal part of myelencephalon, which is adjacent to pons is wider and, in
due course of time, will follow the developmental characteristics as that of pons (see below). Distal part of
myelencephalon, adjacent to spinal cord will remain narrower and in future will show structural pattern more
like spinal cord. So, midbrain and hindbrain vesicles are differentiated into following four parts (Fig. 5.12).
1. Mesencephalon — will form midbrain 2. Ventral part of
Metencephalon — will form pons 3. Proximal part of
Myelencephalon — will form upper wider part of
medulla oblongata 4. Distal part of
Myelencephalon — will form lower narrower part of medulla oblongata
1–
2– 3– 4–
Neuroectodermal lining Mesencephalon (midbrain)
Metencephalon (ventral part to form pons)
Upper wider part

Myelencephalon
]
Lower narrower part
(medulla oblongata)
Fig. 5.12 Differentiation of part of neural tube to form various components of brainstem
Brainstem
101
Alar lamina (alar plate)
Basal lamina (basal plate)

Ependymal layer
Mantle zone formed by nerve cells
Marginal zone formed
by nerve fibers
Fig. 5.13 Formation of mantle zone and marginal zone due to proliferation of neuroectoderm layer of cells, which remains as ependymal
layer
But all these four components of primitive brainstem will follow the common (similar) embryological steps as
follows:
1. Initially, all components will be lined by single
layer of neuroectodermal cells (Fig. 5.12).
2. Cells of this single layer proliferate by mitosis. The newer cells (daughter cells) are pushed to the
periphery and form a definite layer called mantle
zone (Fig. 5.13).

Two different types of cells, neuroblasts and
spongioblasts in mantle zone will form neurons
and neuroglia (macroglia) respectively.
3. Originalliningcellswillformoutlineofthecavity of these parts of neural tube, called ependymal
cells.
4. The processes of developing neurons in the mantle
zone will be pushed to the periphery outside the mantle zone to form marginal zone (Fig. 5.13).
Alar plate Central canal Basal plate
However, this interrelationship between inner mantle zone (gray matter) and outer marginal zone (white
matter) will not persist in all the components of developing brainstem. Ultimately there will be intermingling of
gray and white matter (see below).
5. Midlines of dorsal and ventral aspects of ependymal layer present roof plate and floor plate
respectively.
6. Each half (right and left) of mantle zone is divided into dorsal and ventral components by a linear
sulcus called sulcus limitans. Dorsal part is called alar lamina (alar plate) and ventral part is called
basal lamina (basal plate). Neurons of alar lamina will be sensory in function and those of basal lamina
will be motor in function (Fig. 5.14).
Roof plate
Sulcus limitans Floor plate
Midbrain
Pons
Upper wider part of medulla oblongata
Lower narrower part of medulla oblongata
Fig. 5.14 Developing brainstem showing its components
102
Alar lamina (dorsolateral) Basal lamina (ventromedial)
Pons developing from ventral part of metencephalon
Upper part of medulla oblongata
Stretched out roof plate at the level of pons and upper part of medulla oblongata
Widening of cavity forms 4th ventricle of brain
Lower narrower part of medulla oblongata
Narrow central canal with dorsoventral relation of alar and basal laminae
Fig. 5.15 Pons and upper wider part of medulla oblongata show stretching of roof plate
Dissimilarity in Development in Different Components of Brainstem
Mesencephalon (midbrain) remains comparatively stunted in growth, thus remaining as short segment of
brainstem. Its central cavity becomes very narrow to be named as aqueduct of Sylvius. Alar lamina is dorsal
and basal lamina is ventral in position (Fig. 5.16).
Caudal or lower part of myelencephalon (medulla oblongata), continuous below with spinal cord remain
narrow and tubular like spinal cord. Its central canal becomes narrow. Alar lamina and basal lamina are
related dorsoventrally (Fig. 5.16).
Metencephalon (pons) and proximal or upper part of myelencephalon (medulla oblongata) show following
changes – (Figs 5.15 and 5.17).
a) Roof plate is stretched outwards on both side. b) That is why cavity of this part of neural tube (pons and
upper part of medulla oblongata) is widened which will form 4th ventricle of brain. c) Dorsal aspect of cavity of
4th ventricle of brain will be lined only by ependymal layer as a
result of stretching of roof plate.
Alar plate
Mantle zone
Basal plate
{
d) Basal and alar laminae are thereby not vent- rodorsally related. Alar lamina becomes dorsolateral to basal
lamina.
Organization of Internal Structure at Different Level of Brainstem
Central cavity of brainstem show different characteristics and names at different level. At lower end of
medulla it is a narrow canal continuous below with central canal of spinal cord. At the level of pons and upper
half of medulla oblongata, it becomes wide to form the cavity of 4th ventricle of brain. At the level of midbrain it
is a narrow slit called aqueduct of Sylvius.
Fundamentally, neurons of basal plate are motor and those of alar plate are sensory in function. Thro- ughout
the whole length of developing brainstem, initially, many neurons of both basal as well as alar plate will form
number of continuous columns of cells which are as follows:
In basal plate (from medial to lateral) (Fig. 5.18) 1. Somatic efferent
Ependymal layer
Marginal zone
Fig. 5.16 Similar relationship of differents layers of developing brainstem at the level of midbrain and lower half of medulla oblongata
Brainstem
103
Rhombic lip grows from alar plate to form cerebellum
Sulcus limitans
Marginal zone
Cavity of hindbrain (4th ventricle)
Dorsolateral alar plate
Ventromedial basal plate
Fig. 5.17 Relationship of different layers of developing brainstem at the level of pons and upper half of medulla oblongata Somatic afferent
Alar plate
Basal plate
Special visceral afferent General visceral afferent
General visceral efferent
Special visceral efferent Somatic efferent
Fig. 5.18 Cell columns forming cranial nerve nuclei in developing brainstem where central canal is narrow (midbrain and lower half of
medulla oblongata)
2. Branchial efferent (special visceral efferent) in open part, i.e. pons and upper part of medulla
3. General visceral efferent. oblongata (Fig. 5.19).
In alar plate: From medial to lateral in closed 1. Somatic afferent part of brainstem, i.e. midbrain and lower
end of med-
ulla oblongata (Fig. 5.18) and, from lateral to medial
Stretched out roof plate (lined by ependyma only)
Alar plate
Basal plate
2. Branchial afferent (special visceral afferent) 3. General visceral afferent.

Cavity of 4th ventricle of brain
Somatic afferent
Special visceral afferent
General visceral afferent
General visceral efferent Special visceral efferent
Somatic efferent
Fig. 5.19 Cell columns forming cranial nerve nuclei in developing brainstem where roof plate is outstretched widening central canal to form
fourth ventricle of brain (at the level of pons and upper half of medulla oblongata)
Nucleus gracilis Nucleus cuneatus
Alar plate
}Mantle zone Basal plate

104
Marginal zone
Fig. 5.20 Dorsal migration of cells of alar plate of lower closed part of medulla oblongata leads to development of nucleus gracilis and
nucleus cuneatus
Ultimately, neurons of all these columns will persist in some level and disappear in some level. So they will no
longer be present in the form of continuous cell column althrough. These cell groups will form different motor
and sensory nuclei of 3rd to 12th (last 10) cranial nerves.
Migration of neurons of alar lamina: Apart from formation of sensory (afferent) nuclei of cranial nerves,
neurons of alar plate will migrate from its original position either ventrally or further dorsally to form some
other named nuclei in different level of brainstem (described below). This nuclei, as migrated, will intermingle
with the components (white matter) of marginal zone.
Derivativesofmarginalzone:Itisalreadyund- erstood that, marginal zone is composed of processes of nerve
cells of mantle zone. These processes will form different groups of bundles of nerve fibers which are basically of
following two types—
1. Vertical: These are either ascending (afferent) or
descending (efferent) tracts of nerve fibers connecting spinal cord with various higher centers.
Basal plate Alar plate
2. Horizontal: These are fiber bundles connecting various centers of central nervous system with cerebellum in
both direction, passing through 3 cerebellar peduncles.
Migration of cells of alar plate to form various nuclei: As already stated, neurons of alar plate form
various sensory neclei of last 10 pairs (3rd–12th) of cranial nerves. Besides, neurons from alar plate migrate
either ventrally or further dorsally to form various nuclei in different levels of brainstem as follows.
1. At the level of lower closed part of medulla oblongata (Fig. 5.20): Cells of alar plate migrate further
dorsally on either side of posterior median sulcus to form two nuclei.
1. a) Medial: Nucleus gracilis

2. b) Lateral: Nucleus cuneatus.
2. At the level of upper half of medulla oblon-
gata: Cells of alar plate migrate ventrally in the peripheral plane of marginal zone in the form of following
nuclei (Fig. 5.21).
Cavity of hindbrain (4th ventricle) Ependymal roof
Migration of cells of alar plate forms
Inferior olivary nucleus and
Arcuate nucleus
Fig. 5.21 Ventral migration of cells of alar plate in upper half of medulla oblongata forms inferior olivary nucleus and arcuate nucleus
Brainstem
105
Cavity of hind brain (4th ventricle)
Alar plate Mantle zone

{
Basal plate
Marginal zone forming basilar part of pons
Ependymal roof
Rhombic lip to form cerebellum
Migration of cells of alar plate
Pontine nucleus
Fig. 5.22 Migration of cells of alar plate of developing pons leads to formation of: Ventrally—Pontine nucleus Dorsally—Rhombic lip for
development of cerebellum
a) Medial: Arcuate nucleus, placed ventral to vertical descending bundle of corticospinal (pyramidal) tract
fibers.
b) Lateral: Inferior olivary nucleus, placed lateral to corticospinal (pyramidal) tract fibers.
These nuclei develop from the alar plate cells which are called bulbopontine extension (caudal part).
3. At the level of pons (Fig. 5.22): The cells of
alar plate at this level migrate in two different directions:

a) Ventrally:Thesecellsmigrateventrallyinthe
plane of marginal zone of pons. These are the cells of cephalic part of bulbopontine extension. These neurons
are present in scattered fashion intermingled with white matter developed
Alar plate
Mantle zone
{
Basal plate
Marginal zone
from marginal zone. This is nucleus pontis or
pontine nucleus.
b) Dorsally:Thesecellsmigratedorsallyoverthe
ependymal lining of 4th ventricle of brain from both sides which finally fuse together. This is called rhombic lip.
This will form cerebellum.
4. At the level of midbrain (Fig. 5.23): As in other parts of brainstem, neurons of alar plate of midbrain form
sensory nuclei of some cranial nerves. Some of the neurons migrate in following two directions to form specific
nuclei of midbrain. a) Ventrally:Thesecellgroupsmigrateventrally
beyond basal plate into marginal zone to form two nuclei–Red nucleus and Substantia nigra. Red nucleus is
present in upper half of midbrain, whereas substantia nigra extends throughout its whole length.
Central canal gets narrowed to form aqueduct of midbrain
Tectum
Migration of cells of alar plate
Substantia nigra Red nucleus

Fig. 5.23 Migration of cells of alar plate in developing midbrain form various nuclei as following, Ventrally = Red nuclens and substantia
nigra, Dorsally = Tectum (nuclei of superior and inferior colliculi)
106
Alar plate
Mantle
{ zone
Basal plate
Marginal zone
First order sensory neurons in posterior root ganglia developed from neural crest cells
4. Somatic afferent
3. General visceral afferent
2. General visceral efferent
1. Somatic efferent
Fig. 5.24 Neural tube forming spinal cord gives rise to four cell columns. Basal plate—Somatic efferent and general visceral efferent, Alar
plate—Somatic afferent and general visceral afferent
b) Dorsally: Some of cells of alar plate migrate further dorsally to form two pairs of bulged area called superior
and inferior colliculi which form dorsal part of midbrain called tectum.
Cranial Nerve Nuclei in Brainstem
A spinal nerve is formed by union of ventral and dorsal roots which are functionally motor (efferent) and
sensory (afferent) components respectively. Mo- tor fibers in the ventral root are of two types, somatic motor
(somatic efferent) and visceral motor (general visceral efferent) (Fig. 5.24). 􏲄omatic efferent fibers supply
skeletal (voluntary) muscles and general visceral efferent fibers supply smooth (involuntary) muscles and
exocrine glands. Again, sensory fibers in the dorsal root of spinal nerve are two types— somatic sensory
(somatic afferent) and visceral sensory (general visceral afferent) (Fig. 5.24). Somatic afferent fibers carry
somatic sensations like—touch, pressure, pain, temperature (exteroceptive) and sense of position and
movements (proprioceptive). General visceral afferent fibers carry sense of stretch, pain, distension, compression
from the viscera. Cell bodies of these types of neuronal processes are present in the form four cell columns in
the spinal cord gray matter. In embryonic period, initially all these columns used to extend throughout the
whole length of developing spinal cord. Both of the motor or efferent columns exist in basal plate. Somatic
efferent is medial and general visceral efferent is lateral (Fig. 5.24). Both the sensory or afferent columns exist
in alar plate of mantle zone throughout whole length of spinal cord. Somatic afferent column is medial to
general visceral afferent column (Fig. 5.24). But ultimately, general visceral efferent and general visceral
afferent
columns persist only in T –L segments (forming 12
sympathetic center) and S2–S4 segments (forming parasympathetic center). But both somatic centers (efferent
and afferent) extend althrough the segments of spinal cord.
A cranial nerve (3rd–12th), unlike the spinal nerve is not always a mixed nerve. It may be mixed, motor or
sensory. However, a cranial nerve out of last 10 pairs, may not only contain all the four functional components
as spinal nerve, it may contain in addition, another two components, one motor and one sensory. These are
called special visceral efferent (branchial efferent) and special visceral afferent (branchial afferent).
So, for clear understanding of functional components of cranial nerve, background knowledge of special
visceral efferent and special visceral afferent components is important as well as interesting as stated below.
In embryonic life, six pairs of mesodermal arches (branchial arches or pharyngeal arches) embrace ventrolateral
aspects of primitive pharynx. Out of these six, fifth (5th) arch disappears. Muscular elements of existing five
pairs of branchial arches give rise to some muscles in the region of head and neck. All of which are voluntary
muscles (but not somatic muscle). Some of these voluntary muscles are even related to wall of some viscera like
palate, larynx and pharynx. So these muscles developed from branchial arch mesoderm, not developed from
paraxial mesodermal somites, being voluntary in nature, of which some related to viscera, are called branchial
arch muscle. These muscles lying in the head and neck region, need inervation from cranial nerves. So some of
cranial nerves (between 3rd–12th), need to have an additional component to supply branchial arch muscles
which is called branchial efferent or special visceral efferent.
Brainstem
107
Alar plate
Basal plate
Somatic afferent Special visceral afferent

Fig. 5.25 Neural tube forming brainstem (midbrain and lower closed part of medulla) prescents six (3 + 3) columns of cells forming nuclear
components of cranial nerves
Again from some viscera like—tongue, soft palate and upper end of pharyngeal wall, special sense, like—taste
(gustatory) sensation, need to be carried by special components of some cranial nerves. These component is
called special visceral afferent or branchial afferent.
So, in comparison to four functional components of spinal nerve, six functional components of cranial nerves are
the neuronal processes of following six functional columns of cell groups –
3 in basal plate (from medial to lateral) are as follows (Fig. 5.25):

1. Somatic efferent
Alar plate (Dorsolateral)
Basal plate (ventromedial)
2. Special visceral efferent 3. General visceral efferent.
3 in alar plate (from medial to lateral where developing brainstem is a closed canal, e.g. midbrain and lower
end of medulla oblongata are as follows (Fig. 5.25):
1. Somatic afferent
2. Special visceral afferent
3. General visceral afferent.
In the parts of developing brainstem, where roof
plate is stretched, e.g. pons and upper part of medulla oblongata, above three afferent columns are related
lateral to medial (Fig. 5.26).
Somatic afferent

Fig. 5.26 Developing brainstem at the level of pons and upper part of medulla oblongata present six (3 + 3) columns of cells which form
different functional components of cranial nerves
108
Functional components of cranial nerve nuclei in different level of brainstem
Before the positions of various nuclei of 3rd–12th cranial nerve in different levels of brainstem is studied, it is
very important to note the following two points.
i. Somatic afferent columns in developing brainstem are of two types (Fig. 5.27 inset)—
General somatic afferent column: These cell groups will form general somatic afferent nuclei which will
receive general somatic sensation like–touch, pressure, pain and temperature (exteroceptive) and sense of
position and movements from muscles and joints (proprioceptive).
Special somatic afferent column: These cell groups will form special somatic afferent nuclei which
will receive special somatic sensation like–sense of hearing (exteroceptive) and sense of equilibrium or balance
of body (proprioceptive).
ii. All the 7 cell columns (3 motor and 4 sensory)
will finally not remain continuous althrough the brainstem. In case of each column, somewhere the cells will
persist and in some level, cells will disappear or degenerate. So, continuity of the cells in the columns will be
interrupted, leading to formation of various cranial nerve nuclei.
Location and function of cranial nerve nuclei in different level of brainstem
Considering stretching of root plate, which results abduction of alar plate, various functional groups of cranial
nerve nuclei are positioned from medial to lateral as follows (Fig. 5.27):
Medulla oblongata
Spinal cord
10
95 DN 10 DN 10
Floor plate
Basal plate
Sp visc eff
Sulcus limitans
Alar plate
Sp visc
aff Ex
Som eff
Gen visc eff
Gen visc aff
Gen som aff
Sp som aff
Midbrain
Pons
6
12
7 SP.N
Coch.N
NA– Nucleus ambiguous

EWN– Edinger Westphal nucleus SSN– Superior salivatory nucleus ISN– Inferior salivatory nucleus DN– Dorsal nucleus of vagus
NTS–Nucleus tractus solitarius PSN–Principal sensory nucleus (superior sensory nucleus)

SP.N– Spinal nucleus of trigem Nr. Mes N.– Mesencephalic nucleus of trigem nerve
Floor plate
Sulcus limitans
4
5
9
10 NA
11
11
C5–
PSN S SSN 5 8 8
5 D
EWN
7
9ISN NTS VM
L
I Vest.N
– C2
Prop Ex
Mes.N 5
Prop
Sp. somatic afferent
General somatic afferent
Sp. visceral afferent Gen. visceral afferent
Gen. visceral efferent Sp. visceral efferent
Somatic efferent
Fig. 5.27 Functional components of cranial nerve nuclei in brainstem
1. Somatic efferent
}
2. Specialvisceralefferent Inthebasalplate(between
(Branchial efferent) 􏲄oor plate and sulcus
3. General visceral efferent

4. General visceral afferent
5. Special visceral afferent
6. General somatic afferent
109
7. Special somatic afferent
i. Levator palpebrae superioris

ii. Superior rectus
iii. Inferior rectus
iv. Medial rectus
v. Lateral rectus vi. Superior oblique vii.Inferior oblique
– Elevator of upper eyelid
}}
4 Recti muscles
2 Oblique muscles
Brainstem
supply muscles developed from mesoderm of five (1st to 4th, and 6th) branchial arches.
These nuclei are as follows—

1. Vth(trigeminal)nervenucleus:Thisistheonly
motor nucleus of trigeminal nerve. It is situated in upper half of pons. Motor fibers (axons) arising from this
nucleus supply all the muscles developed from 1st branchial arch.
Somatic efferent nuclei
These are motor nuclei of some of the cranial nerves which send axons to supply the skeletal muscles developed
from somites of preoccipital and occipital myotomes.
Muscles developed from preoccipital myotome are all extrinsic muscles of eyeball, i.e.
These extrinsic muscles of eyeball are supplied by fibers (axons) of following somatic efferent nuclei — 1. IIIrd
(oculomotor) nerve nucleus: Situated in
upper half midbrain supplies all extrinsic muscles listed above except—
a) Superior oblique
b) Lateral rectus.
2. IVth (trochlear) nerve nucleus: Situated in lower half of midbrain, supplies superior oblique.
3. VIth (abducent) nerve nucleus: Situated in lower part of pons, supplies lateral rectus. Muscles developed
from occipital myotome are all
the muscles of tongue except palatoglossus. These muscles are supplied by axonal fibers of—
4. XIIth (hypoglossal) nerve nucleus: It is the
nucleus of somatic efferent column and situated in upper two-thirds of medulla oblongata. Axonal processes of
this nerve supply all muscles of tongue except palatoglossus, which are developed from occipital myotome.
All the above four somatic efferent nuclei of brainstem (IIIrd, IVth, VIth and XIIth nerve nuclei) are in the line
with and homologous to anterior horn cells of all segments of spinal cord which supply somatic segmental
muscles of body.
Special visceral efferent (Branchial efferent) nuclei
These are the motor nuclei of some of cranial nerves which, through their axons (outgoing motor fibers)
2. VIIth (facial) nerve nucleus: This motor nucleus of facial nerve is situated in lower half of pons. Motor
fibers (axons) arising from this nucleus are branchial efferent or special visceral efferent fibers of facial nerve
and these fibers supply muscles developed from mesoderm of second branchial arch.
3. Nucleus ambiguous: This is a composite nucleus of branchial efferent or special visceral efferent column
present in medulla oblongata and extending upto upper 5 cervical segments of spinal cord.
Nucleus ambiguous is composed of following 4 parts of which first 3 parts lie in medulla oblongata and last part
lies in spinal cord.
1stpart:NucleusofIXthcranial(glossopharyngeal)
nerve. It supplies one muscle developed from 3rd
branchial arch which is stylopharyngeus.

2nd part: Nucleus of Xth cranial (vagus) nerve. It supplies one muscle developed from IVth branchial
arch which is cricothyroid.

3rd part: This is the nucleus of XIth cranial (acce-
ssory) nerve. As it lies in medulla oblongata (part
limitans)
}
In the alar plate (lateral to sulcus limitans)
Muscles developed from first branchial arch are 8 in number (4+2+2) which are—
4 Muscles of mastication: i) Masseter
ii) Temporalis
2 Tensor muscles:
2 Companion muscles in neck:
iii) Lateral pterygoid iv) Medial perygoid

v) Tensor palati (tensor of soft palate)
vi) Tensor tympani (tensor of tympanic membrane of ear)
vii) Anterior belly of digastric

viii) Mylohyoid
Muscles developed from second branchial arch are following:
1. Muscles of scalp – Occipitofrontalis

2. Extrinsic as well as intrinsic muscles of auricle
3. All muscles of facial expression with platysma
4. A small muscle in middle ear cavity – Stapedius 5. Two companion muscles in neck – Posterior belly
of digastric and stylohyoid.

of brain), it is called cranial nucleus of accessory nerve which supplies muscles developed from mesoderm of 6th
branchial arch.
These muscles are –
a) All muscles of soft palate except tensor palati b) All muscles of pharynx except stylopharyngeus c) All
muscles of larynx except cricothyroid.
4th part: This part is also nucleus of 11th cranial (accessory) nerve. It is called spinal nucleus of accessory
110 nerve as it is formed by central group of anterior horn cells of first five cervical segments of spinal cord. This
component of nucleus ambiguous supplies two muscles of neck named sternomastoid and trapezius which are
also considered to be muscles developed from mesoderm of 6th branchial arch.
General visceral efferent nuclei
Cranial nerve nuclei of this column of brainstem form the centers for parasympathetic system in brain
(brainstem).
Cell group of these nuclei send axons (motor fibers) to — i) Smooth muscles and ii) exocrine glands.
These nuclei are following:
1. Edinger-Westphalnucleus:Thisisgeneralvisc-
eral efferent nucleus of IIIrd cranial (oculomotor) nerve. Axons of this nucleus supply two
smooth muscles of eyeball – Ciliaris and sphincter pupillae. Being the part of oculomotor
nerve nucleus, it is situated in upper part of midbrain.
2. Superior salivatory nucleus:
It is the general visceral efferent nucleus of VIIth cranial (facial) nerve. This nucleus is so called as it gives
fibers which supply secretomotor fibers to the two out of three salivary glands. These are submandibular and
sublingual glands.
This nucleus has a component called lacrimatory nucleus which gives out secretomotor fibers to lacrimal
gland.
Preganglionic secretomotor fibers for mucous glands of palate, nasal cavity and upper part of pharynx also
arise from this nucleus.
Superior salivatory nucleus is situated in lower part of pons.
3. Inferior salivatory nucleus: It is situated in upper part of medulla oblongata. This general
visceral efferent nucleus supplies secretomotor fibers to another salivary gland, i.e. parotid
gland.It is the nucleus of IXth cranial (glossopharyngeal) nerve.
4. Dorsal nucleus of vagus: This is the general visceral efferent nucleus of Xth cranial (vagus)
nerve. It is situated in lower part of medulla oblongata. Vagus nerve is a very long cranial
nerve having extensive course in head and neck, thorax and abdomen. Through this nerve,
fibers from dorsal nucleus of vagus are distributed to —
i. Smooth muscles of tracheobronchial tree.

ii. Smooth muscles (myocardium) of heart.
iii. Smooth muscles of gut (foregut and midgut)
upto right two-thirds of transverse colon.

iv. Mucous glands of tracheobronchial tree and
above mentioned parts of gut.
General visceral afferent nucleus
Nucleus of this column of brainstem receives incoming nerve fibers which carry general sensation from
viscera, e.g. sensation of pain (due to ischemia), stretch, distension or compression.
In this column there is one and only one nucleus which is dorsal nucleus of vagus (sensory component). Dorsal
nucleus of vagus nerve is a composite nucleus which is composed of a motor and a sensory part. It lies in the
lower part of medulla oblongata. Sensory part of dorsal nucleus of vagus nerve receives incoming sensory fibers
of vagus nerve which carry visceral sensations as stated above from wall of tracheobronchial tree and,
gastrointestinal tract upto right two-thirds of transverse colon.
Special visceral afferent nucleus
Nucleus of cranial nerve of this column receives incoming sensory (afferent) fibers which carry special sensation
from the viscera, e.g. tongue, palate and upper part of pharynx, that is taste.
In this column there is only one composite nucleus which is named —

Nucleus tractus solitarius: It is a composite nucleus of special visceral afferent column situated in
medulla oblongata. This nucleus is composed of three parts as follows —
Upper part: It is the nucleus of seventh cranial (facial) nerve which receives the incoming sensory fibers
carrying taste sensation from anterior two- thirds of tongue soft palate and upper part of pharynx. Middle
part: It is the nucleus of ninth cranial (glossopharyngeal) nerve which receives the incoming sensory fibers
carrying taste sensation from posterior one-third of tongue.
Lower part: It is the nucleus of tenth cranial (vagus) nerve which receives the incoming sensory fibers
carrying taste sensation from posterior most part of tongue, vallecula and epiglottis.
General somatic afferent nuclei
Sensory nuclei of cranial nerves of this group receive general somatic sensations from the area of face including
forehead.
General somatic sensations are of two types, which are carried to the respective nuclei. They are—
Brainstem
ceptive sensations from muscles of mastication, muscles of eyeball, muscles of face, roots of teeth and
temporomandibular joint.
Exteroceptive 111
This nucleus receives exteroceptive sensations from the area of face which
are touch, pressure, pain and temperature.
Proprioceptive
This nucleus
receives proprioceptive sensations from some muscles and joints
in the area of head which are –
i. Muscles of
mastication
ii. Muscles of eyeball iii. Muscles of facial expression
iv. Roots of teeth
v. Temporomandibular joint.
Both the above types are sensory nuclei of Vth cranial (trigeminal) nerve.
Names of these general somatic afferent nuclei of trigeminal nerve are –
In the brainstem these three nuclei are as follows from below upwards.
1. Nucleus of spinal tract of trigeminal nerve
(Spinal nucleus of trigeminal nerve)
This nucleus presents three components:

i. Middle or main component: Extends throughout
the whole length of medulla oblongata
ii. Upper end: Extends into lower end of pons iii.Lower end: Continued in upper two cervical
segments (C1, C2) of spinal cord.
Nucleus of spinal tract of trigeminal nerve receives all the incoming sensory (afferent) fibers of trigeminal nerve
which carry pain and temperature sensations from same side of whole area of face.
2. Superior(principal)sensorynucleusoftrige-
minal nerve
This nucleus is situated in pons.
Superior sensory nucleus receives all the incoming sensory (afferent) fibers of trigeminal nerve which carry
touch and pressure sensations from same half of the whole area of face.
3. Mesencephalic nucleus of trigeminal nerve
It is so named because this nucleus is situated in midbrain (mesencephalon).
Mesencephalic nucleus of trigeminal nerve is the proprioceptive sensory nucleus. It receives incoming sensory
fibers of trigeminal nerve which carry proprio-
Special somatic afferent nuclei
Nuclei of this group of cranial nerve receive sensory fibers which carry special somatic sensation.
All these nuclei are situated in pontomedullary junction.
All of these are nuclei of VIIIth cranial (vestibulocochlear) nerve.
These nuclei are of following two groups:
Special point to note: Cells of mesencephalic nucleus posses a special characteristic. In case of all other
sensory pathway, cell bodies of 1st order of neuron lie outside the central nervous system and their central
processes enter the central nervous system to relay in second order of neurons which constitute the
corresponding sensory nucleus. But mesencephalic nucleus of trigeminal nerve is made up of cell bodies of 1st
order of sensory neurons lying inside the central nervous system which carries proprioceptive sensation from the
end organs as stated above.
i. Nucleus of spinal tract of trigeminal nerve Exteroceptive

ii. Superior (principal) sensory nucleus
nuclei
}
iii. Mesencephalic nucleus of trigeminal nerve — Proprioceptive nucleus
Exteroceptive
Dorsal and ventral cochlear nuclei. These nuclei receive incoming fibers
of cochlear part of vestibulocochlear nerve which carry sense of hearing (cochlear sensation).
Proprioceptive
Four vestibular nuclei named superior, inferior, lateral and medial vestibular nuclei. These nuclei receive
incoming fibers of vestibular part of vestibulocochlear nerve which carry sense of equilibrium (balance).
Important guideline: While studying IIIrd– XIIth (last 10) cranial nerves in the chapter of cranial nerve, a
reader must consult the text, as well as figures of the following components of the chapter of Brainstem as
described here.
i. Embryological background of brainstem.

ii. Functional components of cranial nerve nuclei
in different level of brainstem.

Reader must develop a clear concept on Figure
no. 5.27. 􏲠e􏲠she must practice drawing of this figure again and again till to have a confidence to draw the same
from memory without any help.
Reader must study the Figure no. 5.27 to find the answers of following questions:
i. What are the types of IIIrd–XIIth cranial nerve – motor, sensory or mixed?
112
ii. What are the functional components of the cranial nerves, from IIIrd–XIIth?
iii. What are the cranial nerve nuclei in a particular functional column?
For example: Somatic efferent column present nuclei of IIIrd, IVth, VIth and XIIth cranial nerve.
iv. What are the motor nuclei (nuclei in the basal plate) and what are the sensory nuclei (nuclei in alar
plate)?
v. What are the cranial nerve nuclei present in each of the three segments of brainstem? i.e. in midbrain,
pons and medulla oblongata.
For example: In midbrain lies somatic efferent nuclei of IIIrd and IVth cranial nerve, general visceral
efferent nucleus of IIIrd nerve (EWN) and somatic afferent nucleus (mesencephalic nucleus) of Vth
cranial nerve.
vi. Whatarethemotorand/orsensorycomponents of a cranial nerve, from IIIrd to XIIth?
Internal Structures of Brainstem
Fundamental points: Internal structure will be crystal-clear to a reader if one goes thoroughly with the
previous parts of chapter of Brainstem.
Internal structure of brainstem, at any level, shows intermingling of gray matter and white matter unlike
spinal cord, cerebellum and cerebrum. It may be remembered, in spinal cord, white matter is peripheral and
gray matter is central, whereas in cerebellum as well as cerebrum, arrangement is reverse.
Any level of brainstem shows following components of internal structure—

1. White matter:
a) Vertical fibers – two types
i. Ascending (Afferent): Passing from a lower center to a higher center.
ii. Descending (Efferent): Passing from a higher center to a lower center.
b) 􏲠orizontalfibers:Ineachofthethreecomponents of brainstem, passing horizontally through respective

cerebellar peduncles, e.g.
i. In midbrain: Passing through superior cere-
bellar peduncle.
ii. In pons: Passing through middle cerebellar
cells of alar plate. Many of them are migrated from their original position ventrally to the region of basal plate,
e.g. olivary nucleus of medulla oblongata. Some of these are migrated further dorsally, e.g. tectum of midbrain.
b) Cranial nerve nuclei (IIIrd–XIIth): Motor nuclei of these cranial nerves are developed from cells of basal plate
and the cells of alar plate give rise to sensory nuclei.
Internal Structure of Medulla Oblongata
Internal structure of medulla oblongata is studied in following three levels (Fig. 5.28)—
1. At the lower end of medulla oblongata: Below the
bulge of pyramid, where decussation of motor fibers of pyramidal tract (corticospinal tract), passing through the
pyramid, takes place (at the plane of motor decussation).
2. Abovethemiddleofmedullaoblongata,atthelevel of middle of bulge of pyramid. At this level sensory fibers from

nucleus gracilis and nucleus cuneatus decussate before these sensory tracts pass further upwards (At the plane
of sensory decussation).
3. At the upper end of medulla oblongata, close to pontomedullary junction.
Medulla oblongata at its lower end (at the plane of motor decussation) (Fig. 5.29)
Structural characteristics
1. 2.
76
At this level structure of medulla oblongata is almost similar to the structure of spinal cord, with centrally
positioned gray matter and peripheral white matter.
Ventral horn of gray matter gets separated from main mass due to decussation of pyramidal tract fibers which
pass backwards and laterally to approach lateral white column before passing downwards to the spinal cord.
Level of superior colliculus Level of inferior colliculus
Upper half of pons
Lower half of pons
At upper end of medulla oblongata At the level of pyramid
Lower end of medulla oblongata
5 peduncle. 4
iii. In medulla oblongata: Passing through inferior cerebellar peduncle. 2

3
2. Graymatter:Itispresentintheformoffollowing two varieties of nuclei—
a) Variousnamednucleiofbrainstem:Thesearecell stations of ascending or descending tracts passing through the

brainstem. These are developed from
Fig. 5.28 Different level of brainstem to study internal structure
Brainstem
113
Reticular formation
􏱺ecussating fibers
of lower end of pyramid form lateral corticospinal tract
Nucleus gracilis appears deep to fasciculus gracilis
Nucleus cuneatus appears deep to fasciculus cuneatus
Spinal nucleus and spinal tract of trigeminal nerve
Ventral spinocerebellar tract
Detached anterior grey horn

Fig. 5.29 Internal structure of lower end of medulla oblongata (below pyramidal elevation at the level of motor decussation)
Structural detail
Gray matter:
1. Centralgraymatteristraversedbymoredorsally
pushed central canal lined by ependyma.
2. Apexofposteriorhornofspinalcordisrepresented at this level by nucleus of spinal tract of trigeminal

nerve. On either side it is directed backwards and
laterally with further abduction.
3. Medial to nucleus of spinal tract of trigeminal
nerve, gray matter shows, on either side, two small bulge of gray matter, nucleus gracilis (medial) and
nucleus cuneatus (lateral) which receive the fibers of fasciculus gracilis and fasciculus cuneatus
respectively, which are the ascending tracts in posterior column of white matter.
4. Anterior gray horn becomes detached from main mass of gray matter by decussating fibers of corti-
cospinal (pyramidal) tract.
Topographically, cells of anterior horn is a part of
gray matter of medulla oblongata. But functionally, these are upwards continuation of cells of anterior horn of
upper cervical segments of spinal cord. These cells form following two nuclei.
a) 􏲄upraspinal nucleus of first cervical nerve: It is the upward continuation of anterior horn cells of first cervical
segments of spinal cord. Axons of these neurons pass downward and are distributed along the ventral root of
first cervical nerve.
b) Ascending nucleus: It is the upward continuation of spinal nucleus of accessory nerve which is continuous
below up to fifth cervical segment of spinal cord. Above it is continuous with nucleus ambiguous.
White matter: Pattern of three white columns (funiculi) of spinal cord, namely anterior, lateral and
posterior, is grossly maintained.
1. Anteriorcolumn:Oneithersideofventralmedian
fissure, area of anterior white column mainly presents the bundle of pyramidal tract fibers which shows
decussation of fibers at this level.
Through anterior column, also traverse tectospinal
tract, vestibulospinal tract, anterior spinothalamic tract.
2.
Lateral Column:
a) Peripherally: Dorsal and ventral spinocereb-
ellar tracts.
b) Centrally: i) Lateral corticospinal tract which
is formed at this level after decussation of fibers of pyramid.

ii) At the center of lateral white column, a scattered group of nerve cells intermingled with nerve fibers form
brainstem reticular formation.
iii) Lateral spinothalamic tract.

3. Posterior column: It present upward continua-
tion of fasciculus gracilis and fasciculus cuneatus of posterior white column of spinal cord. As already
mentioned earlier, these two tracts will relay in next order of neurons in nucleus gracilis and nucleus cuneatus
which are seen to appear at this level of medulla oblongata, ventral to the corresponding tracts.
Medulla oblongata at its middle (at the plane of sensory decussation) (Fig. 5.30)
1. There is no more existance of gray matter area which is homologous to anterior horn.
114
Nucleus tractus solitarius Dorsal nucleus of vagus
Hypoglossal nerve nucleus
Medial longitudinal fasciculus
Ventral spinocerebellar tract
Medial lemniscus
􏱺nternal arcuate fibers
from nucleus gracilis

Internal arcuate
fibers from nucleus
cuneatus
Reticular formation
Inferior olivary nucleus Medial lemniscus
Pyramid
Fig. 5.30 Internal structure of medulla oblongata at the level of sensory decussation
2. Gray matter of posterior horn presenting nucleus gracilis, nucleus cuneatus and spinal nucleus of
trigmenial nerve gets detached from central gray matter. This detachment is because of the arched
fibers arising from nucleus gracilis and nucleus cuneatus which decussate ventrally to form ascending
fiber tract which is called medial lemniscus.
3. Central canal surrounded by central gray matter is pushed more dorsally. Central gray matter presents
appearance of cranial nerve nuclei.
4. It is the plane of medulla oblongata from where upward typical relationship of central gray matter and
peripheral white matter of spinal cord is lost. It results intermingling of gray and white matters.
Structural details
1. On either side of ventral median fissure bulge of pyramid presents sections through descending
(efferent) fibers of pyramidal (corticospinal) tract.
2. Lateral to fibers of pyramid, inferior olivary nucleus starts appearing. It looks like a small irregular-
walled sac whose cavity opens backwards and medially.
Inferior olivary nucleus is the most prominent
part of olivary nuclear complex of human brain. Rudimentary components are dorsal and medial olivary nuclei
which together are known as accessory olivary nuclei.
3. Ascending (afferent) tracts, e.g. dorsal and ventral
spinocerebellar tracts, lateral and anterior spino-
thalamic tracts are found to be in corresponding positions as noticed in previous section of medulla oblongata.
4. Nucleusgracilisandnucleuscuneatusareseento be more prominent in this section. These nuclei receive fibers

from fasciculus gracilis and fasciculus cuneatus which carry conscious proprioceptive sensation and sense of
tactile discrimination from lower and upper halves of body respectively.
5. Dorsolateral to nucleus cuneatus, a smaller accessory cuneate nucleus is seen. It receives fibers of fasciculus
cuneatus which carry same sensations from uppermost part (head-end) of body. Cuneocerebellar tract from this
nucleus end in cerebellum as spinocerebellar pathway above T1 spinal cord segment.
6. Central core of the section presents scattered nerve cells and reticulum (network) of fibers to form brainstem
reticular formation.
7. Posterior gray horn separated from central gray matter is represented by spinal nucleus of trigeminal nerve
which is capped on the surface by fibers of sensory root of trigeminal nerve carrying pain and temperature
sensation, called spinal tract of trigeminal nerve.
Nucleus gracilis and nucleus cuneatus are the medial and lateral mass of gray matter on either side of posterior
median septum. These are also the components of posterior gray horn which are detached from central gray
matter.
Reason for separation of spinal nucleus of trigeminal nerve, nucleus gracilis and nucleus cuneatus from
central gray matter is due to following
characteristic of structure of medulla oblongata at this level.
Fasciculus gracilis and fasciculus cuneatus are the two ascending tracts of posterior column of spinal cord
which carry sense of conscious proprioception and tactile discrimination from lower and upper halves of body
respectively. Reaching the medulla oblongata upto this level, fibers of these two tracts relay in corresponding
nuclei lying ventrally. Processes of next order of neurons in nucleus gracilis and nucleus cuneatus, before
ascending further upwards to relay in thalamus, decussate to cross the midline. During decussation, these
fibers presents following three characteristics.
1. Fibers of both nucleus gracilis and nucleus cune-
atus pass forwards arching along the lateral aspect of central gray matter horizontally in a curved fashion that 115
is why they are called internal arcuate fibers.
2. Afterdecussation,thefibersformacompactbundle just behind the bulge of pyramid, before this compact

bundle of fibers ascend upwards to reach thalamus. This bundle is known as medial lemniscus (Plural –
Lemnisci).
3. During formation of medial lemnisci, fibers from nucleus gracilis (carrying sensations from lower half of
body) are positioned anterior to the fibers from nucleus cuneatus (carrying sensation from upper half of
body).
Behind medial lemniscus, pass tectospinal tract
medial longitudinal fasciculus.

Central gray matter: It encircles the central canal of medulla oblongata which is pushed more posteriorly.
It presents following cranial nerve nuclei which are interrelated ventrolaterally.
Dorsal nucleus of vagus
Hypoglossal nerve nucleus Nucleus tractus solitarius
Nucleus ambiguous
Medial longitudinal fasciculus Reticular formation
Lateral spthalamic tract Medial lemniscus
Hypoglossal nerve Pyramidal tract
Arcuate nucleus
Brainstem
i. Hypoglossal nerve nucleus (XII): It is the nucleus of somatic efferent column, lying ventral to central canal of
medulla oblongata.
ii. Nucleus ambiguous (IX, X, XI): It is the nucleus of special visceral efferent column, lying ventrolateral to
central canal of medulla oblongata.
iii. Dorsal nucleus of vagus (X): It is the nucleus having both general visceral efferent as well as general visceral
afferent components, lying ventrolateral to central canal.
iv. Nucleus tractus solitarius (VII, IX, X): It is the nucleus of special visceral afferent column, lying lateral to
central canal.
Medulla oblongata at the level of olive (close to pontomedullary junction) Fig. 5.31
1. Stretching of roof plate at this plane of medulla oblongata in embryonic life causes outward deviation
(abduction) of alar plate. This results widening of central canal to form cavity of fourth ventricle. Stretched
dorsal surface of medulla oblongata forms floor of fourth ventricle.
2. Central gray matter presenting the cranial nerve nuclei pushed more dorsally to lie just beneath the dorsal
surface of medulla oblongata.
3. Fibersfrommedullaoblongatawhichwillconnect cerebellum will form compact bundle of inferior cerebellar

peduncle seen to be present in posterolateral part.
4. Bulge of olive containing inferior olivary nucleus is related to anterolateral and posterolateral sulci on it
medial and lateral sides respectively.
Tectospinal tract
Vestibular nucleus Dorsal cochlear nucleus
Ventral cochlear nucleus
Parolivary nuclei
Vagus nerve
Inferior olivary nucleus
Fig. 5.31 Internal structure of medulla oblongata at the level of olive
116
Structural detail
1. On either side of ventral median fissure, beneath the bulge of pyramid, fibers of pyramidal (cortic-
ospinal) tract from compact bundle.
2. Ventromedial surface of pyramid presents a narrow semilunar strip of gray matter, called arcute
nucleus. It is the detached part of pontine nuclei.
3. Lateraltopyramid,bulgeofolivecontainsinferior olivary nucleus. It is irregular walled sac-like mass of
gray matter. Open mouth of the sac faces medially and backwards.
Adjacent to inferior olivary nucleus, medial and
dorsal components of assessory olivary nucleus are seen.

4. Dorsolateral aspect of medulla oblongata at
this level presents bulge of inferior cerebellar peduncle. It is a compact bundle of white matter
connecting medulla oblongata with cerebellum in both directions.
5. Different fiber tracts in central core

a) Medial: From before backwards close to the
midline –
i. Medial lemniscus: Formed by internal arcu-
ate fibers, situated behind pyramid. This ascending tract passes upwards to reach thalamus.
ii. Tectospinal tract: Descending tract from tectum of midbrain to spinal cord.
iii. Medial longitudinal bundle: It is the fiber bundle connecting vestibular nucleus with motor nuclei of
IIIrd, IVth, VIth and XIth cranial nerves.
b) Lateral: Important ascending tracts passing from below upward –
i. Ventral and dorsal spinocerebellar tracts.

ii. Ventral and lateral spinothalamic tracts.
iii. Spinal tract of trigeminal nerve.
6. Medullary part of brainstem reticular formation: Scattered nerve nuclei with reticulum (network) of
fibers.
7. Cranial nerve nuclei (in central gray matter): Beneath the dorsal surface of medulla oblongata
i. Hypoglossal nerve nucleus: Situated on either
side of midline, just beneath the dorsal surface (on the floor of 􏲠th ventricle) and behind medial longitudinal
bundle.
This is the somatic efferent nucleus which gives out fibers of hypoglossal nerve to supply muscles of tongue
developed from occipital myotome. Intraneural (intramedullary) part of hypoglossal nerve pass from behind
forward through whole depth of medulla oblongata between pyramid and medial lemniscus me-
dially and inferior olivary nucleus laterally. Finally the nerve comes out in the form of multiple rootlets through
anterolateral sulcus.
ii. Dorsal nucleus of vagus: This nucleus is situated lateral to hypoglossal nerve nucleus. It is a mixed nucleus
having general visceral efferent as well as afferent components which supply motor, secretomotor and sensory
fibers to thoracic and abdominal viscera (upto midgut).
iii. Nucleus tractus solitarius: This is a composite nucleus of special visceral afferent column. It is ventrolateral
to dorsal nucleus of vagus and receives taste sensation through sensory fibers of VIIth, IXth and Xth cranial
nerves from anterior two-third and posterior one-third of tongue and also vallecula and epiglottis.
It is important as well as interesting to note here that nucleus tractus solitarius also receives general visceral
afferent fibers t􏲄roug􏲄 vagus nerve which caries visceral sensation from thoracic and abdominal viscera (upto
midgut).
iv. Nucleus ambiguous: This nucleus is placed more ventrally. This is also a composite nucleus of special
visceral efferent group which gives out motor fibers through I􏲠th to 􏲠Ith cranial nerves to supply muscles
developed from mesoderm of IIIrd, IVth and VIth branchial arch respectively.
It is already understood that two composite nuclei, namely nucleus tractus solitarius and nucleus ambiguous
are made up of components belonging to multiple cranial nerves. The former is made up of nuclei of VIIth, IXth
and Xth and the later is formed by nuclei of IXth, Xth and XIth cranial nerve. It is also important to remember
at this stage that these nerves come out of brainstem through different sites. Figure 5.31 shows the fibers of
vagus nerve which is made up of following components coming out from respective nuclei.
General visceral efferent: From motor part of dorsal nucleus.
General visceral afferent: From sensory part of dorsal nucleus.
Special visceral afferent: From nucleus tractus solitarius.
Special visceral efferent: From nucleus ambiguous. The fibers of vagus nerve are seen to come out through
posterolateral sulcus between olive and
inferior cerebellar peduncle.

v. Vestibular nucleus of VIIIth cranial nerve:
It is proprioceptive type of special somatic afferent nucleus of vestibulocochlear nerve. It
117
is present in lateral angle of dorsal surface of pontomedullary junction. Vestibular nucleus is made up of four
parts–superior, inferior, lateral and medial.
vi. Cochlear nucleus of VIIIth cranial nerve: It is exteroceptive type of special somatic afferent nucleus of
vestibulocochlear nerve. It is composed of dorsal and ventral components in close relation to inferior cerebellar
peduncle.
vii. Spinal nucleus (and spinal tract) of trigeminal nerve: It is situated medial to inferior cerebellar peduncle.
Spinal tract is made up of bundles of those sensory fibers of trigeminal nerve which carry pain and temperature
sensation from the skin of face. The fibers of spinal tract relay in cells of spinal nucleus of trigeminal nerve.
Internal Structure of Pons (Figs 5.32 and 5.33)

Throughout the whole length, internal structure of pons is broadly composed of two parts.
Ventral – Basilar part Dorsal – Tegmental part.
Basilar part
It presents similar features throughout its whole length.
The basilar part contains both gray matter as well as white matters as follows:
i. Gray matter: It is scattered cluster of nerve cells called pontine nuclei which intermingles with fibers of white
matter. Neurons of pontine nuclei are as many as 20 millions in number which is the reason for ventral bulging
of basilar part.
ii. White matter: Made up of two types of fibers
1. a) Vertical: Fibers of descending (motor) tracts

2. b) Horizontal: Fibers of pontine nuclei — passing
through middle cerebellar peduncle to the opposite half of cerebellum.
Tegmental part
Unlike the basilar part, it presents different features in lower and upper halves of pons.
Fundamentally, in both the levels, tegmentum of pons shows following structure—
i. Gray matter: Nuclei of cranial nerves

ii. White matter: a) Ascending tracts as well as
b) some descending tracts.
Structural Details
Internal structure of pons is studied under the following 3 headings (Figs 5.32 and 5.33):
Brainstem
1. Basilar part (identical structure in both lower as well as upper levels)
2. Tegmental part in lower half 3. Tegmental part in upper half.
Basilar part (Figs 5.32 and 5.33)
As already stated, basilar part of pons presents similar feature at all levels as follows.
Gray matter: This is present in the form of multiple, small-sized scattered masses, intermingled with white
matter, called pontine nuclei. This is developed from ventrally migrated cells of alar plate. Fibers from all the
lobes of cerebral cortex (corticopontine tracts) relay in pontine nuclei of same side. Axons of pontine nuclei
cross the midline and pass through opposite middle cerebellar peduncle to the contralateral cerebellar
hemisphere to complete corticopontocerebellar tract.
At the time of development of brainstem, some of the cells of pontine nuclei migrate caudally towards ventral
aspect of medulla oblongata to form arcuate nuclei.
White matter: These are fiber tracts of following two kinds –
1. Vertical: Descending or motor (efferent) tracts –
a) Corticospinal tract: Goes down to pass through pyramid of medulla oblongata.
b) Corticonuclear (Corticobulbar) tract: To relay in contralateral motor nuclei of cranial nerves present in pons
and medulla oblongata.
c) Corticopontine tract: It passes from cerebral cortex to same sided pontine nuclei.
2. Horizontal: These are decussating fibers of pontocerebellar tract which pass horizontally to pass through
the middle cerebellar peduncle to opposite half of cerebellum.
Tegmental part at lower half of pons (Fig. 5.32)
Gray matter: Some cranial nerve nuclei and nuclei of pontine part reticular formation.
Abducentnervenucleus:Itisthenucleusofsomatic efferent group. Fibers of abducent (VIth cranial) nerve
arising from this nucleus supply lateral rectus muscle of eyeball which is developed from preoccipital myotome
of paraaxial mesoderm. This nucleus is situated deep to a paramedian bulge adjacent to posterior median
sulcus. The bulge is called facial colliculus because the surface of abducent nucleus is winded by fibers of facial
nerve.
Motor nucleus of facial nerve: This is the nucleus of special visceral efferent column which supplies muscles
developed from mesoderm of second branchial arch.
118
Motor nucleus of facial nerve
Superior salivatory nucleus
Abducent nerve nucleus
Lateral lemniscus
Spinal lemniscus Trigem lemniscus

Medial lemniscus
Trapezoid body
Vestibular nucleus
Dorsal cochlear nucleus Inferior cerebellar
peduncle
Sp. nucl. and sp. tract of trigeminal nerve Ventral cochlear nucleus
Facial nerve Pontocerebellar
nuclei
Bundles of descending
fibers
Abducent nerve
Pontine
}
fibers
Motor nucleus of facial nerve
Fig. 5.32 Transverse section through lower end of pons adjacent to pontomedullary junction
Facial nerve nucleus (nucleus of motor nerve of face) originally used to be situated in embryonic life, lateral to
abducent nerve nucleus more superficially. Spinal nucleus of trigeminal nerve, which is sensory nerve for skin
of face, is situated in deeper plane of tegmentum of pons. To facilitate quicker reflex contraction of facial
muscles, facial nerve nucleus moves deeper to come in close relation to sensory nucleus for sensation of facial
skin, i.e. spinal nucleus of trigeminal nerve. This becomes possible by elongation of motor fibers of facial nerve
nucleus which winds round the abducent nerve nucleus. This process is known as neurobiotaxis.
Superior salivatory nucleus: It is general visceral efferent nucleus of facial nerve, situated lateral to motor
nucleus of facial nerve. It has a component called lacrimatory nucleus. Parasympathetic secretomotor fibers
from these nuclei are directed to supply to submandibular and sublingual salivary glands, and lacrimal gland.
Spinal nucleus of trigeminal nerve: This is exteroceptive variety of general somatic afferent nucleus of
trigeminal nerve, which receives pain and temperature sensation from skin of face. Though called spinal
nucleus, main part of this nucleus extends throughout whole length of medulla oblongata. Its lower end extends
upto 2nd cervical segments of spinal cord and upper end extends to the lower half of pons. This nucleus is
situated in the lateral part of tegmentum of lower end of pons. It receives sensory fibers of trigeminal nerve
which caps dorsal aspect of the nucleus to form spinal tract of the nerve.
Vestibular nucleus of vestibulocochlear nerve: This is proprioceptive type of special somatic afferent nucleus
of vestibulocochlear nerve. It is composed of superior, lateral, medial and inferior parts. Vestibular nucleus is
situated partly in lower part of pons and upper part of medulla. It is placed in superficial plane at the lateral
angle of pontomedullary junction. This nucleus receives afferent fibers which are nothing but vestibular fibers
of VIIIth cranial nerve carrying sense of equilibrium or balance. 􏲠fferent fibers are— i. Vestibulocerebellar
fibers
ii. Vestibulospinal fibers
iii. Medial longitudinal bundle: Which connect vesti-
bular nucleus with nuclei of IIIrd, IVth, VIth and XIth cranial nerves and anterior horn cells of upper cervical
segments of spinal cord. It causes reflex movement of eyeball and head and neck in response to change of
position body.
Cochlear nucleus of vestibulocochlear nerve: It is exteroceptive type of special somatic afferent nucleus of
cochlear component of vestibulocochlear nerve. It is made up of dorsal and ventral components lying dorsal and
ventral to inferior cerebellar peduncle fibers at the level of pontomedullary junction.
Connections of cochlear nuclei:

Afferent: Fibers of cochlear component of vestibulocochlear nerve carrying sense of hearing from receptors
(organ of Corti) at internal ear relay in dorsal and ventral cochlear nuclei.
Efferent: Axons of cochlear nuclei will have to reach upto corresponding thalamic nuclei to carry impulse to
sensory area of cerebral cortex. While ascending through central core of brainstem to reach the thalamus, at the
level of lower end of pons, relay
in a nucleus, called nucleus of trapezoid body. Before the relay, axons of both dorsal and ventral cochlear nuclei
partly remain in the same side, partly cross the midline to relay in nucleus of trapezoid body of opposite side. In 119
horizontal section, the fibers show a trapezoid shape, for which the decussating and non- decussating fibers are
called trapezoid body, so the nucleus is also accordingly named.
White matter:
1. Trapezoid body: Axonal process of dorsal and
ventral cochlear nuclei before ending in thalamic level, i.e. in medial geniculate body (metathalamus), show
following change –
Before ascending through upper half of pons
further upwards, fibers pass forwards and medially towards central tegmentum of midbrain. While doing so,
some fibers may remain in same side, some cross the opposite side to form a trapezoid outlined area, called
trapezoid body.
In the trapezoid body, fibers relay in nucleus of trapezoid body.

Then the fibers will run upwards to form lateral lemniscus.
2. Medial lemniscus: This is a compact bundle of fibers already formed at the level of medulla as a continuation
of internal arcuate fibers from nucleus gracilis and nucleus cuneatus, carrying sense of dirscriminative touch,
sense of position and movement and vibration sense. Medial lemniscus is situated close to midline, behind
basilar part of pons. Fiber bundle is rotated for 􏲠􏲠􏲠, wtih fibers from lower half of body placed medially. So
fibers from upper half are placed laterally.
3. Spinal lemniscus: This compact bundle of fiber is the continuation of lateral spinothalamic tract. Axons from
trigeminal nucleus form another
Cavity of fourth ventricle
Medial longitudinal bundle Principal nucleus of V
nerve
Motor nucleus of V nerve
Tectospinal tract Rubrospinal tract
Brainstem
compact bundle called trigeminal lemniscus which
is placed between medial and spinal lemnisci.
4. Medial longitudinal fasciculus (bundle): It is a compact bundle of fibers passing through central
tegmental core of brainstem. These fibers interconnect nuclei of IIIrd, IVth, VIth and XIth nerves with
vestibular nucleus and anterior horn cells of upper cervical segments of spinal cord. Functionally this
fasciculus causes reflex movement of eyeball, head and neck during
alteration of equilibrium or balance of body.
5. Tectospinal tract: It is placed ventral to medial
longitudinal fasciculus.
6. Rubrospinal tract: It lies in front of tectospinal
tract.
These two fiber bundles are extrapyramidal tracts,
in the group of noncorticospinal tract.

7. Spinal tract of trigeminal nerve: These are fiber
bundles which form a cap over the dorsal aspect of spinal nucleus trigeminal nerve. Spinal nucleus of
trigeminal nerve present along the whole length of medulla oblongata extends upwards in the lower end of
pons. Spinal tract is made up of incoming sensory fibers of trigeminal nerve vertically disposed in brainstem.
These fibers relay in the sensory nuclei of trigeminal nerve. Axons of next order of neurons, i.e. the sensory
nuclei will ascend upwards as trigeminal lemniscus placed between medial lemniscus and spinal lemniscus.
8. Inferiorcerebellarpeduncle:Fibersofmiddlecere- bellar peduncle runs horizontally lateralwards from basilar

part of pons. Behind this, cross section of vertically running fibers of inferior cerebellar peduncle is seen.
Superior medullary velum
Lateral lemniscus
Spinal lemniscus Trigeminal lemniscus
Medial lemniscus
Trigeminal nerve
Bundles of descending tracts
Pontine nuclei
􏱺ecussating pontocerebellar fibers

]
Fig. 5.33 Transverse section through upper end of pons (close to its junction with midbrain)
120
Tegmental part at upper half of pons (Fig. 5.33)
Fundamental differences with the lower half of pons are the following:
1. At the upper end of pons, middle cerebellar
peduncles are passing more obliquely lateralwards than horizontally. So the fibers of t􏲄is peduncle are
seen more on cross section than longitudinal, at lateral side of junction of basilar part and tegmental
part.
2. Asupperendofponsapproachestowardsmidbrain upwards, behind the tegmental part of pons, roof of

fourth ventricle of brain is found to be formed by thin lamina of white matter called superior medullary
velum extending between medial sides of two superior cerebellar peduncles.
3. Trapezoid body disappears as the fibers run vertically upwards forming a compact bundle of ascending
tract called lateral lemniscus.
4. Cranial nerve nuclei seen in lower half of pons disappear. Motor as well as superior sensory nuclei of
trigeminal nerve are seen to appear.
Gray matter: Tegmentum of upper half of pons shows only gray matter in the form of motor and superior
(principal) sensory nuclei of trigeminal nerve.
1. Motornucleusoftrigeminalnerve:Itisthespecial visceral efferent or branchial efferent nucleus of trigeminal

nerve situated deep to floor of fourth ventricle of brain, in the central core. Efferent fibers from this nucleus
supply muscles developed from mesoderm of first pharyngeal arch.
2. Superior (principal) sensory nucleus of trigeminal nerve: It is situated lateral to motor nucleus and
continuous below with spinal nucleus of trigeminal nerve. This nucleus is of general somatic afferent type and
receives touch and pressure sensation from the skin of face.
Fibers from motor and sensory nuclei of trigeminal nerve traverse tegmentum forwards and laterally and comes
out as motor and sensory roots of the nerve at the junction of basilar part of pons and middle cerebellar
peduncle. Motor root is medial to sensory root.
White matter:
1. Ascending tracts as lemnisci: Just behind basilar
part of pons, from medial to lateral, pass four compact bundles of ascending fibers which are medial lemniscus,
trigeminal lemniscus, spinal lemniscus and lateral lemniscus.
Among these, medial and spinal lemnisci are already well-developed from a lower level. Trigeminal lemniscus is
made up of fibers of trigemino-thalamic tract which extends from spinal nucleus of trigeminal
nerve to thalamus. Lateral lemniscus is made up of bundle of fibers which are axonal processes of superior
olivary nucleus and nucleus of trapezoid body. It forms a part of auditory pathway.
As trapezoid body of lower half of pons is continuous upwards as vertical bundle of lateral lemniscus, it
disappears at upper half of pons.
2. 􏲄t􏲄er fiber bundles: Beneath the floor of fourth
ventricle, just on either side of midline, following
fiber tracts are existent from behind forwards.
1. a) Medial longitudinal fasciculus

2. b) Tectospinal tract
3. c) Rubrospinal tract.
3. Middle cerebellar peduncle: Internal structure
of upper half of pons, shows fibers of middle cerebellar peduncle which are more vertically sectioned,
rather than horizontal direction, lateral to junction of basilar part and tegmental part of pons.
4. Superior cerebellar peduncle: Dorsolateral part of section shows fibers of superior cerebellar peduncles
of both sides which are bridged by a thin lamina of white matter called superior medullary velum.
Internal Structure of Midbrain
Structural characteristics (Fig. 5.34)
1.
2. 3.
4.
Alittlebehinditscenter,midbrainistraversedby its narrow central canal, called aqueduct of Sylvius or cerebral

aqueduct. This narrow channel is lined by ependyma and communicates with third ventricle above and fourth
ventricle below.
An imaginary line passing side to side through cerebral aqueduct bisects interior of midbrain in smaller
posterior part and larger anterior part. Smaller posterior part is known as tectum. Tect- um is made up of, as
seen externally, two pairs of round elevations. Upper pair, opposite upper half of midbrain, are called superior
colliculi (Sing- ular– colliculus). Lower pair, opposite lower half of midbrain are accordingly called inferior
colliculi. Each colliculus is a round mass of gray matter. Largeranteriorpart,infrontofcerebralaqueduct, is
known as cerebral peduncle. Cerebral peduncle is made up of following three components from before
backwards—
i. Crus cerebri: Compact bundle of white matter. ii. Substantia nigra: A strip of pigmented gray
matter.
iii. Tegmentum: Central core of midbrain with
admixture of both gray as well as white matter.

Brainstem
121
Aqueduct of Sylvius
Periaqueductal gray matter
5. Therefore, from the above description, it is clear that, internal structure of midbrain is divided into
following broad based components from before backwards.
6. Guidelines for study of structural detail
Internal structure of midbrain is studied at two levels. These are at the levels of superior colliculus and
inferior colliculus.
Internal structure of anterior two components, i.e. crus cerebri and substantia nigra is similar on both levels.
Internal structure of posterior two components, i.e. tegmentum and tectum is dissimilar on two levels.
Therefore, structural details of midbrain are to be studied under following headings.
a) Crus cerebri.
b) Substantia nigra.
c) Tegmentum and tectum of the level of inferior
colliculus.
d) Tegmentumandtectumatthelevelofsuperior
colliculus.
Structural details
Crus cerebri (Figs 5.35 and 5.36)
It extends throughout whole length of midbrain. It is made up of compact bundle of descending fibers.
Right and left halves of crus cerebri are separated by a midline sulcus on ventral surface of midbrain. Crus
cerebri is related posteriorly to substantia nigra.
Tectum
Tegmentum
Substantia nigra
Crus cerebri
Cerebral peduncle
Fig. 5.34 Basic structural components of midbrain
Descending fibers passing through crus cerebri are following –
1. Corticospinal: From cerebral cortex to anterior horn cells of spinal cord.
2. Corticobulbar (Corticonuclear): From cerebral cortex to motor nuclei of cranial nerves.
3. Corticopontine:Fromallthefourlobesofcerebral cortex to pontine nuclei. These are the fibers of

corticopontocerebellar pathway. These are of four groups—frontopontine, parietopontine, occipitopontine and
temporopontine.
Crus cerebri is divided into following three parts transmitting different types of fibers.
1. Intermediate 3/5th: Corticospinal and cortico-
bulbar (corticonuclear) fibers.
2. Medial 1/5th: Frontopontine group of cortic-
opontine fibers.
3. Lateral1/5th:Parietopontine,occipitopontineand
temporopontine groups of corticopontine fibers.

Substantia nigra (Figs 5.35 and 5.36)
Substantia nigra is a large mass of gray matter extending throughout whole length of midbrain.
This nucleus of extrapyramidal system is composed of medium sized multipolar neurons, cytoplasm of which is
composed of melanin pigment granules.
It is crescent (curved) in shape with cocavity facing backwards towards tegmentum. It is broader medially.
Substantia nigra is made up of dorsal and ventral part. Dorsal part presents smooth, concave posterior surface
and is known as pars compacta, being packed up with cells. Ventral part is known as pars reticularis where
loosely arranged neurons are intermingled with reticulum (network) of fibers.
i. Crus cerebri
}
ii. Substantia nigra
– In front of cerebral aqueduct iii. Tegmentum
iv. Tectum (colliculi) – Behind cerebral aqueduct
Trochlear nerve nucleus
Exit of trochlear nerve Reticular nuclei
Lateral lemniscus
Spinal lemniscus
Trigem lemniscus Medial lemniscus
Decussation of superior cerebellar peduncle
Substantia nigra
Nucleus of inferior colliculus

122
Mesencephalic nucleus of V nerve
Tectospinal tract
Parietopontine, occipltopontine and temporopontine fibers
Corticospinal and
corticonuclear fibers 􏱺rontopontine fibers

] Crus cerebri
Fig. 5.35 Internal structure of midbrain at the level of inferior colliculus
Melanin pigment granules are polymers of dopamine. Dopamine, released from cell of substantia nigra is
transported to corpus striatum (basal ganglia) through the course of nigrostriate fibers.
Substantia nigra is connected to cerebral cortex, basal ganglia (corpus striatum), hypothalamus and spinal
cord.
Function of substantia nigra is concerned with maintenance of muscle tone.
Tegmentum and tectum at the level of inferior colliculus (Fig. 5.35)

Tegmentum
It is central core of midbrain. It is composed of groups of neurons in the form of nuclei (gray matter) and white
matter in the form of ascending (afferent) and descending (efferent) fiber bundles.
Gray matter (of tegmentum):

1. Periaqueductal gray matter: It contains follo-
wing two cranial nerve nuclei.

Trochlear nerve nucleus: It is the nucleus of somatic efferent column present in periaqueductal gray matter
ventral to cerebral aqueduct behind medial longitudinal fasciculus. Fibers of trochlear nerve arising from
nucleus winding round lateral aspect of aqueduct, run backwards and come out of midbrain from its posterior
aspect below inferior colliculus piercing superior medullary velum where the fibers decussate.
Mesencephalic nucleus of trigeminal nerve: It is the proprioceptive sensory nucleus of trigeminal nerve
present through whole length of midbrain. The nucleus
is situated lateral to cerebral aqueduct and receives proprioceptive sensation from muscles of mastication,
temporomandibular joint, roots of teeth, muscles of eyeball and face.
2. Reticular nuclei: Nuclei of reticular formation are less prominent than those of pons and medulla
oblongata. These are scattered in the central tegmental area ventral to periaqueductal gray.
White matter (of tegmentum):

1. 􏱧e􏱧uss􏱧􏱧io􏱧 o􏱧 fibers o􏱧 su􏱧erior 􏱧erebell􏱧r
peduncle: Ventral spinocerebellar tract is a crossed tract at the level of formation in spinal cord. It ascend
through the brainstem upto this level of midbrain as a contralateral tract. But fibers of this tract will have to
cross for the second time before reaching ipsilateral half of cerebellum. Decussation of these fibers are present
in anterior most part of tegmentum of midbrain following which fibers will pass through superior cerebellar
peduncle.
2. Lemnisci: Lateral to decussation of fibers of superior cerebellar peduncle, all the four lemnisci, namely
medial, trigeminal, spinal and lateral, are placed medial to lateral in such a curved fashion that lateral
lemniscus is placed posterior to spinal lemniscus infront of inferior colliculus. It is to be noted here that fibers of
lateral lemniscus will terminate in inferior colliculus.
3. Medial longitudinal fasciculus: This bundle of fibers is paramedian in position in front of periaqueductal
gray matter.
4. Tectospinal tract: This descending noncorticospinal tract is placed in front of medial longitudinal
fasciculus.
Motor nucleus of oculomotor nerve
Nucleus of superior colliculus
Reticular nucleus
Decussation of tectospinal tract

123
Red nucleus
Substantia nigra
Decussation of rubrospinal tract
Fig. 5.36 Internal structure of midbrain at the level of superior colliculus
Brainstem
Edinger–Westphal nucleus
Mesencephalic nucleus of Vnerve
Protectal nucleus Spinal lemniscus
Trigeminal lemniscus Medial lemniscus
Parietopontine, occipitopontine
and temporopontine fibers
Corticospinal and
corticonuclear fibers
􏱺rontopontine fibers
Oculomotor nerve
5. Rubrospinal tract: This is another noncorticospinal tract descending in front of tectospinal. It is placed
either in front or behind decussation of fibers of superior cerebellar peduncle.
Tectum(inferiorcolliculus):Beneaththisround bulge, compact mass of neurons forms nucleus of inferior

colliculus. This nucleus forms the cell station in cochlear pathway. Many of the fibers of lateral lemniscus relay
in this nucleus. Efferent fibers from nucleus of inferior colliculus pass via inferior brachium to medial
geniculate body. Inferior colliculus cells are also considered to form
the center of spinoauditory reflex which helps in localizing the source of sound.
Tegmentum and tectum at the level of superior colliculus (Fig. 5.36)
Tegmentum: Like inferior collicular level, tegmentum at the level of superior colliculus fundamentally
presents following features—
Gray matter: In the form of cranial nerve nuclei and, reticular nuclei. Additionally a nucleus of extrap-
yramidal system called red nucleus.
White matter: In the form of ascending (lemnisci) and descending tracts and, decussating fibers of some
descending tract.
Gray matter (of tegmentum):
1. Periaqueductalgraymatter:Graymattersurroun- ding cerebral aqueduct presents following cranial nerve

nuclei.
Somatic efferent nucleus of oculomotor nerve: It is the main motor nucleus of oculomotor nerve which
supplies majority of extraocular muscles. It is situated in ventromedial part of periaqueductal gray matter. The
nucleus of both sides is closely apposed to each other forming a triangular nuclear complex ventral to aqueduct.
Edinger–Westphal nucleus: It is general visceral efferent nucleus of oculomotor nerve which gives out
preganglionic fibers passing through oculomotor nerve to supply two smooth muscles of eyeball, constrictor
pupillae and ciliary muscle. This nucleus is situated dorsolateral to somatic efferent nucleus.
Mesencephalic nucleus of trigeminal nerve: As stated earlier, this proprioceptive sensory nucleus of
trigeminal nerve extends throughout whole length of midbrain. It is situated on lateral part of periaqueductal
gray lateral to cerebral aqueduct. This nucleus receives proprioceptive impulse from muscles of mastication,
temporomandibular joint, roots of teeth, muscles of eyeball and face.
2. Reticular nuclei: This part of brainstem reticular formation is less prominent and situated in lateral part of
tegmentum.
3. Red nucleus: It is so called because it is red or reddish brown in color due to more vascularity and iron
containing pigment in neuronal cytoplasm. It is ovoid in length and round in cross section. This nucleus is
situated dorsal to medial end of substantia nigra. Red nucleus extends only in
upper half of midbrain at the level of superior colliculus. It is one of the centers of extrapyramidal system.
124 Connections of red nucleus: Red nucleus functions as intermediate cell station for following pathways.
1. Corticorubrospinal tract:
Afferent: From motor and premotor area of cerebral cortex (Area 4 and 6) of same side.
Efferent: To anterior horn cells of spinal cord (only upper cervical segments) of opposite side.
2. Corticorubrobulbar tract:
Afferent: From motor and premotor area of cerebral cortex (Area 4 and 6) of same side. Efferent: To
motor nuclei of IIIrd–VIIth cranial nerves of opposite side.
3. Cerebellorubrothalamic tract:
Afferent: From dentate nucleus of cerebellum of opposite side.
Efferent: To thalamic nucleus.
4. Pallidorubrothalamic tract:
Afferent: From globus pallidus of same side. Efferent: To thalamic nucleus of opposite side.
White matter (of tegmentum):
1. 􏲄merging fibers of oculomotor nerve: Both

somatic efferent and general visceral efferent (parasympathetic) fibers of oculomotor nerve, arising from
respective nucleus, traverse through tegmentum of midbrain at the level of superior colliculus. While
doing so, oculomotor nerve traverses through red nucleus and comes in close relation to crus cerebri
through which pass corticospinal (pyramidal) tract fibers.
2. 􏲄ecussationofrubrospinaltractfibers:Itisknown that rubrospinal tract is a crossed tract. Fibers arising

from red nucleus decussate immediately at the level of superior colliculus ventromedial to the nucleus,
and then descend towards spinal cord. This is known as anterior (ventral) tegmental decussation of
Forel.
3. 􏲄ecussation of tectospinal tract fibers: Like rubrospinal tract, tectospinal tract is also a contralateral
tract arising from tectum of midbrain. At the level of superior colliculus, fibers of tectospinal tract
decussate, posteromedial to red nucleus before descending towards spinal cord. It is called posterior
(dorsal) tegmental decussation of Meynert.
4. Compactbundleofascendingtract(aslemniscus): Out of the four lemnisci found of the level of inferior
colliculus, lateral lemniscus was found to end in inferior colliculus. So, at the level of superior
colliculus, three lemnisci, namely medial, trigeminal and spinal, are placed medial to lateral.
These fiber bundles are situated lateral to red
nucleus.
5. Medial longitudinal fasciculus: It is the uppermost
end of this fiber bundle which is situated just in
front of oculomotor nucleus.

Tectum (superior colliculus): It is a part of bulge on the dorsal aspect of upper half of midbrain. Beneath
this round elevation, dorsal part of midbrain (behind cerebral aqueduct) presents concentric layers of gray and
white matters. Neurons of the gray matter form nucleus of superior colliculus which forms cell stations for
spinovisual reflex.
Connections of nucleus of superior colliculus:
Afferent: Fibers of optic tract relay in lateral geniculate body. Some of the fibers from neurons of lateral
geniculate body, passing through superior brachium end in superior colliculus.
Efferent: These are tectobulbar and tectospinal fibers passing to motor nuclei of cranial nerves in brainstem
and anterior horn cells of spinal cord respectively.
Nucleus of superior colliculus acts as a center for spinovisual reflex or visual body reflex pathway.
CLINICAL ANATOMY OF BRAINSTEM MEDULLA OBLONGATA

General consideration: Traumatic, ischemic, infective, degenerative or neoplastic lesions of medulla
oblongata may lead to wide range of clinical manifestations because—
i. It contains various cranial nerve nuclei.

ii. Medulla oblongata is the part of brainstem which contains ‘vital centers’ those regulates
cardiovascular and respiratory functions.

iii. Through medulla oblongata pass many ascending and descending tract which may be affected in
demyelinating diseases, neoplasm
or vascular disorder.
Herniation of Medulla in Increased Intracranial Pressure

Any tumor or space occupying lesion (SOL) in posterior cranial fossa will lead to increase in intracranial
pressure. As a result, to compromise this tension, medulla oblongata with cerebellar tonsil will be pushed
downwards and forwards causing herniation through foramen magnum.
Clinical manifestations
Headache
Neck stiffness or neck rigidity
of medulla oblongata with a part of cerebellum. It is characterized by various manifestations due to lesion of many
nuclei and fiber tracts which are as follows.
Loss of pain and temperature sensation of opposite half of body.
Loss of pain and temperature of same side of face.
Dysphagia (difficulty in swallowing) and dysphonia (difficulty in phonation) due to paralysis of muscles of soft palate, pharynx and layrynx.
Cerebellar ataxia associated with incoordination of movements and in gait affecting limbs.
Vertigo, nausea, vomiting and nystagmus (incoordination in conjugate deviation of eyeball).
Horner’s syndrome characterized by ptosis, miosis, enophthalmus and anhidrosis with flushing of same side of face.
Brainstem
Effect of lesion of lower four cranial nerves due to their traction (IX–XIIth).
Complication
Lumbar puncture, to release the raised intracranial pressure, is contraindicated. Because it may lead to further
herniation of medulla (so also brain) through foramen magnum which may cause sudden failure of vital functions.
Arnold–Chiarimalformation:Itisacongenital disorder associated with craniovertebral anomalies and spina
bifida.
Pathology: Herniation of cerebellar tonsil and medulla oblongata through foramen magnum.
Effect: Herniation of medulla as well as cerebellum will cause obstruction of foramen of Magendie and foramen of
Luschka on the roof of fourth ventricle which communicate subarachnoid space with cavities (ventricles) of brain.
So it will cause internal hydrocephalus.
Medial (ventral) medullary syndrome:

It is one of the vascular disorder of medulla oblongata. In this case of vascular lesion ventral part of medulla is
damaged due to obstruction (thrombosis) of
medullary branch (branches) of vertebral artery.

This syndrome is also known as ‘Crossed paralysis’
as it will cause –
1. Contralateral hemiplegia: It is due to lesion of
pyramid through which passes pyramidal tract before decussation.

As it is upper motor neuron lesion, it is chara-
cterized by contralateral spastic paralysis with increased muscle tone and exaggerated tendon jerks.
2. Ipsilateral paralysis of tongue: It means that
paralysis of muscles of tongue of same side because of lesion of hypoglossal nerve of same side which emerges from
medulla close to pyramid. Due to this defect, as same sided genioglossus with other tongue muscles is paralyzed,
unopposed action of genioglossus of normal side will push the tip of tongue, when protruded, to the paralyzed side.
􏱧􏱧 􏱧􏱧􏱧i􏱧io􏱧􏱧lse􏱧sor􏱧􏱧efi􏱧i􏱧:Atthislevelofmed- ulla (pyramidal level), medial lemniscus is situated behind

pyramid. So, if the lesion is deeper, damage to medial lemniscus will cause loss of sense of position and movement
(due to loss of proprioceptive sensation from muscles, tendons and joints) and loss of discriminative touch of opposite
side.
Lateral medullary (Wallenberg) syndrome: This is a clinical condition which occurs in thrombosis of
posteroinferior cerebellar artery, a branch of vertebral artery. It leads to lesion in posterolateral part
Area of lesion
1. Spinal lemniscus (lateral spinothalamic tract)

2. Spinal nucleus and spinal tract of trigeminal nerve
3. Nucleus ambiguous
4. Ventral and dorsal spinocerebellar tract, inferior cerebellar peduncle and part of cerebellum
5. Vestibular nuclei
6. Descending sympathetic fibers
Traumatic lesion of medulla oblongata: Sudden hyperextension injury of neck leading to fracture dislocation
of axis (second cervical vertebra) causes damage to medulla oblongata. Typical example is Hangman’s fracture of
axis which presses over medulla oblongata leading to suppression of functions of various functional area including
‘vital centers’ which ultimately results to death following hanging.
PONS
Pons is the infratentorial part of brainstem which is lodged in posterior cranial fossa and closely related to
cerebellum with middle cerebellar peduncle and fourth ventricle of brain. Lesion of pons is commonly due to
following two reasons –
1. Vascular: Pons is supplied by –
i. Pontine arteries
ii. Anterior inferior cerebellar artery
iii. Superior cerebellar artery.

All are branches of basilar artery.
Range of vascular lesion may be mild, moderate
or severe. Accordingly it may affect a small area or whole of pons which causes bilateral manifestations.
Nature of vascular lesion may be thrombosis or hemorrhage leading to infarction.

2. Neoplastic: Neoplasm (tumor) of pons may be—
a) Acoustic neuroma: It is a tumor at cerebellopontine angle (CP angle) developed from Schwann cell sheath of
statoacoustic (vestibulocochlear) nerve.
125
126
b) Astrocytoma: It is the tumor originating from astrocytes. Incidence is common in children.
Vascular lesion in paramedian area of basilar part of pons may be due thrombosis or infarction due to
involvement of short multiple pontine branches of basilar artery. It will cause contralateral cerebellar ataxia
with intention tremor due to lesion of corticopontocerebellar pathway. Contralateral hemiplegia will result due
to damage to corticospinal tract passing through basilar part of pons.
Millard Gubler Syndrome: It is the clinical condition which results due to occlusion of paramedian
pontine branches of basilar artery feeding lower and ventral part of pons.
It involves basilar part of pons through which traverses corticospinal tract and emerge fibers of VIth and VIIth
cranial nerve.
Clinical manifestations –
i. Contralateral hemiplegia
ii. Ipsilateral lower motor neuron type (nuclear or
infranuclear) facial paralysis.
iii. Ipsilateral medial strabismus (squint) due to
unopposed action of medial rectus as a result of paralysis of lateral rectus supplied by abducent (VIth cranial)
nerve.
Extensive vascular lesion or expanding tumor (astrocytoma) of pons will cause widespread motor
and sensory deficits depending on different areas of gray and white matter affected as follows–
Area of lesion
1. Corticospinal tract
2. Corticonuclear tract
3. Pontocerebellar fibers
4. Medial and spinal lemnisci
5. Superior (principal) sensory nucleus of trigeminal nerve
6. Abducent nerve nucleus
7. Vestibular nuclei
8. Cochlear nuclei
Contralateral hemiparesis or hemiplegia
Weakness of muscles of face, jaw of opposite side
Cerebellar ataxia
Contralateral sensory deficit of trunk and limbs
Contralateral loss of tactile sensation of face, pain and temperature sensations are preserved as spinal nucleus of Vth nerve is not affected.
Medial strabismus (squint) due to unopposed action of medial rectus muscle.
Vertigo, nausea, vomiting and nystagmus.
Impairment of hearing.
Site of lesion
1. Vestibulocochlear nerve
2. Middle cerebellar peduncle
3. Spinal nucleus and spinal tract of trigeminal nerve
􏲠. 􏲠merging fibers of facial nerve

Cerebellopontine angle (CP angle) tumor: It is the acoustic neuroma which occurs due to tumor arising
from Schwann cell sheath of vestibulocochlear nerve.
Vertigo, nausea, vomiting, tinnitus and progressive deafness.
Cerebellar ataxia with intention tremor and staggering gait.
Ipsilateral loss of pain and temperature sensation of face.
Ipsilateral infranuclear facial paralysis.

Pontine hemorrhage: It is extensive and bilateral in nature so that clinical condition will cause bilateral
type of all manifestations as stated above. In addition, it will present following two specific manifestations.
1. ‘Pinpoint’pupil:Duetoinvolvementofocularsym- pathetic fibers.
2. Hyperpyrexia:Itisbecauseofseverelesionsinpons which disconnect the body from heat regulating center in

hypothalamus.
MIDBRAIN
Causes of lesion in midbrain may be – 1. Traumatic

2. Neoplastic
3. Ischemic
4. Obstructive.
Traumatic Lesion
Midbrain, the short proximal part of the stalk, forms supratentorial part of brainstem. While becoming
continuous with infratentorial part, midbrain is related to tentorial notch formed by sharp free margin of
tentorium cerebelli. Sudden lateral movement of the head may lead to a vulnerable injury, when midbrain (its
cerebral peduncle) may be torn, stretched, twisted or bent against free margin of tentorium cerebelli.
In this case most obvious feature will be involvement of oculomotor nerve at its exit. Depending upon severity
of injury, trochlear nerve and other areas of midbrain will be affected.
Neoplastic Lesion
Tumors pressing and infiltrating neural tissue of midbrain may be internal or external. Any space occupying
lesion (SOL) in the vicinity will have effect on following structural components of midbrain.
1. Important ascending and descending tracts: For example Medial and spinal lemnisci, corticospinal and
corticobulbar (corticonuclear) tracts, medial longitudinal fasciculus.
2. Nucleiofcranialnerves:Likeoculomotorandtroc- hlear nerves.
3. Reflex centers in colliculi

4. Rednucleusandsubstantianigra:Whichpossesses
remarkable influence on motor function.
Vascular Lesion
It occurs due to occlusion of a branch of posterior cerebral artery. Depending upon extent of lesion clinical
syndromes are of following two types:
1. Weber syndrome: It is also known as ‘Crossed 127
oculomotor paralysis’. This lesion damages corticospinal and corticobulbar (corticonuclear) tracts and
emerging fibers of oculomotor nerve. 􏲠ffects of this vascular lesion are following.
Brainstem
Side of lesion
1. Corticospinal tract
2. Corticobulbar tract
3. Oculomotor nerve fibers
Contralateral hemiplegia.
Paresis of lower part of face, tongue (contralateral half).
Ptosis, lateral squint, proptosis with diplopia, dilatation of pupil wih its no reaction to light and accommodation.
2. Benedikt syndrome: This vascular lesion of midbrain is more extensive additionally affecting medial and
spinal lemnisci as well as red nucleus. So clinical findings of Weber syndrome is associated with contralateral
sensory impairment and some involuntary movements.
Midbrain
Brainstem Pons
Cerebellum
Cerebellum
Medulla oblongata
Middle cerebellar peduncle Inferior cerebellar peduncle
INTRODUCTION
Fig. 6.1 Cerebellum in relation to brainstem (lateral view)

POSITION AND RELATIONS (FIGS 6.1 AND 6.2)
Cerebellum is the dorsal part of hindbrain (rhombencephalon) (Fig. 6.1). Among the three components of hindbrain
with pons and medulla oblongata. Cerebellum is the largest in volume.
Cerebellum is considered as motor component of brain. Though it does not initiate voluntary movement, but it
exerts a control on it in a subconscious state.
In contrast to cerebrum, cerebellum is known as ‘little brain’.
Cerebellum exerts ipsilateral control on body.
Cerebellum is situated in posterior cranial fossa, where it is lodged on cerebellar fossa of squamous part of occipital
bone.
Cerebellum is situated below occipital lobe of cerebrum from which it is separated by tentorium cerebelli.
Cerebellum is anteriorly related to dorsal surface of pons and medulla oblongata from which it is separated by
fourth ventricle of brain (Fig. 6.2).
Three components of brainstem, midbrain, pons and medulla oblongata are connected to cerebellum by paired
superior, middle and inferior cerebellar peduncles respectively (Fig. 6.1).
6
Cerebellum
129
Third ventricle of brain
Cerebellum Fourth ventricle of brain
Central canal of medulla
Midbrain
Pons
Medulla oblongata
Fig. 6.2 Cerebellum in relation to fourth ventricle of brain (sagittal sectional view)
PRINCIPLE OF FUNCTIONS
It has already been mentioned, though cerebellum is not concerned with initiation of voluntary movement, it
regulates normal motor activities unconsciously. It acts as a ‘playback singer’ or trainer of a musical troop.
Functions of cerebellum is explained in following three stages.
Stage I
Cerebellum receives various kinds of sensory informations either through direct pathway like spinocerebellar
or indirect pathway like spinothalamo- cortical and corticopontocerebellar tracts.
Sources of informations are as follows—
1. Proprioceptive general somatic sensation: From
end organs of muscles, tendons, joints.
2. Exteroceptive general somatic sensations: Mainly
from end organs for touch and pressure.
3. Proprioceptive special somatic sensation: From
end organ for balance, i.e. vestibular apparatus.
4. Exteroceptivespecialsomaticsensation:Fromend organs for sight (photoreceptors) and end organs
for hearing (cochlear apparatus).
Stage II
All sensory informations are analyzed and coordinated or integrated.

Stage III
After integration of all sensory inputs, a regulatory effect is exerted by cerebellum, in a subconscious or
unconscious state, on brainstem, spinal cord and cerebral cortex for –

1. Maintenance of equilibrium or balance of body
through postural adjustment.

2. Maintenance of muscle tone for desired sense of
position and movements.

3. Coordinated and smooth muscular activities to
proper range, extent and direction. GROSS ANATOMY (FIG. 6.3)
Funamental Components
Cerebellum is fundamentally composed of intermediate part called vermis and two lateral halves called
cerebellar hemispheres. Vermis is so called because it is somewhat like worms in appearance. This terminology
can be compared to the word verm- iform appendix. Centrally situated vermis is narrow and constricted. It is
continuous on either side with rounded and expended cerebellar hemispheres.
Surface views – Superior and inferior
When viewed from superior surface, area of vermis seen is called superior vermis, which presents antero-
posteriorly directed midline ridge, which slopes laterally to become continuous with superior surface of
cerebellar hemispheres.
Inferior aspect of cerebellum shows comparatively independent appearance of vermis which is called inferior
vermis which is more deeply placed as compared to cerebellar hemisphere. The depression on
130
Section of midbrain
Superior vermis
Vallecula lodging inferior vermis
Superior cerebellar peduncle connecting cerebellum with midbrain
Superior half of cerebellar hemisphere above horizontal sulcus
Horizontal sulcus
Inferior half of cerebellar hemisphere below horizontal sulcus
Vallecular sulcus
which inferior vermis is lodged is called vallecula. Vallecular sulcus separates vermis on either side from
inferior aspect of cerebellar hemisphere.
Cerebellar notches
Cerebellum, when viewed from above, present a notch in the midline on its anterosuperior aspect to
accommodate collicular bulge of midbrain. It is called superior cerebellar notch. Posteroinferior aspect of two
cerebellar hemisphere are separated by posterior cerebellar notch which is related to free crescentic margin of
Falx cerebelli.
􏱽urface features 􏱽 􏱽olia an􏱽 fissures
Surface of cerebellum (both hemisphere as well as vermis) presents very narrow and shallow parallel linear
depressions. These are called fissures. These fissures extending from one side of cerebellar hemisphere to the
other side crossing over the vermis, present ‘V’ shaped or ‘U’ shaped appearance, angle or concavity of which is
directed forwards. One fissure intervenes between two adjacent thin and linear ridge like leafy elevations which
are parallel to each other serially. These are called folia (Singular—folium).
PRIMARY FISSURE AND LOBES OF CEREBELLUM
Cerebellum is primarily divided into 3 lobes by primary fissures which are comparatively deeper.
These lobes are known as:
1. Anterior lobe
2. Middle lobe
3. Flocculonodular lobe.
Each of the lobe has a portion of vermis (midline
part) and two lateral extensions on cerebellar hemisphere.
Anterior lobe and middle lobe (also called posterior lobe) are separated by a ‘V’ shaped fissure at the junction of
anterior 1/3rd and posterior 2/3rd of superior surface. It is the primary fissure or fissura prima. Antero- inferior
part of cerebellum is cut off by another primary fissure called posterolateral fissure (sulcus). The part of
cerebellum anterior to this sulcus is called Flocculo- nodular lobe. Superior and inferior halves of middle lobe
(posterior lobe) are separated by a prominent deep fissure called horizontal fissure which is not functionally
primary fissure, though primary in origin.
Each of the lobe made up of lobules: Lobes of cerebellum, namely anterior and posterior, are further divided by
secondary fissures into smaller units, called lobules. Each lobule presents a component in the vermis and its
lateral extensions in both the cerebellar hemisphere.
Before the lobules are studied through following table, it is important to note at this stage that, during
development of cerebellum all the lobules of cerebellum used to be simply placed in cephalocaudal direction on
the dorsal aspect of pons and medulla intervened by cavity of fourth ventricle (Fig. 6.4). But ultimately, part of
it, caudal to the level of future horizontal fissure, is bent on itself inferiorly round the tent-shaped roof of 4th
ventricle as seen in Figure 6.4, to form inferior vermis and inferior part of cerebellar hemisphere.
Fig. 6.3 Posterosuperior view of cerebellum

Anterior lobe
Cerebellum
131
Primary sulcus Horizontal sulcus

Middle (posterior) lobe
Posterolateral sulcus Flocculonodular lobe
Fig. 6.4 Cephalocaudal relationship of different components (lobules) of cerebellum. Fig also shows rostroventral bending of caudal part of
cerebellum (part caudal to horizontal sulcus) to form its inferior part
Lobules of cerebellum (Fig. 6.5):
Horizontal fissure divides cerebellum into superior and inferior halves. Lobules listed above, which are
proximal to horizontal fissure form superior half and those distal to the fissure form inferior half of cerebellum.
PHYLOGENETIC CLASSIFICATION OF CEREBEL- LUM (FIGS 6.5 AND 6.6)
In reference to the stages of evolution, cerebellum is made up of following three phylogenetic components which
are also functionally different.
Archicerebellum
It is the most primitive part of cerebellum which is the only component present in fishes and amphibians.
Vermis Lateral extension in cerebellar hemisphere

1. Lingula
2. Central lobule
Primary 3. fissure
No lateral extension
}
Ala Anterior Anterior quadrangular lobule lobe
Posterior quadrangular lobule
Culmen 4. Declive
Horizontal 5. fissure
Folium
Superior semilunar lobule (lobulus simplex)
Posterolat- 8. eral sulcus
Posterior lobe
– Flocculo- nodular lobe
6. Tuber
7. Pyramid
Inferior semilunar lobule Biventral lobule
Tonsil
Uvula 9. Nodule
Flocculus
Anterior lobe
Posterior lobe
12
4 55
66
2
3
34
􏱺rimar fissure
􏱺ori􏱺ontal fissure (sulcus)
􏱺osterolateral fissure (sulcus)
Archicerebellum Paleocerebellum Neocerebellum
7 88 9
Flocculonodular lobe
Fig. 6.5 Lobes, lobules and fissures of cerebellum
132
Cerebral aqueduct 3 2
􏱺rimary fissure
Midbrain 1 Pons
Medulla oblongata
Cavity of fourth ventricle of brain
Central canal of lower half of medulla oblongata
6
􏱺ori􏱺ontal fissure
Fig. 6.6 Midsagittal section of vermis component of cerebellum (with 4th ventricle and brainstem) contributing to lobular elements. 1.
Lingula, 2. Central lobule, 3. Culmen, 4. Declive, 5. Folium, 6. Tuber, 7. Pyramid, 8. Uvula, 9. Nodule
Composition
Lingula and flocculonodular lobe.
Connection
Vestibular nuclei through vestibulocerebellar fibers.
Function
Maintenance of equilibrium or balance.
Paleocerebellum
It is the part of cerebellum which is superadded in lower vertebrates with limbs, e.g. bird and reptiles.
Composition
1. Central lobule and ala

2. Culmen and anterior quadrangular lobule
3. Pyramid, i.e. only vermis portion 4. Uvula, i.e. only vermis portion.
Connection
Receives connection from spinal cord via spinocerebellar fibers.
Function
Maintenance of muscle tone and posture.
Neocerebellum
This component of cerebellum is the most recently evolved part which is well-developed in higher mam-
mals, where development of central nervous system is characterized by telencephalization, which means
differentiation of telencephalon in the brain.
Composition
The largest middle (posterior) lobe of cerebellum except pyramid and uvula of inferior vermis.
Connection
It receives afferent connections from cerebral cortex via corticopontocerebellar pathway.
Function
Neocerebellum is concerned with a coordination of voluntary movement so that it is smooth and skilled, and it
is performed in right direction and within proper range.
INTERNAL STRUCTURE OF CEREBELLUM (FIG. 6.7)
Cerebellum is structurally made up of following two fundamental zones.

1. Outerlayerofgraymattercalledcerebellarcortex. 2. Innercentralcoreofwhitematterwhichpresentsa
pattern like branching of a tree projecting superficially beneath the cortex of each and every folium, called
arbor vitae cerebelli.
Inside the substance of white matter are embedded
mass of gray matter called cerebellar nuclei.
Structure of Cerebellar Cortex
Cortex is made up of following cerebellar neurons arranged in three layers.
78
􏱺osterolateral fissure
Cerebellum
133
Stellate cell Busket cell
Purkinje cell Golgi cell

Granule cell Glomerulus
Molecular layer
Purkinje cell layer
Granular layer
Climbing fibers
Mossy fibers
Cerebellar afferents
Neurons of cerebellar nuclei
}Cerebellar efferents
Axon of some Purkinje cells leave cerebellum directly as cerebello 􏱺fastigio􏱺􏱺 vestibular fibers
White matter
Fig. 6.7 Cytoarchitecture of cerebellum showing afferent and efferent fibers and interrelationship of neurons
1. Outer molecular layer: Stellate cells and busket cells.

2. IntermediatelayerofPurkinjecells:Purkinjecells.
3. Inner granular layer: Granule cells and Golgi
cells. Neuroglia are present in all the layers.
Fundamental structural and functional basis of cortical architecture

Principal cells of cortex are Purkinje cells. It receives afferent input entering cerebellum through following two
different routes.
1. Some of cerebellar afferent relay in Purkinje cells
reaching upto superficial molecular layer.
2.
Some afferent reaching the innermost granular layer relay in granule cells which pass further superficially to
relay in Purkinje cells dendrites in molecular layer.
Through both the ways Purkinje cells receive excitatory impulse continuously. This excitatory impulse in
relayed to neurons of cerebellar nuclei in deeper white matter. Axons of cerebellar nuclei pass out as efferent to
carry the same excitatory impulse. But this impulse is limited time to time by inhibitory influence of stellate
cells, busket cells and Golgi cells of cortex on Purkinje cells, so also on cells of cerebellar nuclei.
134 STRUCTURAL DETAIL OF CEREBELLAR CORTEX (FIG. 6.7)
Molecular Layer
This outermost layer of cortex receives cerebellar afferent called climbing fibers. Among all afferents to
cerebellum, these are only olivocerebellar fibers. Entering through inferior cerebellar peduncle and traversing
through white matter these fibers climb up to the outermost layer of cortex. These fibers divide into numerous
branches which wrap around the bush- like dendritic tree of Purkinje cells in molecular layer. These are called
climbing fibers as they look like a vine on a tree. One climbing fiber forms synaptic connections with dendritic
tree of 1–10 Purkinje neurons through which all the times excitatory sensory inputs are discharged on Purkinje
cells.
Neurons present in molecular layer are stellate cells and busket cells. Stellate cells are small star- shaped
superficially placed cells. Axons of these cells relays in dendritic spines of Purkinje cells to produce inhibitory
effect. Busket cells are placed in deeper part of molecular layer. These are so called because multiple axon
terminals give a busket-like appearance to hold the Purkinje cell body. Through this connection excitatory
impulse of Purkinje cells are limited.
Molecular layer also receives axons of granule cells situated in granular layer. In this layer long axons of
granule cells divided into T-shaped manner. Two limbs of T-shaped axon of granule cells run in opposite
direction which synapse with Purkinje cell dendritic spines.
Purkinje Cell Layer
This layer is made up of single row of cells called Purkinje cells. These are large, flask-shaped Golgi type I
neurons. Dendrites of these cells are like tree bush showing primary, secondary and tertiary or final branching.
Final branches present dendritic spines. Whole dendritic process extend into superficial molecular layer.
Long axons of Purkinje cells acquire myelin sheath on entering granular layer. These pass further deeper to
relay in neurons of cerebellar nuclei.
Axons of a few Purkinje cells end directly to vestibular nuclei, without relaying in cerebellar nuclei.
Granular Layer
This layer is so called because it is filled with densely packed, small sized, multipolar neurons called granule
cells. The cells present scanty cytoplasm with deeply stained nuclei. Granule cells are intermediate in
position between all the afferent fibers to cerebellum other than olivocerebellar group and the Purkinje cells.
These cerebellar afferent fibers are known as Mossy fibers. Granule cells present four to five dendrites which
present claw-like endings. Mossy fibers, which are all the afferents, other than olivocerebellar fibers (climbing
fibers) reach upto granular layer where they show multiple branching. These fiber terminals form synaptic
connection with claw-like dendrites of granule cells. One mossy fiber forming synaptic connection with
thousand of Purkinje cells, thus producing diffuse excitatory effect.
Axons of granule cells are long enough to reach upto superficial molecular layer traversing through Purkinje
layer. Terminal end of granule cell axons divide in ‘T’ shaped manner, ends of which run in opposite direction
which are called parallel fibers. Ends of parallel fibers form synaptic connection with dendritic tree of Purkinje
cells at right angle.
Second type of neurons in granular layer are Golgi cells. Their dendrites are spread out in molecular layer and
axon split up into branches which form synapses with dendrites of granules cells at the site of their junction
with mossy fiber terminals which form glomerulus.
Neuroglial cells are also abundant in whole granular layer.
MECHANISM OF CEREBELLAR CORTICAL CIRCUIT
Purkinje cells receive constantly the excitatory inputs entering cerebellum through afferent fibers. The afferent
fibers are of two types. Climbing fibers are only the olivocerebellar fibers among all afferent fibers to
cerebellum. These fibers are longer to wrap around and to relay in dendritic spines of Purkinje cells at
molecular layer. Mossy fibers are all other afferents, which also produce excitatory affect on Purkinje cells
through granule cells. Axons of Purkinje cells leave the cortex to reach deeper white core of cerebellum where
they excite neurons of cerebellar nuclei. Axons of the nuclear neurons leave cerebellum as efferents via superior
and inferior cerebellar peduncles to reach centers in brainstem, spinal cord and cerebral cortex.
So, it clear till now that, receiving all sensory inputs through climbing as well as mossy fibers, excitation of
Purkinje cells is conveyed via cerebellar nuclear axons for motor activities, maintenance of equilibrium, muscle
tone and muscular activity coordination. But for this motor activity, to reach upto optimum range, proper
extent and right direction, time to time modification or limitation of excited state of Purkinje cells conveyed to
cerebellar nuclear axons as efferent fibers are necessary. This becomes possible by inhibitory whip
of stellate cells, busket cells of molecular layer and Golgi cells of granular layer. It is to be recalled that axons of
stellate cells form synaptic connection with dendrites, and axons of busket cells come in contact with cell bodies
of Purkinje cells. Through these connections both these cells exert inhibitory effect on Purkinje cells. In
granular layer, axons of Golgi cells form synaptic contact with dendrites of granule cells, through which
inhibitory influence is exerted on Purkinje cells, so on axons of neurons of cerebellar nuclei coming out as
efferent fibers from cerebellum. So, it is clear that inhibitory impulse from stellate cells, busket cells and Golgi
cells are transmitted by Purkinje cells to the cerebellar nuclei, axons of which in turn, projecting on motor
centers of brainstem, spinal cord and cerebral cortex modify or limit muscular activity for maintenance of
equilibrium, muscle tone and coordination of smooth and skilled movements.
Neurotransmitters: Climbing as well as mossy fibers release glutamate or gamma-aminobutyric acid (GABA) as
excitatory transmitter on dendrites of Purkinje cells. Axons of stellate cells, busket cells and Golgi cells release
norepinephrine and serotonin which are inhibitory transmitter to have effect on Purkinje cells.
Afferents from vermal (median) zone of cortex to fastigial nucleus
WHITE MATTER OF CEREBELLUM
Small amount of white matter present in vermis looks like trunk and branches of a tree. It is called arbor vitae
cerebelli. Cerebellar hemispheres present larger amount of white matter.
135
White matter is made up of following three groups of fibers.
1. Afferent fibers: These are climbing and mossy fibers as already described. These form the main bulk of
cerebellar fibers which enter mostly through middle and inferior cerebellar peduncles.
2. Efferent fibers: These fibers leave cerebellum through superior and inferior cerebellar peduncles. Most
of these efferent fibers from cerebellum are axons cerebellar nuclei neurons. Some of axons of Purkinje
cells of flocculonodular lobe and part of vermis pass, bypassing cerebellar nuclei, directly as cerebellar
efferents.
3. Intrinsic fibers: These are so called as they exist within the cerebellum. It means these fibers, being the
processes of different cerebellar neurons interconnect with each other.
NUCLEI OF CEREBELLUM (FIG. 6.8)
These are small but compact masses of gray matter embedded in central core of white matter. Axons
Afferents from paravermal (medial) zone to nucleus interpositus
Afferents from lateral zone of cerebellar cortex to dentate nucleus
Cerebellum
B
BA
Fig. 6.8 A. Intracerebellar nuclei, B. Afferents from vermal (median), paravermal (medial) and later zones of cerebellar cortex relaying to
respective nuclei, C. Efferents from three phylogenetic groups of nuclei leaving for different destinations
Efferents from dentate nucleus to thalamus for dentatothalamocortical pathway
Efferents from nucleus interpositus to red nucleus for cerebellorubrospinal pathway
Efferents from fastigial nucleus to–

• 􏱺estibular nucleus for fastigiovestibular (fastigiobulbar) pathway
• 􏱺eticular nucleus for fastigioreticular pathway
of neurons of these nuclei, as already discussed, leave out of cerebellum through either superior or inferior
cerebellar peduncles as cerebellar efferents. Cerebellar nuclei are four in number on either side of midline from
vermis to cerebellum hemisphere. From lateral to medial the nuclei are –
1. Dentate nucleus (Nucleus dentatus) – D 2. Emboliform nucleus (Nucleus emboliformis)– E 3. Globose nucleus
(Nucleus globossus)– G 4. Fastigial nucleus (Nucleus fastigius)– F
136 Nucleus emboliformis and nucleus globossus are together known as nucleus interpositus.
Dentate Nucleus
Dentate nucleus is the most lateral and largest among the four nuclei of cerebellum. It is most prominent in
higher animals, specially in human brain. Phylogenetically it is the latest in evolution and obviously related to
neocerebellum. Dentate nucleus, on section, looks like a folded bag with its opening (concavity) facing medially.
From the concave side emerge efferent fibers from the nucleus. Efferent fibers leave cerebellum through
superior cerebellar peduncle.
Emboliform Nucleus
Emboliform nucleus is oval in outline. It is situated just medial to dentate nucleus and may be closely
approximated to concavity (hilum) of dentate nucleus.
Globose Nucleus
It is round in shape and sometimes may be more than one in number.
Globose and emboliform nuclei are closely apposed to each other and interposed between dentate nucleus
laterally and fastigial nucleus medially. That is why they together are named as nucleus interpositus.
Nucleus interpositus is related to paleocerebellum. Fastigial Nucleus

Fastigial nucleus is close to midline and thereby lies in the white core of vermis. It is ovoid or elliptical in
outline and intermediate in size between dentate nucleus and nucleus interpositus. This nucleus is related to
archicerebellum.
RELATIONSHIP BETWEEN CEREBELLAR NUCLEI AND MEDIOLATERAL SUBDIVISIONS OF CEREBELLAR

CORTEX (FIG. 6.8)
i. Vestibular and reticular nuclei of brainstem ii. Via red nucleus to spinal cord
iii. Via thalamus to motor and premotor areas of
cerebral cortex.
It is interesting to note at this stage that fastigial
nucleus, nucleus interpositus and dentate nuclei receive afferent (Purkinje cell axons) from three components of
cerebellar cortex which are subdivided from medial to lateral as follows:
1. Medial (vermal): Cortex of vermis

2. Intermediate (paravermal): Cortex of medial half
of hemisphere
3. Lateral: Cortex of lateral half of hemisphere.
So, afferent from three mediolaterally divided portions of cortex to three phylogenetic types of cerebellar nuclei
and their efferents in three different destination are related as follows.
Cerebellar
Afferents from Efferents
nucleus
1. Vermal (medial) zone of cerebellar cortex Fastigial nucleus Fastigiovestibular tract –to vestibular nuclei
2. Paravermal (intermediate) zone of cerebellar Nucleus
Cerebellorubrospinal tract – to anterior horn cell of spinal cord
cortex interpositus
3. Lateral zone Dentatothalamocortical tract – to motor and premotor area of
Dentate nucleus
of cerebellar cortex cerebral cortex
It is already understood that cerebellar nuclei receive afferents, all of which are axons of Purkinje cells. Of
course, axons of some Purkinje cells leave cerebellum straightway to end in vestibular nuclei as cerebello-
vestibular fibers. Efferents from cerebellar nuclei pass as their axons. They go out through superior and inferior
cerebellar peduncles to –
CEREBELLAR PEDUNCLES
Superior, middle and inferior cerebellar peduncles connecting midbrain, pons and medulla oblongata with the
cerebellum respectively, are the bridges through which pass fibers to and from the cerebellum (cerebellopetal
and cerebellofugal).
Middle cerebellar peduncle is thickest and superior cerebellar peduncle is thinnest, while inferior is
intermediate.
Middle cerebellar peduncle, though thickest, is composed of afferent (cerebellopetal) fibers only which are only
the fibers of pontocerebellar tract. Superior and inferior cerebellar peduncles are composed of both afferent
(cerebellopetal) as well as efferent (cerebellofugal) fibers.
Composition of Cerebellar Peduncles
Afferent

2. Anterior external arcuate fibers: From arcuate
{
nucleus
3. Posterior external arcuate fibers: From acc-
essory cuneate nucleus (cuneocerebellar tract)
4. Par olivocerebellar tract: From medial and superior (dorsal) olivary nuclei
{
5. Olivocerebellar tract: From inferior olivary nucleus
{
6. Vestibulocerebellar tract 7. Reticulocerebellar tract
(A reader can remember t􏲄e fibers in groups as above).
Efferent
1. Cerebelloolivary tract
2. Cerebellovestibular (fastigiovestibular or fast-
igiobulbar) tract
3. Cerebelloreticular (fastigioreticular) tract.
A reader can remember three efferents as reverse of last three afferents. 137
It is composed of only afferent fibers. These fibers are pontocerebellar fibers of corticopontocerebellar pathway.
Afferent
1. Ventral spinocerebellar tract

2. Tectocerebellar tract.
Efferent
1. Dentatorubraltract:Fordentatorubrospinalpath- way
2. Dentatothalamic tract: For dentatothalamocortical pathway.
3. Ischemic: Vascular occlusive disorder, e.g. thrombosis of any of the three cerebellar arteries.
4. Degenerative: For example multiple sclerosis.
5. Neoplastic: Expanding tumors, medulloblastoma
in children.
Cerebellar Lesion – May be Compensated by Other Parts of Nervous System
Cerebellar lesions may be acute due to trauma or sudden vascular occlusion when the symptoms are severe. In
chronic lesion, like slowly expanding tumor, clinical features are less severe. But it has been seen in many cases
of the lesion, either acute or chronic, patient recovers from the clinical deficits due to compensation of cerebellar
dysfunction by other parts of nervous system.
Cerebellar Syndrome
Cerebellar syndrome is defined as combination of signs and symptoms which are manifested due to lesion of
cerebellum for any cause. Fundamental of cerebellar syndrome is motor dysfunction without motor paralysis.
Following are the two types of cerebellar syndromes.
1. Archicerebellar syndrome
2. Neocerebellar syndrome.
Depending upon the nature and extent of lesion in cerebellum, a patient may present combination or
overlapping of clinical findings of two cerebellar syndromes.
Neocerebellar syndrome presents the symptoms and signs due lesion of both paleocerebellum and
neocerebellum.
Archicerebellar Syndrome
It is due to lesion of archicerebellum which is composed of Flocculonodular lobe and lingula. It affects vermal
zone or area of vermis. That is why it is also called vermis syndrome. Commonest example is medulloblastoma
in children.
Archicerebellar syndrome is characterized by group of clinical findings which are due to disorders in
equilibrium manifested by some motor dysfunctions which are as follows.
Unsteadiness in stance: Due to impaired balance, while standing, the patient will have a tendency to fall.
He or she will try to compensate this difficulty by overcontraction of muscles of lower limb which presents
stiffed legs. The disability will also be compensated with the help of vision and the patient will stand on a broad
base with legs and feet being always wide apert. When the patient is asked to close
Cerebellum
CLINICAL ANATOMY
As cerebellum has ipsilateral control on body, lesion of one half of cerebellum leads to clinical effect on same
half of body.
To study the effect of lesion of cerebellum or cerebellar dysfunction, functions of cerebellum are to be briefly
recapitulated which are as follows:
1. Maintenance of equilibrium or balance of body
through all reflex activities and voluntary move-
ments.
2. Harmonizationofmuscletoneandmaintenanceof
normal body posture.
3. Cerebellum, though not concerned with initiation
of voluntary movements, coordinates smooth, precise movement upto right extent and range in right
direction maintaining the economy of force.
Causes of Cerebellar Lesion
1. Congenital: Hypoplasia or dysgenesis 2. Traumatic
failure to reach in right direction, upto proper extent with optimum force. The basic defect is termed as cerebellar
ataxia characterized by following manifestations.
1. Intention tremor: Tremor is defined as abnormal, undesired, repetitive oscillatory movement affecting
distal part of limbs, especially hands and fingers. In case of neocerebellar syndrome tremor is noticed when
the patient attempts or intends for finer hand movements, like picking up an object, attempts for writing or
buttoning clothes. That is why it is called intention tremor.
2. Dysmetria: This disability is due to loss of knowledge to assess the range of movement. It is elicited by
finger nose test. Patient is asked to touch the tip of nose with tip of finger. While attempting for this, either
the finger tip fails to reach tip of nose or it overshoots (pastpointing) the target. Patient suffers from loss of
harmonization of movement of different groups of muscles which results in decomposition of movements.
3. Dysdiadochokinesia: This is the effect of incoordination between antagonist groups of muscles. It is elicited
by asking the patient to perform repeated pronation and supination movements of forearm. When
attempted, it is found to occur in slow, jerky and incoordinated manner.
4. Dysarthria: This is the disorder in articulation of speech due to incoordination of muscles of larynx, tongue
and lips. During speech, two major defects are observed.
i. Use of unnatural force for muscle action.

ii. Unusual or abnormal separation of syllables
leading to slurred speech.

This disorder will have a best example when the patient is asked to pronounce the word ‘cerebellum’. Because of
disability, patient will pronounce as ‘CEH- RREH-BEH-LLUHM’.
5. Nystagmus: This disorder is the result of incoo-
rdination of movement of extraocular muscles. It is characterized by rhythmical oscillation of eyeball in an attempt

to fix the gaze (vision) for an object of interest for a longer time. Incoordination of eye movement also occurs during
horizontal side to side movement. When the gaze is returned back after horizontal movement, sudden jerk is
observed in eyeball at the end of movement.
eyes while standing, he or she will have a tendency to fall. It is known as positive Romberg’s sign.
Unsteadiness in gait: Gait is the pattern or style of walking of an individual. In archicerebellar syndrome, due
to impairment of balance, patient will sway from side to side in an attempt to maintain balance of body. This is
called staggering gait.
Unsteadiness of trunk of body: This is evident in vermis syndrome in case of children suffering from
medulloblastoma. The child will be unable to keep head erect due to imbalance of head and neck. Due to impairment
of balance of trunk, while walking, body of the patient will move to and fro forwards and backwards.
Neocerebellar Syndrome
It is the combined effect of lesion of paleocerebellum and neocerebellum.
IMPAIRED FUNCTION OF PALEOCEREBELLUM
Hypotonia: This is manifested as following –

1. Onpalpation,muscleisfoundtohavelossofresil-
ience.
2. In an attempt for passive movement of a joint,
diminished resistance by the patient is felt.
3. Musclegetfatiguedearly.Defectisknownasast-
henia.
4. During shaking of a limb, excessive movement of
terminal joints is observed due to loss of influence of cerebellum on stretch reflex.
Postural Defect
1. Head is rotated and flexed.

2. Shoulder is on a lower level – on the affected side.
Pendulous Knee Jark
In case of normal individual, normal jerky movement of knee joint is self-limited after taping patellar tendon, which
is due to normal stretch reflex under regulation of cerebellum. When influence of cerebellum on stretch reflex is lost,
a series of pendulous flexion and extension movement of knee joint occurs while knee jerk is elicited.
IMPAIRED FUNCTION OF NEOCEREBELLUM
Fundamental effect is incoordination or asynergy of smooth and precise voluntary movement with its
138
Fourth Ventricle of Brain

Fourth ventricle of brain is the cavity of hindbrain. This cavity, being a dilated part of original neural tube, is lined
by ependyma and contains cerebrospinal fluid (Fig. 7.1).
Fourth ventricle is situated behind pons and upper half of medulla oblongata and in front of cerebellum.
Shape of fourth ventricle is like that of a tent.
Walls of the cavity are following –

1. Floor: Formed by dorsal surfaces of pons and
upper part of medulla oblongata. It is flat like

ground of a tent.
2. Roof: It is made up of two slopes-like roof of a
tent. It projects toward white core of cerebellum. 3. Lateral walls, where roof meets with floor.
Morphological components: Fourth ventricle presents following three parts morphologically.
Cavity of third ventricle of brain
Fourth ventricle of brain Pons
Medulla oblongata
Central canal of lower closed part of medulla
1. Upper part: It is narrower part opposite the level of rhombencephalic isthmus.
2. Middle part: At the level of pons.

3. Lower part: At the level of upper half of medulla
oblongata.
Communications
A. With other parts of cavity of central nervous system
Above, through aqueduct of midbrain, fourth ventricle communicates with cavity of third ventricle of brain.
Below it communicates with central canal of spinal cord through narrow canal of lower closed part of medulla
oblongata.
Cerebellum Pia mater
Foramen of Magendie
Fig. 7.1 Fourth ventricle of brain seen in sagittal section

7
140
Superior medullary velum (white matter lamina) forming upper part of roof
Ependyma of inferior medullary velum forming lower half of roof
Foramen of Magendie in lower ependymal half of roof

Fig. 7.2 Upper and lower halves of roof of fourth ventricle show different nature of formation
Superior cerebellar peduncle forming superolateral boundary
Inferolateral boundary
{ Cuneate tubercle Gracile tubercle
B. With subarachnoid space (Fig. 7.2)
Cavity of fourth ventricle communicates with subarachnoid space through three apertures. One is in the
midline on lower part of roof and two are present in lateral angles. These apertures are as follows:
1. Foramen of Magendie: This is a midline foramen present in lower part of roof where it is lined by ependyma
only (see below)
2. Foramen of Luschka: They are present at the end of lateral recesses placed at lateral angle of cavity (Fig.7.4).
Recesses (Fig. 7.3)
Recesses of fourth ventricle of brain are small conical outpouching from its cavity as following.
1. Dorsalrecess:Thisistheapexofconicaltent-shaped
roof projecting into white core of cerebellum.

2. Dorsolateral recesses: These are bilateral and project dorsolaterally on either side of dorsal recess. Dorsal
recess is found to be proximal to nodule of
cerebellum, dorsolateral recesses are lateral to it.
3. Lateral recesses (Fig. 7.4): These are also bilateral which projects between inferior cerebellar peduncle
ventrally and peduncle of floccules dorsally. End of the recess presents an aperture at cerebellopontine angle.
Ventricular system communicates through this aperture with subarachnoid space which has already been
mentioned.
Boundaries of Fourth Ventricle
Lateral boundaries: One each side, it is the side where roof meets with the floor.
Caudal part is bounded by two inferior cerebellar peduncles which from lower angle, pass upward and laterally.
On either side of midline, lower angle of inferolateral boundary is formed by gracile and cuneate tubercles,
where former is inferomedial to later (Fig. 7.2). Proximal part of lateral boundary is formed by two superior
cerebellar peduncles which pass downwards and laterally from upper angle.
Dorsal recess
Dorsolateral recesses
Foramen of Luschka
Flocculus
Lateral recess
Lateral recess opening in lateral aperture–Foramen of Luschka
Fig. 7.3 Recesses of tent-shaped fourth ventricle cavity
Fig. 7.4 Lateral recess projects between inferior cerebellar peduncle (deep) and flocculus of flocculonodular lobe of cerebellum (superficial)
141
Trochlear nerve
Frenulum veli
Superior medullary velum
Ependyma
Inferior half of the roof is further thinner than superior half. It is made up of nonneural elements. This thin
lamina is called inferior medullary velum which is nothing but simple ependymal lining of the ventricle covered
on its surface by pia mater forming tela choroidea.
In the midline of upper end, dorsal surface of inferior medullary velum is related to nodule of inferior vermis of
cerebellum (Figs 7.5 and 7.6).
Lower part of inferior medullary velum present an aperture in the midline which is named foramen of
Magendie through which ventricular cavity communicates with subarachnoid space.
Lateral angle of the roof presents lateral recess which ends in lateral opening called foramen of Luschka
through which also ventricular cavity opens into subarachnoid space.
It is important to notice at this stage that cerebrospinal fluid is constantly synthesized and initially poured in
the cavity of ventricular system of brain. The fluid circulates from ventricular system into subarachnoid space
from where it is absorbed also constantly. That is why communication between ventricular cavity and
subarachnoid space through above mentioned 3 foramina in the lower ependymal part of roof of 4th ventricle is
important.
Choroid Plexus and Tela Choroidea on Roof (Fig. 7.7)
On the lower-half of roof of fourth ventricle, pia mater from cerebellum is reflected back to form double layer.
This double layered pia mater contributed by fine network of blood vessels which are branches of posterior
inferior cerebellar artery, lines over the ependyma to form tela choroidea.
Choroid plexus is formed by the highly vascular tela choroidea. It is ‘T’-shaped. Longitudinal limb of
Lingula of cerebellum
Nodule of cerebellum
Foramen of Magendie
Roof is like that of a tent. So it presents two slopes which are upper (proximal) and lower (distal). Apex of the
roof projects into the cerebellum (Fig. 7.6).
Superior half of the roof is formed by a thin lamina of white matter called superior medullary velum. It bridges
between medial margin of two superior cerebellar peduncles.
Superior medullary velum presents a thin ridge along the midline which is called frenulum veli. On either side
of frenulum, superior medullary velum is pierced by trochlear nerve emerging from brainstem.
White matter of superior medullary velum contains some fibers of tectocerebellar tract.
Caudal end of superior half of roof is related to lingula of superior vermis of cerebellum in the midline (Figs 7.5
and 7.6).
Fig. 7.5 Features of roof of fourth ventricle Roof or Dorsal Wall (Fig. 7.5)
Cavity of fourth ventricle
Choroid plexus
Tela choroidea
Olive
Pyramid
Cavity of fourth ventricle Pons
Medulla oblongata
Lingula
Cerebellum Nodule
Fig. 7.6 Upper and lower half of midline roof of fourth ventricle related to lingula and nodule of cerebellum
Fig. 7.7 Choroid plexus projecting from roof of fourth ventricle
142
Median sulcus Substantia ferrugenia
Superior fovea Stria medullaris
Sulcus limitans Inferior fovea
Funiculus seperens Obex Calamus scriptorius
Free margin of superior medullary velum
Locus coeruleus
Facial colliculus
Vestibular triangle Tinea
Vagal triangle Area postrema
Fig. 7.8 Floor of fourth ventricle (Rhomboid fossa)

‘T’ is double. The choroid plexus invaginates through ependyma lined lower-half of roof towards the cavity of
ventricle to secrete cerebrospinal fluid.
Floor or Rhomboid Fossa (Fig. 7.8)
Floor of fourth ventricle is formed by dorsal surfaces of pons and upper-half of medulla oblongata.
It is called rhomboid fossa because it is rhomboid in outline. The area is outlined superolaterally by superior
cerebellar peduncles and inferolaterally by inferior cerebellar peduncles. At the inferior angle, on either side of
midline, floor is limited by gracile tubercle and superolateral to it lies cuneate tubercle.
Whole area of rhomboid fossa is lined by ependyma, just beneath which lie different areas of gray matter, which
are more precisely some cranial nerve nuclei.
Floor of fourth ventricle is divided by a vertically running midline sulcus called median sulcus.
Each half of the floor is again subdivided into a medial part called medial eminence and a lateral part called
vestibular area by a narrower sulcus limitans. 􏲠ust above the horizontal line of pontomedullary junction,
medial eminence presents a round elevation called facial colliculus. It is so called because, efferent facial nerve
fibers from motor nucleus of facial nerve loop around abducens nucleus beneath this bulge.
Above the level of facial colliculus, sulcus limitans presents a small depression called superior fovea.
Above the level of superior fovea, sulcus limitans becomes flattened and forms lateral limit of floor of fourth
ventricle. This area is bluish gray in color and named locus coeruleus (to be pronounced –
ceruleus). Beneath this area, the group of neurons, containing melanin pigment, is called substantia ferrugenia.
These neurons are rich in noradrenaline (norepinephrine).
Lateral to sulcus limitans, rhomboid fossa presents a wide triangular area known as vestibular area or
vestibular triangle. Vestibular nuclei are situated beneath this area.
􏲠ust below the level of facial colliculus, fine strands of nerve fibers are found to pass beneath ependyma, in
mediolateral direction, from median sulcus across medial eminence towards lateral angle. These are known as
stria medullaris. These are efferent fibers from arcunate nucleus present on ventral aspect from pyramid.
These fibers initially pass in ventrodorsal direction across whole thickness of medulla oblongata to reach
rhomboid fossa, where they bend at right angle and cross the median sulcus to pass horizontally towards lateral
angle. Finally the fibers reach opposite half of cerebellum via inferior cerebellar peduncle (Fig. 7.9).
Below the level of stria medullaris, medial eminence presents a triangular area with apex directed downward.
This area is known as hypoglossal triangle beneath which lies nucleus of hypoglossal nerve.
Lateral to hypoglossal triangle, lower end of sulcus limitans presents a small depression called inferior fovea.
Below inferior fovea, lateral to apical part of hypoglossal triangle, a smaller triangular area is present with the
apex directed upward. This is called vagal triangle as beneath this area lies dorsal nucleus of vagus.
Inferolateral to vagal triangle, just above the upper end of central canal of medulla oblongata, a
2. Foramen of Magendie and foramen of Luschka in the wall of fourth ventricle permit cerebrospinal fluid to
circulate freely from ventricular system to subarachnoid space. This communication thus maintains the balance
or harmony between secretion and absorption of cerebrospinal fluid.
Tumors Adjacent to Fourth Ventricle
Very often tumors may arise in cerebellopontine angle (CP angle) which is related to cavity of fourth ventricle.
These are classically named as CP angle tumors.
Tumors may arise also from ependyma lining the floor of fourth ventricle. It is called ependymoma.
In case of children medulloblastoma is very common. It is an expanding tumor arising from undifferentiated
neuroectodermal cells of vermis of cerebellum.
These tumors presents the following effects.
1. Effectsduetocerebellarlesionwhichisfundamen- tally manifested by disorder in equilibrium or balance,

hypotonia and incoordination of move-
ments.
2. Effect due to pressure on vital centers with

143
hypoglossal and vagal triangles. It may cause disorders in cardiovascular functions, difficulty in
respiration, swallowing and movements of tongue, when the patient needs artificial life support.
Blockage of Flow of Cerebrospinal Fluid
Foramen of Magendie and foramen of Luschka may be occluded due to following reasons.
1. Obstruction by expanding tumors in the vicinity.

2. Obstruction due to fibrous adhesion in arachnoid
mater in close proximity of foramina following meningitis.

Obstruction of the foramina will interfere with
free circulation of cerebrospinal fluid from ventricular system of central nervous system to subarachnoid space.
It will lead to dilatation of ventricular system due to over accumulation of cerebrospinal fluid. It is called
internal hydrocephalus. This condition will have a pressure effect on surrounding neural tissue and finally lead
to atrophy of brain.

􏱺pendyma lining floor of fourth ventricle
Stria medullaris

Arcuate nucleus
Fig. 7.9 Formation of stria medullaris by the axons from arcuate nucleus which, after decussation, pass beneath ependyma of floor and
enter cerebellum through inferior cerebellar peduncle
narrow area is called area postrema. This narrow area contains some neurons covered by thickened ependyma.
Area postrema is separated from vagal triangle by a ridge of ependyma called funiculus seperans.
Lower angle of floor of fourth ventricle looks like a pen’s nib for which it is known as calamus scriptorius.
Following features are not parts of floor of fourth ventricle, but are closely related to it.
1. Inferolateralboundaryofrhomboidfossa,whichis
formed by inferior cerebellar peduncle is crossed
by tranverse ridge of white matter called tinea.

2. Tinea from both sides converge inferomedially towards the lower apex of fourth ventricle to form a thin fold
called obex. It forms the roof of lower
apex of fourth ventricle.
CLINICAL ANATOMY
Clinical importance of knowledge of fourth ventricle
Knowledge of fourth ventricle of brain is clinically important because–

1. Many vital centers are present in pons, medulla
oblongata and cerebellum which surround fourth ventricle cavity.
Cerebrum—Cortical Gray Matter
INTRODUCTION
Cerebrum (telencephalon) is the largest part of the brain. It is largest in size because of maximum proximalization
of various motor as well as sensory centers of human brain. It means that, during evolution, many motor and
sensory centers of central nervous system have shifted to cerebrum from lower brain.
Left cerebral hemisphere
The whole cerebrum – a sphere (Fig. 8.1): The total cerebrum, when seen from above, looks like a ‘sphere’
which is slighty broader in its posterior part. Its maximum diameter is opposite the level of an imaginary line
joining two parietal tuberosities skull. Outer gray matter and inner white matter: Superficial part of
cerebrum is made up of grayish colored neuronal cell bodies which forms gray matter.
Right cerebral hemisphere
Sulcus Gyrus
Median longitudinal fissure dividing cerebrum into two cerebral hemispheres

Cerebrum is widest a little behind the middle
Fig. 8.1 Cerebrum–Spherical in outline when viewed from above
8
This constitutes cerebral cortex. Deep inner or central core is made up of process of neurons which are whitish
myelinated nerve fibers. This component of cerebrum is called white matter or medullary substance.
Gyrus (Plural – gyri) and Sulcus (Plural – sulci) of cerebral cortex: Since fetal life cerebrum grows
within the limited volume of cranial cavity. There appears need for increase of surface area of cerebral cortex
which finally attains 2􏲠􏲠􏲠 sq cm in adult brain. That is why surface of cerebral cortex (gray matter) presents
foldings or convolutions which are called gyri (Singular – gyrus). Adjacent gyri are separated from each other by
fissures which are called sulci (Singular – sulcus). Formation of convolutions or gyri increase the surface area of
cerebral gray matter 3 times. It’s one-third is visible on the surface and two-third is hidden on the walls and
floor of sulci.
145
‘Sphere’ofcerebrumdividedintorightandleft symmetrical halves (Fig. 8.2): Spherical cerebrum is

divided into two (right and left) symmetrical halves with the help of a deep, anteroposteriorly running midline
cleft called median longitudinal fissure. This fissure completely divides the cerebrum into two halves from
anterior, superior and posterior aspect of cerebrum. Each half of the sphere of cerebrum is called thereby
‘Cerebral Hemisphere’. However, both the hemispheres are not separated from each other on the inferior aspect
where they together form the base of the brain because,
i. At the bottom of median longitudinal fissure, a curved ‘C’ shaped structure transversely running across
the midline links or connects identical areas of both cerebral hemispheres which is called corpus
callosum (Fig. 8.2).
ii. Inferiorly, both cerebral hemispheres, merging with each other, form base of the brain which is
continuous with ventral diencephalon (hypothalamus and subthalamus) and brainstem.
Medial surface of right cerebral hemisphere
CEREBRAL HEMISPHERES
Gross Surface Features
Initially cerebral hemispheres are to be studied under the heading of following gross surface features.
Poles
3 in numbers as follows (Figs 8.3 to 8.5).
1. Frontalpole:Itisthemoreroundedanteriorend of cerebral hemisphere. It lies beneath medial part
of superciliary arch of frontal bone.
2. Occipital pole: It is the more pointed posterior
end of cerebral hemisphere. This pole lies beneath occipital bone a little superolateral to
external occipital protuberance.
3. Temporal pole: It is the anteroinferior end of cerebral hemisphere. It is lodged into anterior
end of middle cranial fossa.
Embryologically, temporal pole is the posteriormost
end of developing cerebrum, which is curved ventrally during rotational growth of brain (Fig. 8.6).
Surfaces
Primarily, cerebral hemispheres presents 3 surfaces.
1. Superolateral surface (Fig. 8.3)
It is the convex and widest surface. Its convexity fits with the concavity of corresponding half of cranium.
2. Medial surface (Fig. 8.􏲠)
It is flat and corresponds to paramedian vertical plane. Most important features of this surface are–
i. Compact section through horizontally running fibers in the form of 􏲠C􏲠 shaped band with its convexity
upwards. It is corpus callosum.
Outer (superolateral) surface
Corpus callosum, a thick compact band of fibers crossing midline to connect two cerebral hemisphere
Fig. 8.2 Cerebral hemisphere (Rt) seen from medial side
146
Lateral sulcus
Frontal lobe Frontal pole
Temporal pole Temporal lobe
Central sulcus
Parietal lobe Parietooccipital sulcus
Occipital pole Occipital lobe
ii. Below corpus callosum, smooth medial surface of diencephalan (thalamus) of corresponding side.
3. Inferior surface (Fig. 8.5)
Outline of temporal pole divides this surface into two parts.
i. Anterior: It is smaller and anterior to temporal pole. It is flat and called orbital surface as it rests on the
roof of orbit formed by anterior cranial fossa of skull.
ii. Posterior: It is elongated and slightly concavo- convex lying behind temporal pole. It is called tentorial
surface because it rests on a horizontal fold of dura mater (outermost covering of brain) called
tentorium cerebelli.
Borders
Borders are to demarcate (separate) adjacent surface. These are as follows:
In total, borders are six in number. Before going to study and recognize the borders, readers are to understand
following points.
First 3 borders separate superolateral surface from medial surface (1 border) and inferior surface (2 borders).
Next 3 borders separate medial surface from inferior surface. These borders together are known as inferomedial
border.
1. Superomedial border: It separate superolateral
surface from medial surface (Figs 8.􏲠 and 8.􏲠).

2. Inferolateral border: This border separates superolateral surface from posterior tentorial part of inferior
surface. It extends from temporal pole to occipital pole (Fig. 8.5). A little in front of occipital pole, this border
presents a notch called
preoccipital notch.
3. Superciliary border: This is a small curved
border which separates superolateral surface from anterior orbital part of inferior surface (Fig. 8.5).
Fornix
Superomedial border
Corpus callosum
Septum pellucidum
Frontal pole
Superciliary border
Temporal pole Orbital
surface Inferior
}
surface
Tentorial surface
Hippocampal border
Inferolateral border
Occipital pole
Fig. 8.3 Superolateral surface of cerebrum showing poles and lobes

Occipital pole
Thalamus Temporal pole
Frontal pole
Medial orbital border
Optic chiasma
Infundibulum of pituitary Mammillary
body Posterior
perforated substance
Midbrain
Medial occipital border
Fig. 8.4 Medial surface of cerebral hemisphere
Fig. 8.5 Inferior surface of cerebral hemisphere

Superomedial border
147
Superolateral surface
Inferior surface Inferolateral border
Fig. 8.6 Borders and surfaces of cerebral hemisphere on coronal section
Medial surface
Medial border
Medial surface of cerebral hemisphere is separated from 3 components of inferior surface by following 3 borders
(Fig. 8.5).
4. Medial orbital border: It separates medial surface from anterior, frontal part of inferior surface (orbital
surface).
5. Hippocampal border: It separates medial surface from middle, temporal part (hippocampal gyrus) of
interior surface.
6. Medial occipital border: It separates medial surface from posterior, occipital part of inferior surface.
Gyri and Sulci
Gyri, so also sulci are present in human brain and brain of higher mammals. These are called gyrencephalic
brain. Cerebral cortex of lower mammals, birds and reptiles, presents smooth surface called lissencephalic
brain.
Sulci of cerebral cortex are of variable length and depth. A suclus separates two adjacent gyri (Fig. 8.7).
It has two adjacent walls and floor which are lined by layer of gray matter overlying the core of white matter.
Some important sulci
Sulci of cerebral hemisphere are many. Some are named and some are unnamed. It is not yet the stage of this
chapter to know the names of all the sulci. But it is the time to be acquainted with some of the sulci which are
important embryologically and functionally.
1. Lateral sulcus (Fig. 8.8A)
Lateral sulcus is also called fissure of Sylvius. It is most prominent sulcus recognized between temporal pole
and orbital surface from where it begins as stem. The stem passes upwards and backwards on the superolateral
surface. Immediately then, at a point known as sylvian point, it divides into 3 limbs as follows—
i. Anterior horizontal limb: 2.5 cm in length, passes horizontally forwards.
ii. Anterior ascending limb: Also 2.5 cm in length, passes vertically upwards.
iii. Posterior limb: 7.5 cm long, passes upwards and backwards. Its end is curved and directed upwards.
2. Central sulcus of Rolando (Fig. 8.8A)
On the superolateral surface, central sulcus begins by cutting superomedial border 1 cm behind the midpoint
between frontal and occipital poles. It runs downwards and forwards on the superolateral surface making an
angle of 7􏲠􏲠 with superomedial border. It ends a little above posterior ramus of lateral sulcus. 􏲠pper end of the
sulcus extends for 1–2 cm on the
Gyrus
Sulcus Gyrus
White matter
Fig. 8.7 Interrelation of gyrus and sulcus
Posterior ramus of lateral sulcus
Anterior vertical ramus
Anterior horizontal ramus
Stem of lateral
sulcus A
Central sulcus
Curved upper end of parieto􏱺 occipital sulcus
Curved upper end of central sulcus
148
Parietooccipital sulcus
Postcalcarine sulcus
Calcarine sulcus
Figs 8.8 A and B A.Some important sulci on superolateral surface, B. Some important sulci on medial surface
medial surface of cerebral hemisphere. A learner may easily identify central sulcus as it is the sulcus cutting
superomedial border. Besides, other sulci in front and behind, can easily be identified with its help.
3. Parietooccipital sulcus (Fig. 8.8B)
This sulcus is present on the medial surface of cerebral hemisphere. It starts by cutting superomedial border 5
cm in front of occipital pole and runs downwards and forwards. It ends by joining the junction of calcarine
sulcus and postcalcarine sulcus (see below).
It may extend on the superolateral surface (Fig. 8.8A).
􏲠. Calcarine and postcalcarine sulcus (Fig. 8.8B)
They are continuous with each other and present on medial surface of cerebral hemisphere. Calca-rine sulcus
starts a little behind and below the posterior end of corpus callosum (splenium). It then runs backwards with a
convexity upwards and continued as postcalcarine sulcus, where it is joined by parietooccipital sulcus.
Postcalcarine sulcus ends at occipital pole and extends slightly on superolateral surface.
Types of sulcus
According to the nature and function, sulci of cerebral cortex are classified in following types.
1. Primarysulcus(Fig.8.10):Mostofthesulciare
of primary type which are developed in embryonic life just to increase the surface area of the cerebral cortex.
2. Secondary sulcus (Figs 8.9A and 8.10): Exa- mple is lateral sulcus. Secondary sulcus is that sulcus which
is developed because of rotational growth of cerebral hemisphere around it.
3. Complete sulcus (Fig. 8.9B): This is the sulcus which is complete in depth to extend through whole
thickness of cerebral cortex and medulla to reach up to the wall of the cavity (ventricle) of cerebrum where it
produces an indentation. Example is calcarine sulcus (Fig. 8.1􏲠B) and collateral sulcus.
4. Limitingsulcus(Fig.8.9A):Thissulcuslimitsor separates two different areas in its two walls which are
different functionally as well as structurally. Example is central sulcus on superolateral surface which
separates motor area (in front) and sensory area (behind).
5. Axial sulcus (Fig. 8.9B): By nature it is just opposite to limiting sulcus. It means that, this is the sulcus
bounded by two walls which are similar functionally and also structurally. Example is
Central sulcus is an example of limiting sulcus
Lunate sulcus is an example of operculated sulcus 149
A
Lateral sulcus is an example of secondary sulcus which is developed due to rotation growth of cerebrum
􏱺all of ventricle
Postcalcarine sulcus is an example of axial sulcus
Calcarine sulcus is an example of complete sulcus
Figs 8.9A and B A.Varieties of sulcus (superolateral surface), B.Varieties of sulcus (medial surface)
postcalcarine sulcus whose both walls are primary
visual area.
6. Operculated sulcus (Fig. 8.9A): This is the
sulcus where the two lips are two functional areas and both the walls are lined by third functional areas.
Example is lunate sulcus which is a small semilunar sulcus present just in front of the occipital pole on
superolateral surface with concavity backward.
Lobes of Cerebral Hemisphere
􏲠ach of the cerebral hemisphere is divided into five lobes as i) Frontal lobe, ii) Parietal lobe, iii) Occipital lobe,
iv) Temporal lobe and v) Central lobe.
The first four lobes are incompletely separated from each other by 3 important sulci and two imaginary
lines on superolateral surface of cerebral hemisphere. The central lobe is submerged at the bottom (floor) of
stem of lateral sulcus.
3 important sulci separating the lobes on superolateral surface are – (Figs 8.3 and 8.11A)
Central sulcus
Stem of lateral sulcus and its continuation as posterior limb.
Curved upper end of parietooccipital sulcus extending on to the superolateral surface after cutting
superomedial border.
2 lines drawn on superolateral surface are (Fig. 8.11A).
A vertical line drawn from curved upper end of parietooccipital sulcus on supermedial border to preoccipital
notch on inferolateral border.
150
Primary sulci start appearing to increase surface area of cerebral cortex
Secondary sulcus appears as axis for rotational growth

Frontal lobe
Lateral sulcus
Formation of temporal lobe starts
Parietal lobe
Occipital lobe
Temporal lobe
Figs 8.10 A to C Stages of development different lobes of cerebral cortex with gradual development of primary and secondary sulci
A horizontal line extending from end of posterior limb of lateral sulcus up to the vertical line as mentioned
above.
The four lobes outlined on superolateral surface (Vide Figs 8.3 and 8.11A) are following:
1. Frontal lobe
2. Parietal lobe
3. Occipital lobe
􏲠. Temporal lobe.
Central lobe (Insula or Island of Reil) (Fig. 8.11B)
Central lobe is also called insula or island of Reil. It is situated at the bottom or floor of stem of lateral sulcus. It
is submerged and is visualized when two lips of stem of lateral sulcus are everted.
Embryological backgrounds: It is not the fifth, rather embryologically it is the first lobe of cerebral
hemisphere. Around this insula, rotational overgrowth of the cortex sequentially gives rise to formation of
frontal, parietal, occipital and temporal lobes (Fig. 8.1􏲠).
Sulci and gyri of insula (Fig. 8.11B): Whole of area of insula is surrounded by a circular sulcus. A vertical
sulcus called central sulcus of insula subdivides central lobe (insula) into anterior and posterior parts both of
which present vertical gyri. Anterior to central sulcus of insula, gyri are shorter therefore called gyrus brevis
which are 3–􏲠 in number. Posterior group of gyri are longer and 1–2 in numbers. They are called gyrus longus.
Frontal lobe
Parietal lobe
151
Temporal lobe
Occipital lobe
A
Central sulcus of insula
􏱺yrus brevis
Two lips of lateral sulcus separated to expose central lobe (insula) or island of Reil
Circular sulcus Gyrus longus
Figs 8.11A and B A. Four lobes of cerebral hemisphere, B. Central lobe (insula) of cerebral hemisphere
Operculum: Insula is hidden or overlapped by areas of frontal, parietal and temporal lobes which are called
frontal, frontoparietal and temporal opercula.
Sulci and gyri on three surfaces of cerebral hemisphere
Superolateral surface (Fig. 8.12)
On this surface, sulci and gyri can be divided according to four different lobes as follows. (Sulci and gyri of
central lobe or insula has already been described above).
Frontal lobe
1. Precentral gyrus: This gyrus is situated in front and parallel to central sulcus which limits frontal lobe
from parietal lobe. Precentral gyrus is bounded in front by precentral sulcus.
2. Superior, middle and inferior frontal gyri: These are three anteroposteriorly directed gyri, parallel to
each other, extending forward towards
frontal pole. These three gyri are situated in front of precentral sulcus and are demarcated from each other by
two anteroposteriorly directed sulci called superior and inferior frontal sulci.
3. Subdivisions of inferior frontal gyrus: Infe- rior frontal gyrus is divided into three parts by two limbs of
lateral sulcus which are anterior horizontal and anterior ascending limbs.
i. Pars orbitalis: Part of inferior frontal gyrus below anterior horizontal limb of lateral sulcus.
ii. Pars triangularis: It is the part between anterior horizontal and anterior ascending limbs of lateral sulcus.
iii. Pars opercularis: It is the part of inferior frontal gyrus between anterior ascending ramus and posterior limb
of lateral sulcus.
Parietal lobe
1. Postcentral gyrus: It is the anterior most gyrus of parietal lobe running downwards and
Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented) Superior frontal gyrus
Precentral gyrus Central sulcus
Postcentral gyrus Intraparietal sulcus
Superior parietal lobule
Parietooccipital sulcus
Supramarginal gyrus Inferior parietal lobule
152 Angular gyrus
Lunate sulcus
Upturned posterior end of postcalcarine sulcus
Inferior temporal gyrus Inferior temporal sulcus

Superior frontal sulcus Middle frontal gyrus
Inferior frontal sulcus

Anterior ascending limb
Anterior horizontal limb and stem of lateral sulcus
Posterior ramus of lateral sulcus
Superior temporal gyrus Superior temporal sulcus
Middle temporal gyrus
Fig. 8.12 Important sulci and gyri on superolateral surface of cerebral hemisphere
forwards from superomedial border. It is bounded
posteriorly by postcentral sulcus.

2. Superior and inferior parietal lobule: Rema-
ining part of parietal lobe behind postcentral gyrus is divided in upper and lower segments, called superior and
inferior parietal lobules with the help of anteroposteriorly directed horizontal sulcus called intraparietal sulcus.
3. Subdivisions of inferior parietal lobule: These are two small semilunar gyrus as follows.
i. Supramarginal gyrus: It is anterior of the two,
which caps round the upturned posterior end
of posterior limb of lateral sulcus.

ii. Angular gyrus: It is posterior of the two small
semilunar gyrus which caps over the posterior end of superior temporal sulcus.
Occipital lobe
1. Occipital pole: It is the posterior end which is cut from remaining part of occipital lobe by a small
semilunar sulcus which is convex forwards. This sulcus is known as lunate sulcus. This polar area of occipital
lobe is bisected into anteroinferior and posterosuperior lips by continuation of postcalcarine sulcus from
medial surface of cerebral hemisphere on its superolateral surface.
2. Upper and lower occipital lobules: One anteroposterior sulcus subdivides remaining parts of occipital
lobe anterior to lunate sulcus into upper and lower occipital lobule. The sulcus is known as transverse occipital
sulcus.
Another small vertical sulcus called lateral occipital sulcus runs vertically for short distance, in front of
parietooccipital sulcus. It divides upper occipital lobule into anterior and posterior parts.
Temporal lobe
1. Superior, middle and inferior temporal gyri: These are three anteroposteriorly directed gyri of temporal
lobe situated from above downwards respectively, below and parallel to stem and posterior limb of lateral
sulcus.
These three gyri are separated by two anteroposterior sulci called superior and inferior temporal sulci.
2. Transverse temporal gyri: These are two in
number. These gyri is visualized when two lips of stem of lateral sulcus are widened with fingers. They are
lateromedially directed on the superior surface of superior temporal gyrus. Anterior of two transverse temporal
gyri is known as Heschl’s gyrus.
153
Paracentral lobule Central sulcus
Isthmus Suprasplenial sulcus
Precuneus
Cuneus Parietooccipital sulcus

Calcarine sulcus Postcalcarine sulcus
Lingual gyrus
Medial temporooccipital gyrus Temporooccipital sulcus
Thalamus
Fornix
Septum pellucidum
Corpus callosum
Callosal sulcus Cingulate gyrus
Medial frontal gyrus Anterior commissure
Paraterminal gyrus
Parahippocampal gyrus
Rhinal sulcus Uncus
Collateral sulcus
Lateral temporooccipital gyrus
Fig. 8.13 Different features (with important sulci and gyri) of medial surface of cerebral hemisphere
MEDIAL SURFACE (FIG. 8.13)
Before going to study the gyri and sulci of medial surface of cerebral hemisphere, a reader must note the
following two important points.
1. Medial surface presents some prominent stru-
ctures which are other than cortical gyri.

2. Gyri and sulci are not studied in individual lobewise because some of them are continuous
from one lobe to adjacent lobe.
Structures Other than Cortical Gyri
1. Corpuscallosum:Itisa‘C’shapedcompactband of white matter (fibers) with convexity directed upwards,

present at the center of medial surface of cerebral hemisphere.
Fibers passing through all the parts of corpus callosum cross the midline and connect identical cortical areas of
all the parts of both cerebral hemispheres. This is an example of commissural fibers.
Most rostral (cephalic) part of corpus callosum is thin and directed downwards and backwards. It is called
rostrum. Next, the bend is known as genu. Behind genu the main part is known as body which ends posteriorly
into a blunt rounded end called splenium.
2. Fornix:Belowthemiddleofcorpuscallosumstarts
a white band of fibers which extends downwards
and forwards upto rostral end of corpus callosum. It is called fornix. Fibers in the fornix connect different areas
of same cerebral hemisphere and is an example of association fibers.
3. Septum pellucidum: It is a thin bilaminar membrane bridging between fornix and anterior part of corpus
callosum. Lateral to this septum lies the cavity of cerebral hemisphere (telencephalon) called lateral ventricle of
brain.
4. Thalamus: Below posterior part of corpus callosum and behind fornix, medial surface of thalamus
(diencephalon) is visible. On either side of midline, medial surface of thalamus of both cerebral hemispheres
forms lateral boundary of third ventricle of brain (cavity of diencephalon). Thalamus is continuous with
hypothalamus below and in front, and with subthalamus below and behind.
5. Anterior commissure: It is small cross section of compact bundle of commissural fibers which is situated in
front of anterior end (anterior column) of fornix.
Gyri and Sulci on Medial Surface
1. Cingulate gyrus: It is a thick curved gyrus with convexity upwards, above and surrounding the curvature of
corpus callosum.
154
It is separated from corpus callosum by callosal sulcus. Cingulate gyrus is demarcated above by cingulate
sulcus. This sulcus starts at its anteroinferior end below rostrum of corpus callosum. Its posterior end is
upturned behind upper end of central sulcus. A small limb from it extends upwards towards superomedial
border in front of central sulcus.
End of cingulate gyrus:
5. Paracentral lobule: It is another quadrangular cortical area in front of precuneus.
Boundaries:
Behind: Posterior limb of posterior upturned end of cingulate sulcus.
In front: Upturned anterior limb of cingulate sulcus.
Below: Posterior end of cingulate sulcus.
Above: Superomedial border of cerebral hemisphere.
Subdivision: Paracentral lobule is bisected by upward continuation of central sulcus on medial surface into
anterior and posterior parts. These two parts are upward continuation of precentral gyrus and postcentral
gyrus respectively on medial surface. 6. Medial frontal gyrus: It is the wide, flat and
curved gyrus on medial surface of frontal lobe starting in front of paracentral lobule, curving over the frontal
pole and ending below genu and in front of rostrum of corpus callosum.
Gyri and Sulci on Medial Surface of Temporal Lobe (Consult both Figs 8.13 and 8.14)
These gyri and sulci are continuous from medial surface to inferior surface (tentorial part) of cerebral
hemisphere which are mentioned below.
Gyri and Sulci on Inferior Surface (Fig. 8.14)
These are divided into two parts—

Gyri and sulci on inferior surfaces of occipital and temporal lobes (tentorial surface).
i.
Anterior end: It is very narrow end which is below rostrum of corpus callosum. It is called paraterminal gyrus.
ii. Posterior end: It curves round splenium of corpus callosum and ends at the posterior end of temporal lobe.
It is called isthmus.
Next group of gyri are studied from occipital pole to frontal pole.
2. Lingual gyrus: It is a curved gyrus with convexity
upwards like that of tongue, situated on lower part of medial surface of occipital pole. It is
bounded above calcarine and postcalarine sulci.
3. Cuneus: It is a triangular area of cortex bounded by parietooccipital sulcus and

postcalcarine sulcus. It is situated above posterior end of lingual gyrus.
4. Precuneus: It is the quadrangular area in front of cuneus. It is bounded behind by
parietooccipital sulcus and in front by posterior limb of curved upturned end of cingulate
sulcus. Inferiorly it is demarcated from posterior end of cingulate gyrus by superosplenial
sulcus which is a small curved sulcus posterosuperior to splenium of corpus callosum.
Olfactory sulcus Olfactory bulb
Olfactory tract Gyrus rectus
Lateral olfactory stria
Optic chiasma Infundibulum
Mammillary body
Posterior perforated substance Midbrain
Anterior Medial
Lateral Posterior
Orbital gyri }
Anterior perforated substance Uncus
Medial temporooccipital gyrus
Temporooccipital sulcus
Lateral temporooccipital gyrus Collateral sulcus
Fig. 8.14 Different features (with sulci and gyri) of inferior surface of cerebral hemisphere
Gyri and sulci on inferior surface of frontal lobe (orbital surface).
TENTORIAL SURFACE (FROM MEDIAL TO LATERAL)
1. Parahippocampal gyrus: It is anterior continuation of lingual gyrus extending from medial
surface to inferior surface of temporal lobe. This gyrus is demarcated laterally by
collateral sulcus.
Parahippocampal gyrus presents anteriorly a hook-like ending known as uncus which is

bounded outwards by a small curved sulcus called rhinal sulcus. 155
2. Medial and lateral temporooccipital gyri: As the name suggests, these two gyri extend
anteroposteriorly and parallel to each other from temporal lobe to occipital lobe. These two
gyri are separated from each other by the sulcus known as temporooccipital sulcus. Medial
of the two gyri is separated from parahippocampal gyrus by collateral sulcus.
ORBITAL SURFACE
1. Gyrus rectus: It is a thin and narrow anteroposteriorly running straight gyrus just lateral
to medial border of orbital surface. It is laterally bounded by an anteroposterior sulcus
called olfactory sulcus. It is so called because it lodges olfactory tract with its anterior
rounded end called olfactory bulb.
2. Orbital gyri: They are four in number present lateral to olfactory suclus. They are named as
per their interrelationship—anterior, posterior, medial and lateral. These four orbital gyri
are separated from each other by a ‘H’–shaped orbital sulci.
SOME IMPORTANT POINTS ABOUT CEREBRAL CORTEX
1. As per as evolution concerned, cerebral cortex indicates the highest stage of development of
human brain.
2. Phylogenetic subdivision:
a) Archicortex: In human brain, phylogenetically
it is the most primitive part of cerebral cortex. It is composed of parts of rhinencephalon

including hippocampus (parahippocampal gyrus). Therefore, archicortex covers small area
of cerebral cortex.
But in lower vertebrates, archicortex is of considerable size.
b) Paleocortex: It is intermediate in evolution. In human brain it is represented by cingulate

gyrus.
c) Neocortex: It is the major part of human cerebral cortex which is evolved latest. It is represented by 􏲠􏲠􏲠 of
human cortex.
3. Structural composition: Cerebral cortex is made up of –
i. Neurons with chain of synapses.

ii. Neuroglia.
Total number of neurons in human cerebral cortex
is 1􏲠􏲠􏲠􏲠 millions.
Neurons are arranged in stratification of layers.
Maximum number of layers are six (􏲠) in neocortex. Minimum number are three (3) in archicortex.
4. Grossfunctions:Inreferencetobothmotorcom-
mands and sensory responses, cerebral cortex posseses influence over opposite half of body.
Basic functions of cerebral cortex are as follows:

i. Perception of various sensations.
ii. Reaction or response as per perception of
sensation.
iii. To send motor commands to opposite half of
body.
iv. Various types of higher functions for mental
activities, e.g. memory, intelligence, learning, creative thinking, etc.
TYPES OF NEURONS IN CEREBRAL CORTEX (FIG. 8.15)
There are five varieties of neurons in cerebral cortex as stated below. But first two types, namely pyramidal
cells and granule cells are most important.
1. Pyramidal cells: These are so called because of
pyramidal shape. Their long axis are at right angle to the surface of cortex. In longitudinal section cells are
triangular in appearance with their apices directed towards the surface and bases face towards white matter.
Dendrites are connected to the angles. From the bases, long axons arise and pass to the depth of white matter
of cerebrum.
Types of pyramidal cells as per size.

i. Small size – 1􏲠 um (micron)
ii. Medium size – 5􏲠 um (micron)
iii. Large size – 1􏲠􏲠 um (micron). These cell group
are also called Betz cells or pyramidal cells of
Betz.
2. Granule cells: These cells are also called stellate
cells as they are small star-shaped cells with many radiating dendrites and short axon.
Diameter of cell bodies are 8 um (micron). Small cell bodies give granular appearance of the
cortex for which they are called granule cells.
3. Cells of Martinotti: These are small multipolar cells present in all the layers of cortex. Figure
8.15 shows their axons projecting towards the surface of cortex.
156
1
Gray matter layers 3 Pyramidal cell
Horizontal cell of Cajal Granule (stellate) cell
Granule (stellate) Cell
Fusiform cell
Cells of Martinotti
Betz cell
White matter
􏲠. Horizontal cells of Cajal (pronounce as cahal): The cells are fusiform in outline with the long axis of cell
body placed parallel to cortical surface. These neurons are present in all the layers of cortex.
5. Fusiform cells: Cell bodies of these neurons are spindle-shaped or fusiform in outline with their long axis
placed at right angle to the cortical surface. They are present in deeper layer of cortex and their axons
projecting towards white matter.
LAYER OF CEREBRAL CORTEX (FIG. 8.16)
Neurons of cerebral cortex are arranged in multiple numbers of stratum which varies from 3 to 6. When the
neocortex presents 6 layers, archicortex is made up of 3 layers.
From superficial to deep, six layers of the cortex are as follows—
1. Molecular or plexiform layer: It is made up of
mainly reticulum or network of nerve fibers with
intermingling horizontal cells of Cajal.
2. External granular layer: This layer is made up of granule cells or stellate cells.
Characteristic of this layer is that cells are densely packed. There is
intermingling of minimum number of fibers.
3. External pyramidal layer: It is made up of small and medium size of pyramidal cell. Long-
axis of the
cells are at right of the angle to the plane of the cortex. Apex of the cells are directed towards the surface of the
cortex and bases are directed towards the depth. Size of the pyramidal cells gradually increase from superficial
to deeper plane.
4. Internal granular layer: This layer is made up of closely packed granule cells or stellate cells. Structurally
this layer gives striated appearance because middle of this layer is traversed by band of nerve fibers. This band
is called external band of Baillarger. The cortex of this type is called striate cortex. Example of this type of
cortex is visual cortex on either lip of postcalcarine sulcus.
5. Internal pyramidal layer (ganglionic layer):
Fig. 8.15 Types of neurons in cerebral cortex
6.
This layer is made up of large pyramidal cells of Betz. Axon of this cells form corticospinal tract. Basal part of
this layer is traversed by band of horizontally running fibers called internal band of Baillarger.
Multiform layer or polymorphic cell layer: Charact- eristic of this layer are following –
i. It presents neurons of different types, size and
shape.
ii. Cells of this layer are intermingled with nerve
fibers.
iii. This cellular layer merges with white matter
deep to it.
Fig. 8.16 Different layers of cerebral cortex

157
1. Molecular or plexiform layer 2. External granular layer
3. External pyramidal layer
4. Internal granular layer
5. Internal pyramidal or ganglionic layer
6. Multiform or polymorphic cell layer
The cortical areas which show all of the above mentioned si􏲄 la􏲄ers of corte􏲄 􏲄ell􏲄defined, are called
homotypical cortex.
In heterotypical cortex, all the six layers are not e􏲄uall􏲄 defined. Even same may have less than six layers, two
main varieties of this cortex are as follows:
i. Granular cortex: In this type, granule cell layer is well-defined and pyramidal cell layer is poorly developed.
Example is sensory cortex.
ii. Agranular cortex: This cortex shows poor development of granule cell layer with well-defined pyramidal cell
layer. Example is motor cortex.
FUNCTIONAL AREAS OF CEREBRAL CORTEX
It has already been seen that cerebral cortex presents different named areas in different surface. It has also
been seen many of them are structurally different. It is the time now to note that they are functionally
different. In the year 1􏲠􏲠􏲠, Brodmann classified these areas from number 1–􏲠7 and thereby called
Brodmann’s area. It is important to note that these functional areas are not numbered serially or sequentially.
So the cortical areas are mentioned below with their names, Brodmann’s numbers and respective functions
(Figs 8.17 and 8.18).
􏱺eticulum of fibers and horizontal cells of Cajal
Densely packed granule or stellate cells
Small and intermediate pyramidal cells
Closely packed granule (stellate) cells with outer (external) band of Baillarger
Large pyramidal cells of Betz and inner (internal) band of Baillarger
􏱺ayer of neurons of various types, si􏱺e and shape inter􏱺 mingled with nerve fiber
FUNCTIONAL AREAS IN FRONTAL LOBE
Area-4 of Brodmann
Location
It is the precentral gyrus on superolateral surface of frontal lobe with its extension as anterior part of
paracentral lobule on medial surface.
It is called primary motor area (Fig. 8.17).
Functions
Area 􏲠 (primary motor area) controls or commands movements of voluntary muscles of opposite half of body
through corticospinal and corticonuclear tracts.
Different parts of the gyrus, starting from lower end to uppermost end extending to anterior part of paracentral
lobule on medial surface, controls muscle groups of different part of body.
Different areas of body are represented to the gyrus in upside down manner. It called inverted homunculus (Fig.
8.19).
On superolateral surface, from lower end to upper end, precentral gyrus (area 􏲠) controls voluntary muscles of
following regions of body in inverted order as— pharynx, larynx, tongue, face, neck, hand, forearm, arm,
shoulder, thorax and abdomen.
158
Primary motor area Premotor area 􏱺rontal eye field
Prefrontal area
Broca’s area (Motor speech area)
46
1
40
22
5
7
Primary somatosensory area
Sensory association area for stereognosis
Visual association area 􏱺rimary visual area
􏱺osterior end of postcal􏱺 carine sulcus
Supplementary motor area
Prefrontal area
44 45
32
39
19
18 17
Primary auditory area Secondary auditory area
Wernicke’s sensory speech area
Fig. 8.17 Functional areas on superolateral surface of cerebral hemisphere Paracentral lobule
42
6
8
23 9 24
11
10
􏱺rimary visual area (striate cortex)
17 17
Uncus Primary olfactory area
Muscles of perineum and lower limb are controlled by anterior (motor) components of paracentral lobule on
medial surface which is the continuation of area 􏲠.
It is interesting to note that one part of surface area of the cortex of area 􏲠 is not directly proportional to the
bulk of the muscle or area of the body it controls. Rather it coincides with the skill of the muscle group. For
example, Figure 8.19 of inverted homunculus shows that face with lips and eyeballs
coincide with comparatively wider part of precentral gyrus (area 􏲠).
28
Fig. 8.18 Functional areas on medial surface of cerebral hemisphere
Effect of lesion: Like other parts of brain, lesions of any part of cerebral cortex are mostly vascular in
origin. But it may be traumatic, degenerative or neoplastic. Lesions of area 􏲠 of Brodmann will cause loss of
function of voluntary muscles (paralysis) of opposite half of body. It is grossly manifested by paralysis of
contralateral upper and lower limbs. It is called hemiplegia.
43
41, 42
159
Fingers
Functions
Like primary motor area (area 􏲠), the premotor area (area 6) also gives rise to corticospinal and corticonuclear
fibers which project downwards from cerebral cortex. Through these projection fibers, very characteristic
function of premotor area is to produce skilled movements of voluntary muscles, whose movements are planned
or designed grossly by corticospinal and corticonuclear tracts from primary motor area.
Premotor area is called secondary motor area. Both primary (area 􏲠) and secondary (area 􏲠) motor areas are
together known as primary somatomotor area.
Frontal Eye Field (Area 8)
This area is located in the middle of middle frontal gyrus in front of area 6. It is so called because stimulation of
this area causes conjugate deviation of both eyes to the opposite side. It means that, if left sided frontal eye field
is stimulated, both eyeball will be deviated to the right side by contraction of lateral rectus muscle of right eye
and medial rectus muscle of left eye. It is called scanning movement of eyeball.
Broca’s Area or Motor Speech Area (Area 44 and 45)
Location
Most important point is to note that, this area is not located for functioning in both cerebral hemisphere. In
right handed person (about 􏲠􏲠􏲠) it is located in left cerebral hemisphere, so vice versa.
Broca’s area for motor speech is located in pars triangularis (area 􏲠5) and par opercularis (area 􏲠􏲠) of inferior
frontal gyrus.
Function
Laryngeal muscles, with the assistance of those of lips, tongue, palate are concerned with the production of
voice or phonation. Muscles causing vocalization
Fig. 8.19 Motor humunculus showing somatopical as well as proportional representation in the primary motor area of cerebral
cortex (Ref. and courtesy– W. Penfield T. Rasumussen, 1􏲠5􏲠)
Area 6, 8, 9 of Brodmann
These areas are located from behind forwards in the following gyri of frontal lobe.
1. Superior frontal gyrus
}
2. Middle frontal gyrus on superolateral surface
3. Inferior frontal gyrus
􏲠. Medial frontal gyrus – on medial surface
In all of the above 􏲠 gyri, area 􏲠, 8 and 􏲠 are located as follows:
i. Area 6 in their posterior parts

ii. Area 8 in their middle parts
iii. Area 9 in their anterior parts.
These areas are concerned with various functions which are mentioned below:
Area 10 and 11 of Brodmann
These two areas are located on medial surface of frontal pole as continuation of area 9.
Premotor Area (Area 6 of Brodmann)

Location
Premotor area is located in posterior parts of superior, middle, and inferior frontal gyri on superolateral surface
of frontal lobe. Therefore it is lying just in front of primary motor area (area 􏲠).
Effect of lesion: Motor dysfunction caused by lesion of premotor area is called apraxia which is
characterized by impairment of skillful movements of voluntary muscles, even if primary motor area is
normally functioning.
Effect of lesion: From the function of frontal eye field mentioned above, it is clear that, lesion of this area
will cause impairment of deviation of both eyeball to the opposite side. So, unopposed action of frontal eye field
of normal side will cause deviation of both eyes to the side of lesion.
Trunk
Hip
Knee
Wrist
Hand
Shoulder Elbow
Ankle
Little Ring
Toes
Middle Index
Thumb
Neck Brow
Face
Lips
Eyelid and eyeball
Z
I
Jaw
Tongue
Swallowing
160
or formation of words are under the control of Broca’s area or motor speech area (area 􏲠􏲠 and 􏲠5).
Supplementary Motor Area
Location
It is located on medial frontal gyrus in front of paracentral lobule on medial surface of cerebral hemisphere.
Function
This area is concerned with ‘toning’ of voluntary muscles for adjustment of posture of trunk and lower limb.
Prefrontal Area
Location
Prefrontal area is in anteriormost part of frontal lobe in front of premotor area and frontal eye field.
Functions
This area maintains personality of an individual through following functions:
i. Social awareness
ii. Initiative for any work
iii. Power of judgment
iv. Concentration and orientation for any work v. Emotions.
FUNCTIONAL AREAS IN PARIETAL LOBE
Area 3, 1, 2 of Brodmann
Location
It is the postcentral gyrus on superolateral surface of parietal lobe with its extension as posterior part of
paracentral lobule on medial surface.
It is called primary sensory area.
On superolateral surface, order of Brodmann’s number from above downwards and backwards are as 3, 1 and 2.
Structurally, primary sensory area is an example of granular cortex with thick population of granule cells and
less pyramidal cells.
Function
Area 3, 1, 2 (primary sensory area) receives following sensory inputs with the help of various ascending
(sensory) tracts through their relay in thalamus.
1. Exteroceptivesensations:Touch,pressure,pain
and temperature from opposite half of body.

2. Proprioceptivesensations:Vibrationsensation, sensation from muscles and joints of opposite half
of body.
Like primary motor area, contralateral half of body is represented to the primary sensory area in an upside
down manner for all the somatic sensations mentioned above. It is called inverted sensory homunculus (Fig.
8.2􏲠). Areas from where finer sensations are carried, e.g. fingers, hand, lips, tongue are represented by
proportionately larger area of postcentral gyrus.
Taste sensation (gustatory sensation) is carried to the small cortical area (area 43) which is adjacent to lower
end of postcentral gyrus.
Fig. 8.20 Sensory homunculus showing somatopical as well as proportional representation in the primary somatosensory of cerebral cortex
(Ref. and courtesy– W. Penfield and T. Rasmussen, 1􏲠5􏲠)
Effect of lesion: It will cause inability to produce speech. It is called motor aphasia. However, this patient
posseses the ability of frame the words and even write the words.
Effect of lesion: Lesion of the supplementary motor area causes hypotonia with no paralysis.
Effect of lesion: Lesion of prefrontal area is commonly due to trauma or tumor. Bilateral lesion of the area
causes degradation of personality through loss of functions as stated above. It is typically manifested by altered
social behavior which is mismatched with surroundings.
Trunk Neck Head
Shoulder Arm
Elbow
Forearm
Wrist
Hip
Leg
Hand
Toes Genitalia
Foot
Little
Ring Middle
Index
Thumb
Eye
Nose
Face
Fingers
Upper lip Lips
Lower lip
Teeth, gums and jaw Tongue
Pharynx
Intraabdominal
Effect of lesion: Lesion of primary sensory area (area 3, 1, 2) or postcentral gyrus causes loss of
exteroceptive as well as proprioceptive sensations of opposite half of body. It is called contralateral 161
hemianesthesia. It is interesting to note that, pain sensation may not be lost, as once pain fibers reach upto
thalamus, perception of this sensation is not affected.
Secondary sensory area is located in upper lip of posterior ramus of lateral sulcus just behind lower end of
postcentral gyrus (primary sensory area). This area posseses bilateral influence over pain sensation.
Sensory Association Area (Area 5 and 7)
Location
This area is located in anterior (area 5) and posterior (area 7) segments of superior parietal lobule.
Function
Sensory association area (area 5 and 7) helps an individual to recognize or identify shape, size, surface
character, texture of an object by handling but without looking at it, i.e. without help of vision. This power is
known as stereognosis.
Sensory Speech Area or Wernicke’s Speech Area (Area 22, 39 and 40 of Brodmann)
Location
There are three areas of sensory speech located adjacent to each other on superolateral surface of cerebral
hemisphere close to Broca’s area for motor speech. Like Broca’s area, these areas are located in left cerebral
hemisphere in case of right handed persons.
Area 22 is situated on posterior part of superior temporal gyrus.
Area 39 is angular gyrus and area 􏲠􏲠 is supramarginal gyrus on inferior parietal lobule. All these areas are
interconnected with each other and motor speech area (area 􏲠􏲠 and 􏲠5).
Functions
Very simply, Wernicke’s area can be compared with a dictionary. This area helps in comprehension of speech
heard and in selection of words to express ideas.
Area 22 helps in comprehension of spoken lang- uage and recognition of familiar sounds.
Area 39 is concerned with visual speech and reading.
Area 􏲠􏲠 is concerned for recognition and naming an object by tactile and proprioceptive sensation.
Lesion of area 39 causes word blindness. It is characterized by reading difficulty (alexia) and writing difficulty
(agraphia).
In case of lesion of area 􏲠􏲠, the patient suffers from inability to name an object by touching it. The defect is
named tactile agnosia.
FUNCTIONAL AREAS IN OCCIPITAL LOBE
Area 17 of Brodmann (Primary Visual Area)
Location
Area 17 or primary visual area is located in both upper as well as lower walls (lips) of postcalcarine sulcus on
medial surface of occipital lobe. This sulcus is also termed as posterior part of calcarine sulcus.
Very often this area extends around occipital pole on superolateral surface of occipital lobe, curving round
extended end of postcalcarine sulcus.
Macroscopically, cortex of primary visual area (area 17) is characterized by its thinness.
Microscopically, it is an example of granular cortex where layer IV type of cortical architecture is evident.
Further, it is traversed by fibers called ‘Stria of Gennari’. As it gives a striated appearance, the visual cortex
is also known as striate cortex.
Function
Visual cortex receives axons of last order of neurons (thalamic level) of visual pathway from lateral geniculate
body via optic radiation which is made up of corticopetal fibers of retrolentiform part of internal capsule.
Somatotopic representation with retina and visual field

Cortex of primary visual area corresponds with same half of retina (right or left) so therefore with opposite half
of visual field (left or right). For example, right visual cortex corresponds to right (temporal) half of right retina
and right (nasal) half of left retina, so left half of field of vision of both the eyes. Further, it is important
Effect of lesion: In lesion of area 22, a patient speaks without understanding what is spoken. The defect is
called word deafness or 􏲄uent ap􏲄asia.
Effect of lesion: Lesion of this area causes inability to recognize an object without help of vision. This
neurological defect is called astereognosis or tactile agnosia.
162
to note at this state that, in one side upper lip of visual cortex corresponds to upper quadrant of retina, so lower
quadrant of field of vision and vice versa.
Fibers from peripheral part of retina is related to more anterior part of both the lips of visual cortex. Fibers
from macular area of the retina (for central vision) corresponds to posterior most part of visual cortex which
extends round the occipital pole on superolateral surface of cerebral cortex.
Location
It is located on superior surface of superior temporal gyrus.
The area corresponds to inferior wall of lateral sulcus.
The specific area is called transverse temporal gyrus being two in number. Anterior one is called Heschl’s
gyrus.
Function
Primary auditory area is the cortical sensory center for hearing. Projection fibers arising from medial geniculate
body pass through auditory radiation of sublentiform part of internal capsule to end in primary auditory cortex.
Anterior of the two transverse temporal gyrus (Heschl’s gyrus) is concerned for reception of sound of low
frequency and posterior one is for sound of higher frequency.
But greater loss of hearing may be noticed in opposite ear as because medial geniculate body receives majority
of the fibers from contralateral organ of Corti with lesser number of fibers from ipsilateral side.
Secondary Auditory Area (Area 22 of Brod- mann)
Location
This area, also called auditory association area, is situated in posterior end of superior temporal gyrus,
posterior to primary auditory area.
Function
It receives inputs from primary auditory area and thalamus. Here the inputs are coordinated for inter-
pretation of auditory impulse in relation to other sensory information.
is to be recalled, frontal eye field regulates voluntary scanning of eyes which is independent of visual stimuli.
FUNCTIONAL AREAS IN TEMPORAL LOBE
Primary Auditory Area (Areas 41and 42 of Brodmann)

Effect of lesion: Occlusive disorder of posterior cerebral artery supplying medial surface of occipital lobe
may cause lesion in primary visual area. If right visual area is lesioned, it will cause loss of function of right
half of both retina, so loss of left half of field of vision of both eyes. This defect is known as homonymous
hemianopia.
Macular vision will be spared as posterior end of visual area concerned with macular vision is extended on
superolateral surface of cortex which receives its blood supply through collateral circulation with branches of
middle cerebral artery.
Areas 18 and 19 of Brodmann (Secondary Visual Area)
Location
Areas 18 and 1􏲠 are sequentially superimposed on outer aspect of area 17 and these also extends on the
superolateral surface of cerebral hemisphere.
Function
This area receives afferent inputs from 1. Area 17

2. Other cortical areas
3. Thalamus.
Secondary visual area helps an individual to recognize and appreciate the presently visualized object in relation
to past visual experience.
Occipital Eye Field
Location
In human brain, it is located in secondary visual area (areas 18 and 19).
Function
It produces conjugate deviation of both eyes to the opposite side, obviously related to visual stimuli. It
Effect of lesion: Unilateral lesion of one sided auditory area, due to occlusive vascular disorder affecting
middle cerebral artery causes partial deafness of both ears.
Effect of lesion: In case of lesion of areas 18 and 19, though it is not practicable without lesion of area 17,
the patient is unable to utilize his/her past visual experience when looking for a present object.
Cerebrum— White Matter

White matter of cerebrum are huge number of myelinated nerve fibers of different diameter with associated
neuroglial cells. It forms a compact mass situated in the central core of cerebrum deep to cortex. In contrast to the
term of cortical gray matter, white matter is referred as medullary substance. The compact bundle of fibers in white
matter may be restricted within cerebral hemisphere or may connect areas or centers outside it.
CLASSIFICATION (FIG. 9.1)
Bundles of white matter are classified into following three groups:
Association fibers
Commissural fibers 􏱺ro􏱺ection fibers
Three fundamental types of fibers of white matter of brain
1. Association fibers
2. Commissural fibers
3. Projection fibers.
Fundamental comparison among three types:
1. Association fibers are the fiber bundles which
2.
interconnect different areas of same cerebral hemisphere. But these may be restricted in one lobe or may extend
from one lobe to another.
So, these fibers do not cross midline and do not go to any subcortical centers.
Commissuralfibersinterconnectidenticalareasof two cerebral hemispheres.
So these fibers cross the midline but do not extend to any center below cerebral cortex.
Cerebral cortex
Lateral ventricle of brain Thalamus
Lentiform nucleus
Brainstem
Fig. 9.1 Fundamental types of fibers of white matter of brain

9
Corpus callosum
164
Short association fibers
Cingulum
Uncinate fasciculus
Superior longitudinal fasciculus
Cingulum
Inferior longitudinal fasciculus
3. Projection fibers, as they are so called, project from one cerebral hemisphere to subcortical centers of same
side or opposite side.
So these fibers extend beyond cerebral cortex and may or may not cross the midline.
Association Fibers (Fig. 9.2)
These kind of fibers may be shortest, just to connect adjacent gyri, so may be very superficial being just beneath
the cortex to lie on the floor of the sulcus. It may be intermediate in length. These are restricted within a lobe of
cerebral hemisphere, but cross the floors of more than one sulci. Again, it may be longest to extend from frontal
pole to occipital pole.
Broadly, association fibers are classified into following two groups.
􏱽􏱽ort association fi􏱽ers
These are restricted to one of the lobes of cerebral hemisphere. As already briefed, some of the fibers cross floor
of one sulcus to interconnect adjacent gyri. In the group of short association fibers some are longer to cross over
more than one sulci and thereby more than one gyrus. But these fibers are restricted to one lobe of hemisphere.
􏱽on􏱽 association fi􏱽ers
These fibers extend from one lobe to another in the form of bundle. They are present in the form of following
names —
1. 􏲠ncinate fasciculus
Septum pellucidum
Fornix Anterior commissure
Fig. 9.2 Association fibers of white matter of cerebrum
This is so called because, fiber bundles hook around the depth of stem of lateral sulcus. Fibers of uncinate
fasciculus form an arc, that is why also termed as arcuate fibers. Bundle of fibers connect motor speech area
(Broca􏲠s area) and orbital gyri of frontal lobe with adjacent part of temporal cortex. The fibers fan out at both
ends with compact and constricted central part.
2. Cingulum
This is the association fiber bundle of limbic system for which it is called limbic association bundle. Cingu- lum
is a long but curved bundle. It starts from cortex of medial surface of frontal lobe (below rostrum of corpus
callosum), passes beneath cingulate gyrus and then parahippocampal gyrus and spreads in adjoining part of
temporal lobe.
3. Superior longitudinal fasciculus
Considering the extent it is called frontooccipito- temporal fasciculus and is the longest among long association
fibers. It starts from anterior part of frontal lobe (frontal eye field) to area 18 and 1􏲠 of occipital lobe. Some of
the fibers further curves downwards and forwards behind insular cortex to reach temporal lobe.
􏲠. Frontooccipital fasciculus
This bundle of fibers is same as superior longitudinal fasciculus. But it is at a deeper plane and separated
165
by descending bundle of projection fibers known as corona radiata. It starts from frontal lobe and extend upto
occipital as well as temporal lobes.
5. Inferior longitudinal fasciculus
Cerebrum—White Matter
it is cut in median sagittal plane, corpus callosum is found to be curved or bent on itself with concavity looking
downwards, like the letter 􏲠C􏲠.
Length
􏲠nd to end length of corpus callosum is 1􏲠 cm.
Curvature
1. Dorsoventral curvature: With concavity facing downwards.

2. Anterior(cephalic)curvature:Cephalicorant- erior end present one anteroposterior bend
called genu.
Surface
1. Dorsal convex surface

2. Ventral concave surface.
Dorsal convex surface is covered by a thin layer of gray matter called induseum griseum. On each side of
midline, surface of this gray matter presents two fine anteroposteriorly directed fibers, called medial and
lateral longitudinal striae.
Ventral concave surface, on either side of midline, is mostly related to different parts of lateral ventricle of
brain.
Parts
From cephalic to caudal end, parts of corpus callosum
It starts from visual association area (area 18 and 1􏲠) and extend forwards to spread out to be distributed to
the whole temporal lobe.
Commissural Fibers
Commissural fibers interconnect identical or similar areas of two cerebral hemispheres. These fibers, which are
also known as interhemispheric fibers, are present in the form of bundles. The bundles are known as
commissures.
Name of important commissures – 1. Corpus callosum

2. Anterior commissure
3. 􏲠abenular commissure
􏲠. Posterior commissure
5. 􏲠ippocampal commissure.
Corpus callosum (Figs 9.3 and 9.4)
Corpus callosum is the largest and most compact bundle of commissural fibers. This thick bundle of fibers
crosses the midline across the bottom of median longitudinal fissure of brain to interconnect almost all the
identical area of two cerebral hemispheres (neop- alium). So, to separate two cerebral hemisphere, when
are the following –
1. 3.
Rostrum Body (trunk)

2. Genu
􏲠. Splenium.
Body of corpus callosum
Splenium
Inferior sagittal sinus Transverse sinus (left)
Great cerebral vein of Galen
Tela choroidea
Falx cerebri
Inferior sagittal sinus
Genu Rostrum
Lamina terminalis
Septum pellucidum
Fornix
Pineal body
Fig. 9.3 Median relations of corpus callosum
166
Cingulate gyrus
Pericallosal artery
Genu
Callosomarginal artery
Anterior cerebral artery
Splenium
Posterior horn of lateral ventricle
Inferior horn of lateral ventricle
Body or central part of lateral ventricle

Rostrum
Anterior horn of lateral ventricle
Fig. 9.4 Paramedian relations of corpus callosum
Rostrum : It is so called because, it is most rostral part of corpus callosum. It is also thinnest among the
four part and directed backwards and downwards as continued with a thin layer of gray matter called lamina
terminalis.
Relation (Figs 9.3 and 9.4):
Superiorly:Inthemidline,itgivesattachment,to septum pellucidum. On either side of midline, rostrum forms

floor of anterior horn of lateral ventricle.
Inferior: On either side of midline rostrum of corpus callosum is related to paraterminal gyrus.
Fiberinterconnecting: Fibers of rostrum interconnect cortical areas of orbital surface of two frontal
lobes.
Genu: Genu is the bend at the anterior end of corpus callosum with convexity directed forwards.
It is 􏲠 cm behind frontal pole. It is continuous below with rostrum and above with body of corpus callosum.
Important relations:
In the midline: Posterior concavity of genu gives
attachment to septum pellucidum.
LATERAL TO MIDLINE
Anterior: Genu is separated from anterior end of cingulate gyrus by pericallosal sulcus where anterior
cerebral artery divides into pericallosal and callosomarginal branches.
Posteriorly: Genu forms anterior boundary of ante-rior horn of lateral ventricle of brain.
Fiberspassingthrough:Whilethefibersofgenu cross the midline, they are horizontal or transverse. But on
either side the fibers from a 􏲠􏲠􏲠–shaped loop to reach frontal lobe. This loop with fork-like appearance is
known as Forceps minor which interconnect identical areas of both frontal lobes except orbital surface (Fig.
􏲠.5).
Body (Trunk): Body of corpus callosum is also called trunk or central part. In the midline, in between two
hemisphere, it is placed at the bottom of median longitudinal fissure (interhemispheric fissure).
Important relations:
In the midline: Superior surface is related to lower free margin of falx cerebri which lodges inferior sagittal
sinus.
Inferior surface gives attachment to septum pellucidum and posterosuperior end of body of fornix (Fig. 􏲠.3).
On either side of midline: Superior surface is related to cingulate gyrus from which it is separated by
pericallosal sulcus lodging pericallosal branch of anterior cerebral artery.
Inferior surface forms the roof of central part or body of lateral ventricle of brain (Fig. 􏲠.􏲠).
Fibers interconnecting (Fig. 9.6): Fibers passing through body of corpus callosum are better understood
in coronal section. Crossing midline
167
horizontally, fibers on either hemisphere fan out or radiate. These fibers are known as Callosal radiation. The
fibers which curve upwards and laterally interconnect two parietal lobe areas. It is called superior callosal
radiation. Again fibers passing downwards and laterally to interconnect temporal lobe area form inferior
callosal radiation.
Splenium: Splenium is the posterior end and thickest part of corpus callosum.
It is 􏲠 cm in front of occipital pole.
Parietal lobe
Temporal lobe
Fibers of genu form forceps minor
Fibers of body of corpus callosum
Fibers of posterior part of body and part of splenium form tapetum
Fibers of splenium form forceps major
Important relation:
Superiorly splenium is related to inferior sagittal
sinus and falx cerebri.

Inferiorly, in the median plane it is related to tela
choroidea of third ventricle of brain and pineal body (Fig. 􏲠.3). On either side of midline, splenium is related to
pulvinar of thalamus and tectum of midbrain.
Posteriorly splenium is related to great cerebral vein of Galen which joins with inferior sagittal sinus to form
straight sinus.
Fibers of body of corpus callosum crossing midline at the bottom of median longitudinal sulcus
Superior callosal radiation
Inferior callosal radiation
Fig. 9.5 Fibers of corpus callosum

Fig. 9.6 Fibers of body of corpus callosum forming callosal radiation (seen through coronal section of brain)
168
􏱧􏱧􏱧er􏱧o􏱧􏱧e􏱧􏱧i􏱧􏱧 fibers 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧: Transversely running fibers of splenium, crossing midline form
􏲠􏲠􏲠– shaped loop with its concavity directed backwards to connect occipital lobes of both sides. These fibers,
having fork-like appearance, form a curved bundle, known as Forceps major.
Fibers of forceps major, while passing backwards and medially along the upper part of medial wall of posterior
horn of lateral ventricle, form a bulge on the wall called bulb of posterior horn.
Some of the fibers of splenium and posterior end of trunk of corpus callosum posses different course and
destination. These fibers arch downward, backwards and laterally along the roof and lateral wall of posterior
horn and lateral wall of inferior horn of lateral ventricle to connect both sided parietal and temporal lobes. This
band of fibers is known as tapetum of corpus callosum.
􏲄linical significance of corpus callosum:

It is already known that corpus callosum links or interconnects identical areas of two cerebral hemisphere. It
is called homotopic connection. But it may link also heterogeneous areas of cerebral cortex. These areas of two
sides may be functionally similar but anatomically different. This types of connection is known as heterotopic
connection.
Interhemispheric connection for all the identical areas of both hemisphere does not functionally exist
classically through corpus callosum. Areas of midline representation only are linked to contralateral hemis-
phere. For example, somatic areas representing trunks or body are callosally linked, but areas representing
limb are not.
But it has also been seen, in case of congenital absence (agenesis) or in case where corpus callosum is bisected
surgically, each of the cerebral hemisphere becomes isolated from other. The conditions is called split brain
s􏲄ndrome in which case patient reacts in such way that he or she has two separate brains.
􏱽nterior co􏱽􏱽issure 􏱽􏱽i􏱽s 􏱽.􏱽 an􏱽 􏱽.􏱽􏱽
Anterior commissure is a compact bundle of myelinated nerve fibers crossing midline horizontally. It crosses
in front of anterior column of fornix being embedded in a thin layer of gray matter called lamina terminalis. In
sagittal section, it is oval in outline with longer vertical diameter measuring 1.5 mm.
􏱧i􏱧isio􏱧 o􏱧 fibers: On either side of midline bundle of anterior commissure splits into anterior and
posterior divisions.
Anterior limb: Fibers of anterior limb extend anterolaterally toward frontal lobe and interconnect following
identical areas of both sides.
1. Olfactory bulb
2. Anterior olfactory nucleus
Uncus
Hippocampus
Posterior bundle of anterior commissure
Anterior bundle of anterior commissure
Olfactory bulb
Olfactory tubercle
Anterior perforated substance

Anterior commissure
Fig. 9.7 Fibers of anterior commissure
3. Anterior perforated substance

􏲠. Olfactory tubercle.
Posterior limb: Fibers of posterior limb are directed posterolaterally towards temporal lobe to interconnect
–
1. Parahippocampal gyrus with
2. Anteroinferior part of temporal lobe.
Co􏱽􏱽issure relate􏱽 􏱽ineal 􏱽lan􏱽 􏱽􏱽o􏱽􏱽􏱽

169
Pineal gland or pineal body is a small sessile structure which is attached through pineal stalk to back of
diencephalon.
Pineal stalk is divided into two laminae – upper (proximal) and lower (distal). Small angular area between two
stalks form pineal recess of third ventricle of brain.
Both the laminae of pineal stalk are traversed by transversely running fibers passing through the midline from
one side of the brain to other. These are commissural fibers connecting identical areas of both sides.
Fibers passing through upper or proximal lamina of pineal stalk are called 􏲠abenular commissure.
Those of the lower or distal stalk form posterior commissure (Fig. 􏲠.8).
􏱽a􏱽enular co􏱽􏱽issure 􏱽􏱽i􏱽s 􏱽.􏱽 an􏱽 􏱽.􏱽􏱽
􏲠abenular commissure is a thin bundle of fibers passing transversely through proximal lamina of pineal stalk.
These fibers primarily interconnect neurons of Habenular nucleus of both side located in Habenular trigone.
􏲠abenular trigone is a small triangular area bounded by following structures (Fig. 􏲠.􏲠).
Medially – Pineal gland Superolaterally – Thalamus Inferolaterally – Superior colliculus
􏲠abenular nucleus receives afferent from amygdaloid nucleus and hippocampus. Some of the fibers from these
two areas of one side interconnect with identical areas of other side passing through 􏲠abenular trigone (nuclei)
and promixal lamina of pineal stalk.
Functions of 􏲠abenular nucleus and its connections in human are not clearly known.
Fiber forming Habenular commissure
Fibers forming posterior commissure
Pineal gland Proximal lamina
Habenular commissure Posterior commissure
Distal lamina
Pineal gland
Proximal lamina of pineal stalk
Distal lamina of pineal stalk
Habenular commissure
Posterior commissure
A
Fig. 9.8 Pineal gland showing two laminae of its stalk through which traverse two types of commissural fibers. A. Sagittal section of pineal
gland, B. Posterosuperior view of pineal gland
170
Thalamus
Pineal gland Superior colliculus
Inferior colliculus
Habenular commissure passing through proximal lamina of pineal stalk
Habenular trigone Habenular nucleus
Fig. 9.9 Fibers of 􏲠abenular commissure connecting 􏲠abenular nucleus
􏱽osterior co􏱽􏱽issure 􏱽􏱽i􏱽. 􏱽.􏱽􏱽􏱽
Posterior commissure is a thin bundle of fibers which cross the midline through distal lamina of pineal stalk. It
connects identical areas of both sides which are
as follows:
1. Superior colliculus
2. Pretectal nucleus.
􏱽i􏱽􏱽oca􏱽􏱽al co􏱽􏱽issure 􏱽􏱽i􏱽. 􏱽.􏱽􏱽􏱽 􏱽co􏱽􏱽issure of t􏱽e forni􏱽􏱽
As per the name, hippocampal commissure is made up bunch of fibers which interconnect hippocampal
formation of both sides. It is also called commissure of the fornix because its fibers cross the midline following
the course of fibers of posterior column of fornix.
Proximal lamina of pineal stalk
Distal lamina of pineal stal􏱺 transmitting fibers of posterior commissure
Midbrain
Fornix is a band of myelinated fibers which starts as efferent pathway from hippocampus to mammillary body
of hypothalamus. These efferent fibers start as posterior column of fornix from hippocampus and curve round
forwards and upwards where fibers of posterior column of both side meet to form body of fornix. Fibers of body
of fornix again diverge downwards and forwards as anterior column to end in mammillary body of
hypothalamus in same side. So fibers of fornix extending from hippocampus (part of cerebrum) to hypothalamus
(part of diencephalons) beyond cortex are considered as projection fibers. But fibers of hippocampal commissure,
starting from hippocampus of one side pass along posterior column of fornix upto posterior end of body. From
this level commissural fibers follow the path of posterior column of fornix of other side to reach other sided
hippocampus (consult Figure 􏲠.11).
Pineal gland
Fibers of posterior commissure connect nucleus of superior colliculus and pretectal nucleus of both sides
Superior colliculus Pretectal nucleus

Fig. 9.10 Fibers of posterior commissure
171
Posterior column of fornix
Body of fornix
Anterior column fornix
Mammillary body
Hippocampus
Hippocampus
Fibers of hippocampal commissure passing from posterior column of fornix of one side to that of other connecting hippocampal gyrus of both side
Projection Fibers
Projection fibers differ fundamentally from association and commissural fibers by the fact that, existence of
this kind of fibers are not limited within cerebral hemisphere of forebrain. These fibers are vertically disposed
in the central nervous system. These are the fibers by which cerebral cortex is connected to many centers
ranging from the level just below the cortex which are commonly termed as subcortical centers. It is clear
therefore, projection fibers connect cerebral cortex with subcortical centers in both directions. So projection
fibers are fundamentally of following two types.
1. 􏱧or􏱧i􏱧o􏱧u􏱧􏱧l fibers: These are efferent outflow from cerebral cortex to subcortical centers which are at
following level –
Corpus striatum: These are components of basal ganglia which are submerged collection of gray matter
embedded in central core of white matter of cerebrum. Fibers are called corticostriate fibers.
Thalamus: Corticothalamic fibers

Various centers in brainstem: These fibers either project to some specific nuclei, e.g. corticorubral,
corticonigral, corticopontine. Again these fibers project to motor nuclei of some cranial nerves which are called
corticobulbar or corticonuclear tract.
Anterior horn cells of spinal cord: The projection fibers are called Corticospinal tract.
2. 􏱧or􏱧i􏱧o􏱧e􏱧􏱧l fibers: These are afferent fibers
projecting into cerebral cortex from various cen-
ters. But it is important and interesting to note that fibers from any subcortical centers do not project directly
to cerebral cortex. All incoming (afferent) projection fibers initially terminate in thalamus. After relay, from
thalamus corticopetal projection fibers reach cerebral cortex.
Thalamic radiation: From the above description, it is clear that cerebral cortex and thalamus are connected
by fibers of both way directions. These fibers connecting thalamus with all the four lobes of cerebrum are called
thalamic radiations which are as follows.
1. Anterior thalamic radiation: Connecting frontal lobe.
2. Superior thalamic radiation: Connecting parietal lobe.
3. Posterior thalamic radiation: Connecting occipital lobe.
4. Inferior thalamic radiation: Connecting temporal lobe.
􏱽􏱽􏱽lo􏱽enetic classification of 􏱽ro􏱽ection fi􏱽ers
1. 􏱧ro􏱧e􏱧􏱧io􏱧 fibers o􏱧 􏱧llo􏱧or􏱧e􏱧 􏱧􏱧r􏱧􏱧i􏱧or􏱧e􏱧 and paleocortex): The fibers starts as fimbria.
Fimbria starts as a thin layer of white matter which covers ventricular surface of hippocampus. It is known as
alveus. From the alveus fibers starts as fimbria.
Fimbria of both sides increases in thickness and arch upwards and forwards beyond hippocampus,
Fig. 9.11 Fibers of hippocampal commissure

around posterior aspect of thalamus, below corpus callosum to form posterior column of fornix. Fornix ends
through its anterior column in mammillary body of hypothalamus (diencephalon).
Fornix has been discussed above in the column of hippocampal commissure.

2. 􏱧ro􏱧e􏱧􏱧io􏱧 fibers o􏱧 􏱧eo􏱧or􏱧e􏱧: Projection fibers related to neocortex connect all the four lobes of
cerebral hemisphere with various subcortical centers. These fibers are directed bothways.
Fibers connecting different lobes of cerebral hemisphere with thalamus in both direction are called thalamic
radiations.
172
All the fibers extending from wide area of cerebral cortex converge downward towards central or inner core of
white matter.
􏲠ust beneath the cortex, the convergent fibers present a radiating appearance in a fan-shaped maner called
corona radiata (Fig. 􏲠.12).
In the deeper part of white matter, the projection fibers of corona radiation find less space to pass through due
to presence of some masses of gray matter, e.g. thalamus, lentiform nucleus, caudate nucleus, etc. That is why
the projection fibers are condensed and compact. The vertically passing bundles of fibers are compressed
between thalamus and head of caudate nucleus lying medially and lentiform nucleus (shaped like biconvex
lens) laterally.
As this compact band of white matter is present as a capsule on internal (medial) side of lentiform (lens- like)
nucleus, it is called internal capsule.
INTERNAL CAPSULE (FIG. 9.13)
Internal capsule appears as a broad and compact band of white matter in horizontal section of cerebral
Corticospinal and corticonuclear fibers
􏱺rontopontine fibers
Temporopontine fibers
􏱺ro􏱺ection fibers passing through crus cerebri of midbrain
hemisphere. It presents a lateral concavity to come in contact with and thus to accommodate medial (internal)
convex surface of lentiform nucleus which presents the shape like that of a biconvex lens.
Parts of Internal Capsule
1. Anterior limb: Between lentiform nucleus laterally and head of caudata nucleus medially.
2. Posterior limb: Between lentiform nucleus laterally and thalamus medially.
3. Genu: The bend between anterior and posterior limbs.
4. Retrolenticular (retrolentiform) part: The part behind or beyond lentiform nucleus.
5. Sublenticular (sublentiform) part: The part below lentiform nucleus.
Identity of Various Fibers Passing Through Internal Capsule
1. 􏱧or􏱧i􏱧o􏱧o􏱧􏱧i􏱧e fibers: These are efferent fibers cerebral cortex which form part of corticoponto-
cerebellar pathway. Through these fibers cerebral cortex influence opposite cerebellar hemisphere. Fibers arise
from different areas of all the four lobes of cerebrum. So these are frontopontine, parietopontine, occipitopontine
and temporopontine fibers. These descending fibers relay in pontine nuclei of same side in basilar part of
pons. Then pontocerebellar fibers cross the midline and pass through middle cerebellar peduncle to contral-
ateral half of cerebellum.
Beyond corona radiata and internal capsule, while passing through crus cerebri of midbrain, differant
􏱺arietopontine fibers
Corona radiata 􏱺ccipitopontine fibers

Fig. 9.12 Projection fibers forming corona radiata adjacent to cortex, then form compact subcortical component before they reach midbrain
to be mediolaterally directed
􏱺rontopontine fibers Head of caudate nucleus
Genu Corticonuclear fibers 173
Corticospinal fibers
Thalamus
Medial geniculate body Lateral geniculate body
Anterior thalamic radiation Corticofugal fibers
Lentiform nucleus
Corticorubral fibers Auditory radiation
Sublentiform part Posterior limb
Retrolentiform part
Optic radiation
corticopontine fibers are mediolaterally directed
as follows (Fig. 􏲠.12):
1. Frontopontine 􏲠 In medial 1􏲠5th of crus cerebri

2. Parietopontine
3. Occipitopontine 􏲠 In lateral 1􏲠5th of crus cerebri
􏲠. Temporopontine }
2. Thalamic radiation: These are the fibers which
connect thalamus with four lobes of cerebral hemisphere in both directions. Corticopetal fibers of thalamic
radiation, i.e. the fibers which extend from different parts of thalamus to cerebral cortex, are the axons of last
order of neurons of various sensory pathways to terminate in respective sensory areas of cerebral cortex.
Thalamic radiations are –

Anterior thalamic radiation: It connects thalamus with frontal lobe.
Superior thalamic radiation: It connects thalamus with parietal lobe. Corticopetal fibers of superior thalamic
radiation extending from ventroposterolateral nucleus of thalamus to postcentral gyrus (area 3,2,1) of parietal
lobe carry somatic sensations from opposite half of body.
Posterior thalamic radiation: It connects metathalamus (lateral geniculate bod􏲄) to occipital lobe of
cerebrum. Corticopetal fibers of this thalamic radiation extends from lateral geniculate body to primary visual
area (area 17) of occipital lobe. These fibers bundle is called optic radiation. So optic radiation is the afferent
component of posterior thalamic radiation.
Inferior thalamic radiation: It connects metathalamus (medial geniculate bod􏲄) with temporal lobe of
cerebral hemisphere. Corticopetal fibers of inferior thalamic radiation extend from medial geniculate body to
transverse gyrus (area 􏲠1 and 􏲠2) on superior surface of superior temporal gyrus, known as auditory area.
These fiber bundle is called auditory radiation.
It is clear therefore, auditory radiation is the afferent component of inferior thalamic radiation.
3. 􏱧or􏱧i􏱧os􏱧i􏱧􏱧l fibers: These are the fibers of
motor (descending) tracts arising from motor area (area 􏲠) and premotor area (area 􏲠) of frontal lobe of cerebral
hemisphere. These are axons of upper motor neurons (􏲠MN) projecting on contralateral anterior horn cells of
spinal cord known as lower motor neurons (LMN). This bundle of fibers, as passing through the pyramidal
elevation of medulla oblongata lower down, are termed as pyramidal tract.
4. 􏱧or􏱧i􏱧obulb􏱧r 􏱧􏱧or􏱧i􏱧o􏱧u􏱧le􏱧r􏱧 fibers: These are descending (efferent) fibers from motor area of
cerebral cortex to the all motor nuclei of cranial nerves of contralateral side.
5. 􏱧or􏱧i􏱧orub􏱧l fibers: These fibers project from cerebral cortex to red nucleus of midbrain.
Fibers Passing Through Different Parts of Internal Capsule (Fig. 9.13)
Anterior limb:
1. Frontopontinefibers
Fig. 9.13 Parts of internal capsule with its fiber components
174
2. Anterior thalamic radiation Genu:
1. Corticobulbar (corticonuclear) fibers

2. Anterior part of superior thalamic radiation
􏲄osterior limb:
1. Parietopontinefibers
2. Superior thalamic radiation
3. Corticospinal fibers in the form of multiple,
compact, discrete bundles. Fibers for head-neck, upper limb, trunk and lower limb are placed in
anteroposterior order.
􏲠. Corticorubralfibers
Retrolenticular (retrolentiform) part:
1. Occipitopontinefibers
2. Posterior thalamic radiation: Corticopetal comp-
onent of posterior thalamic radiation form optic
radiation.
􏲄ublenticular 􏲄sublentiform􏲄 part:
1. Temporopontinefibers
2. Inferior thalamic radiation— Corticopetal comp-
onent of inferior thalamic radiation is auditory radiation.
Blood Supply of Internal Capsule (Fig. 9.14)
Various types of vertically running projection fibers (both efferent as well as afferent types) pass through
compact and condensed area of internal capsule. The compact band of white matter of cerebral hemisphere is
supplied by multiple sources of arteries. So vascular lesion in advanced age is very common.
Arteries supplying internal capsule are direct branches of circle of Willis lodged in interpeduncular cistern of
subarachnoid space at the base of brain. These branches are called central, nuclear or ganglionic branches,
because in addition to central white matter core of cerebral hemisphere, they supply centrally placed masses of
gray matter like caudate nucleus and lentiform nucleus which are known as basal ganglia. These central
branches are example of end arteries.
Arteries Supplying Different Component of Internal Capsule
1. Anterior part of anterior limb:

a) Striate branches of anterior cerebral artery
b) Recurrent arter􏲄 of Heubner: Branch of ante-
rior cerebral artery.
2. Posterior part of anterior limb, genu and anterior two-third of posterior limb:
a) Striate branches of middle cerebral artery.
One of the lateral striate branches is very long. which is very often subjected to be ruptured
following cerebrovascular lesion. This branch is called 􏱴􏱴arcot􏱴s arter􏱴 of cerebral 􏱴emo􏱴
rrhage.
b) Genu is also supplied by direct branch from internal carotid artery.
3. Posterior one-third of posterior limb, retrolentiform and sublentiform parts: Branches
from anterior choroidal artery.
Parent arteries
Anterior communicating artery Anterior cerebral artery
Middle cerebral artery Internal carotid artery
Posterior communicating artery Posterior cerebral artery

Basilar artery Anterior choroidal artery
RL– Retrolentiform part SL– Sublentiform part
Branches for internal capsule
Recurrent artery of Heubner
Striate branch of anterior cerebral artery
Striate branches of middle cerebral artery
Direct branch from internal carotid artery
SL
Branches from anterior choroidal artery
AL– Anterior limb G– Genu PL– Posterior limb
AL
G PL
RL
Fig. 9.14 Arteries supplying diferent parts of internal capsule

CLINICAL ANATOMY OF INTERNAL CAPSULE
In elderly persons, internal capsule is very frequently lesioned in case of cerebrovascular accidents. Most
common causes are arterial hemorrhage following atheromatous degeneration of any of the cerebral arteries
supplying internal capsule in a patient suffering from hypertension. Because of high concentration of
descending as well as ascending fibers passing through compact area of internal capsule, even a small vascular
lesion may lead to widespread motor and sensory deficit on the contralateral half of body. Pathological reason
behind this widespread lesion is not only ischemic injury to the neural tissue, but also compression by blood clot
and edema of the neural tissue.
In many cases of cerebral hemorrhage, long Charcot􏲠s artery of cerebral hemorrhage, a lateral striate branch
of middle cerebral artery, is ruptured. As this supplies posterior limb of internal capsule, corticospinal tract
fiber bundles and superior thalamic radiation carrying somatic sensory fibers are damaged. So effect will be
contralateral spastic paralysis (hemiplegia) and loss of all somatic sensation (hemianesthesia).
175
In some cases of cerebrovascular lesion retrolentiform as well as sublentiform parts are also damaged along
with posterior limb. In this case, in addition to contralateral hemiplegia following sensory deficit will be noted
on contralateral side.
1. Hemianesthesia: Loss of somatic sensation of opposite half of body due to effect on superior thalamic
radiation of posterior limb.
2. Hemianopia:Lossofoppositehalfoffieldofvision due to effect on optic radiation of retrolentiform part.
3. Hemihypoacusis: Impairment of hearing of opposite ear due to effect on auditory radiation of sublentiform
part of internal capsule.
These three kinds of sensory defects together are
known as contralateral triad.

A branch from recurrent artery of 􏲠eubner may
be responsible to supply genu of internal capsule. In such case, rupture of this branch cause lesion of
corticobulbar (corticonuclear) tract. 􏲠ffect will be supranuclear paralysis of face along with weakness of muscles
for swallowing and phonation. Lesion in genu may also cause paralysis of muscles of head- neck and upper limb
due to involvement of anterior fibers of corticospinal tract.
General Consideration
Basal ganglia are subcortical masses of gray matter inside cerebral hemisphere.
They are also known as basal nuclei.

Basal ganglia or basal nuclei are embedded in the central white core of cerebral hemisphere
(telencephalon) at the level of diencephalon.

Though basal ganglia are concerned with control of posture and voluntary movements, they do not have any
direct input or output connections with
spinal cord.
Basal ganglia are the important components of
extrapyramidal system.
Principle of Functions
Grossly, it can be stated that basal ganglia is concerned with execution of quality of movements through
maintenance of muscle tone and posture with coordination of voluntary movements. But function of basal ganglia is
actually the result of integration of neurocircuit connecting various centers of central nervous system with it.
First, basal ganglia receive afferent informations from motor as well as sensory areas of cerebral cortex, thalamus,
subthalamus, brainstem including substantia nigra.
Informations are then integrated.
Then outflow from basal ganglia passes to cerebral cortex and centers of brainstem for the following directives.
1. For initiation of gross movements of voluntary
muscles of trunk and proximal joints of the
limbs as a function of ‘extrapyramidal system’ which reciprocates function of pyramidal system concerned with
skilled and precise movements.
2. Basal ganglia exert influence on the centers for voluntary motor function through –
a) Initiation of desired movement
b) Restriction or limitation of unwanted movement c) Cessation of movement when needed.
3. As basal ganglia parallelly inhibit unwanted move-ment. It means that these centers helps in smoo-thening
of voluntary movement.
4. Basalgangliaalsoinfluencestereotypedassociated voluntary movements, e.g. swinging of arms while walking.
Components of Basal Ganglia
1. Caudate nucleus
2. Lentiform nucleus
3. Amygdaloid nucleus (body)
4. Claustrum.
Subthalamic nuclei, substantia nigra and red
nucleus are correlated and colisted with the components of basal ganglia clinically only because all these masses of
gray matter are the centers for extrapyramidal system.
Other Terminologies
Head end of ‘coma’-shaped caudate nucleus and lentiform nucleus are separated by vertically running fibers of
anterior limb of internal capsule. Anteroinferior aspects of both these nuclei are connected by a narrow band of
gray matter. This band
Basal Ganglia
10
Basal Ganglia
177
Internal capsule
Caudate nucleus
Lentiform nucleus
Striated mass of gray matter
Fig. 10.1 Connecting band of gray matter between caudate nucleus and lentiform nucleus present striated appearance as traversed by
fibers of internal capsule
of gray matter mass is traversed by some fibers of anterior limb of internal capsule, so presenting a striated
appearance (Fig. 10.1). That is why caudate nucleus and lentiform nucleus together are termed corpus striatum.
Lentiform nucleus, biconvex in outline is divided into a lateral and medial part by a thin lamina of white
matter called external medullary lamina. Lateral part is termed putamen and medial part is known as globus
pallidus. Internal medullary lamina, another thin lamina of white matter divides globus pallidus into lateral
(external) and medial (internal) parts. It is the putamen of lentiform nucleus that is connected to caudate
nucleus by intermediate band of gray matter (Fig. 10.1).
Caudatenucleusandputamenoflentiformnucleus are jointly known as striatum. Globus pallidus is simply termed

as pallidum.
Internal capsule
Head of caudate nucleus Lentiform nucleus
Amygdaloid body
Difference between striatum and pallidum
Striatum (Caudate nucleus and Putamen) Pallidum (Globus pallidus)

1. Phylogenetically newer part (Neostriatum). Phyltogenetically older part (Paleostriatum).
2. Neurons are round or spherical. Neurons are polygonal.
3. Darker in color as more vascular. Paler in color as less vascular.
4. Receptive part of corpus striatum- So receives inputs. Effector part of corpus striatum-So sends output.
Phylogenetic Classification of 􏱪asal 􏱪an􏱪lia
Phylogenetically, basal ganglia are classified as follows:

Archistriatum:Amygdaloidnucleusandclaustrum Paleostriatum: Globus pallidus
Neostriatum: Caudate nucleus and putamen.

Body of caudate nucleus
Tail of caudate nucleus
Thalamus
Fig. 10.2 Caudate nucleus with structures adjacent to it
178
Stria terminalis
Anterior horn
Head of caudate nucleus
Anterior perforated substance Hypothalamus
Amygdaloid body
Body of lateral ventricle Body of caudate nucleus
Thalamus
Caudate nucleus (Figs 10.2 and 10.3)
Caudate nucleus is ‘C’-shaped or ‘coma’-shaped mass of gray matter forming a component of corpus striatum or
striatum.
It presents curvature because it curves round thalamus and its convex side fits with concavity of cavity of
lateral ventricle (Fig. 10.3).
Parts
1. Head: Proximal, expanded and rounded end.

2. Body: Intermediate and gradually tapering part.
3. Tail:Distalanterioinferiorendwhichisconnected
to rounded amygdaloid body (nucleus).
Head of caudate nucleus is demarcated from the body

by the landmark of interventricular foramen of Monro. Head is joined below with putamen of lentiform nucleus
by a band of gray matter which is traversed by fibers of internal capsule (Fig. 10.1).
Corpus callosum
Septum pellucidum
Head of caudate nucleus forms inferolateral boundary of anterior horn of lateral ventricle (Fig. 10.4).
Body of caudate nucleus extends from head as elongated and gradually tapering part till it curves around
posterior pole of thalamus to be continued as tail.
It forms the floor of central part or trunk of lateral ventricle lateral to superior surface of thalamus. On the floor
of central part of lateral ventricle from lateral to medial are placed body of caudate nucleus, stria terminalis,
thalamostriate vein and superior surface of thalamus (Fig. 10.5).
Tail of caudate nucleus is the long and narrow continuation of body around posterior end of thalamus.
Following the curve of lateral ventricle, tail is related to roof of inferior horn of the ventricle. It ends at its
anterior extremity being attached to amygdaloid body (nucleus) (Fig. 10.3).
Cavity of anterior horn of lateral ventricle
Rostrum of corpus callosum
Fig. 10.3 Caudate nucleus with related structures
Fig. 10.4 Head of caudate nucleus forming inferolateral boundary of anterior horn of lateral ventricle (coronal sectional view)
Thalamus
Amygdaloid body

179
Basal Ganglia
Lentiform nucleus (Fig. 10.6)
It is so called because this mass of gray matter looks like a biconvex lens in outline, as evident both in cross
section as well as in coronal section.
Medial surface of the nucleus presents more acute cervature, whereas its lateral surface is uniformly curved.
Inferiorly, lentiform nucleus merges with gray matter of base of brain at the site of anterior perforated
substance.
Capsules of lentiform nucleus
Both the medial as well as lateral surfaces are covered by capsules made up of band of white matter. Medial
surface is covered by thick compact internal capsule and lateral surface is covered by thinner lamina of white
matter, called external capsule. Lateral surf-
Internal capsule Fornix
Internal ventricle Thalamus
ace, outside the capsule is related to lateral striate branches of circle of Willis which pierce the capsule to supply
the nuclear mass.
Subdivisions of lentiform nucleus
Primarily, a thin lamina of white matter, called external medullary lamina subdivides lentiform nucleus into
lateral part called putamen and medial part, globus pallidus. Globus pallidus is again divided into medial
(internal) and lateral (external) parts by another thin sheet white matter called internal medullary lamina.
Relations of lentiform nucleus
Medial: On medial side lentiform nucleus is separated from head of caudate nucleus and thalamus by
compact band of fibers of internal capsule.
Fig. 10.5 Caudate nucleus viewed from above with related structures
Caudate nucleus (head)
Putamen
Globus pallidus
Claustrum Insula
Extreme capsule External capsule
Fig. 10.6 Coronal section of brain to show lentiform nucleus with other components of basal ganglia and related structures
180
Stria terminalis
Septal area
Ant. perforated substance Amygdaloid body
Olfactory bulb
Olfactory tract
Anterior Hypothalamic nuclei
Lateral: From medial to lateral, lateral surface of lentiform nucleus is related to following structures. 1.
External capsule
2. Claustrum
3. Extreme capsule
4. Insular cortex at the floor of stem of lateral sulcus. Inferior: Below, lentiform nucleus merges with
cortical area of base of brain forming anterior perforated substance.
Amygdaloid body (nucleus) (Fig. 10.7)
Identity and location
Amygdaloid body or amygdaloid nucleus is an almond- shaped mass of gray matter attached to the tip of tail of
caudate nucleus. It is located deep to uncus of temporal lobe and related to anterior most end of roof of inferior
horn of lateral ventricle (Fig. 10.3).
Connections
Afferents: From olfactory bulb via olfactory tract and from primary olfactory area.
Efferent: Efferent fibers start from amygdaloid nucleus in the form of a curved fibrous band which runs
around the curve of thalamus following reverse course of, and parallel to curve of caudate nucleus. It is called
stria terminalis. Reaching close to anterior commissure and anterior pole of thalamus, stria terminalis ends
in—
i. Septal area
ii. Anterior hypothalamic nuclei iii. Anterior perforated substance.
Functions
Developmentally, so anatomically amygdaloid body is a component of archistriatum (basal ganglia).
But functionally it is considered to be part of limbic system.
Very simply, it can be stated that amygdaloid body help to adjust emotion and behavior of an individual
according to the environmental situation. Amygdaloid body is concerned with feeling and expression of fear, rage
and irritability. The nucleus functions for limitation for interest for intake of food and sexual activity.
In a patient suffering from highly aggressiveness, bilateral destruction of amygdaloid body result in— 1.
Decreased aggressiveness with change in docile
attitude.
2. Decreased emotional instability and diminished
restlessness.
3. Increased interest for food.

4. Increased sexual activity.
Claustrum (Fig. 10.6)
Claustrum is a thin, curved and wavy sheet of gray matter which is well demonstrated in cross section of
cerebrum.
It is situated lateral to lentiform nucleus from which it is separated by external capsule.
Laterally claustrum is related to insular cortex, but separated by extreme capsule.
Developmentally, claustrum is a component of archistriatum.
Connections and functions of claustrum are not known.

Connections of corpus striatum (Fig. 10.8)
Fundamentals of connections of corpus striatum are to be understood first. Neostriatum (caudate nucleus and
putamen) receive inputs from various parts of central nervous system. Informations are then
Olfactory stria
Fig. 10.7 Amygdaloid body and its connections
Basal Ganglia
Motor and sensory areas of cerebral cortex
Glutamate
Thalamus
Corpus striatum
Globus pallidus
Thalamus
GABA
pamine
Serotonin
Do-
GABA, Substance p, Acetylcholine

Substantia nigra
Brainstem
integrated. Next, directives are sent to palleostriatum (globus pallidus) which sends output.
􏱧􏱧􏱧ere􏱧􏱧 fibers 􏱧􏱧o 􏱧eos􏱧ri􏱧􏱧u􏱧􏱧 􏱧 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧:
1. 􏱧or􏱧i􏱧os􏱧ri􏱧􏱧e fibers: Fibers from each part of
motor as well as sensory areas of cerebral cortex project to a specific part of caudate-putamen complex. The fibers
are mostly ipsilateral. Maximum number of inputs are from motor and sensory cortex.
Neurotransmitter is glutamate.
2. 􏱧􏱧􏱧l􏱧􏱧os􏱧ri􏱧􏱧e fibers: These fibers originate
from intralaminar nuclei of thalamus.

3. Ni􏱧ros􏱧ri􏱧􏱧e fibers: Neurons of substantia nigra sendaxonswhichendincaudatenucleusandputamen
to release dopamine which is inhibitory in function. 4. 􏱧s􏱧e􏱧􏱧i􏱧􏱧 fibers 􏱧ro􏱧 br􏱧i􏱧s􏱧e􏱧 􏱧􏱧􏱧 s􏱧i􏱧􏱧l cord:
From different centers of brainstem other
Spinal cord
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Connections of corpus striatum
181

than substantia nigra, fibers ascend to neostriatum to liberate serotonin which is also inhibitory in function.
Similar functional fibers also ascend from spinal cord.
􏱧􏱧􏱧er􏱧o􏱧􏱧e􏱧􏱧i􏱧􏱧 fibers 􏱧􏱧􏱧rio􏱧􏱧lli􏱧􏱧l fibers􏱧 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧: These fibers pass from neostriatum
(caudate nucleus and putamen) to pallidum (globus pallidus).
Neurotransmitter released by these fibers are Gamma-aminobutyric acid (GABA). Some of the fibers from
caudate nucleus – putamen complex pass back to substantia nigra. Neurotransmitters released from these
fibers are GABA or acetylcholine.
182
􏱧􏱧􏱧ere􏱧􏱧 fibers 􏱧􏱧􏱧lli􏱧o􏱧u􏱧􏱧l fibers􏱧 􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧: After the informations (inputs) from different
centers of central nervous system are received and integrated
in corpus striatum (caudate nucleus and putamen), these are channelled to globus pallidus. Globus pallidus
then influences activities of motor areas of cerebral cortex and other motor centers in brainstem. Globus
pallidus influence directly to brainstem centers. But cerebral cortex, so also spinal cord are influenced indirectly
through thalamus. So direct pallidofugal fibers are to –
1. Thalamus
2. Subthalamus
3. Brainstem tegmental centers.
􏲄􏲄ese pallidofugal fiber are as follo􏲄s—
Ansalenticularis(Fig.10.9A):Thesepallidofugal fibers loop around posterior limb of internal capsule to
reach ventroanterior and ventrolateral nuclei of thalamus.
Putamen
Globus pallidus
Posterior limb of internal capsule Ansa lenticularis
Internal capsule
Subthalamic fasciculus
Globus pallidus Putamen
Putamen
Globus pallidus
􏱺allidotegmental fibers Tegmentum of midbrain
Caudate nucleus
Fasciculus lenticularis
Thalamus
Thalamus
Subthalamic nucleus
Figs 10.9A to C Some of the pallidofugal fibers. A. Ansa lenticularis and fasciculus lenticularis (Pallidothalamic fibers), B. Subthalamic
fasciculus, C. Pallidotegmental fibers
Fasciculus lenticularis (Fig. 10.9A): These fibers also reach the same nuclei of thalamus, but traversing
through posterior limb of internal capsule. Subthalamic fasciculus (Fig. 10.9B): These pallidofugal fibers
connect subthalamic nucleus in both directions. Subthalamic nucleus is a small mass of gray matter which presents
biconvex appearance in coronal section. It is located caudal to thalamus and inferomedial to globus pallidus from
which it is separated by fibers of internal capsule. Subthalamic fasciculus connect globus pallidus with subthalamic
nucleus in both directions. The fibers of the fasciculus traverse internal capsule.
􏱧􏱧lli􏱧o􏱧e􏱧􏱧e􏱧􏱧􏱧l fibers 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧􏱧: These fibers descend from globus pallidus to motor centers
situated in tegmentum of brainstem.
Basal Ganglia
CLINICAL ANATOMY
Disorder of function of basal ganglia results from lesion in basal ganglia. Lesion of basal ganglia may be vascular in
orgin or due to genetic disorder, less commonly may be infective or degenerative.
Lesion of basal ganglia is clinically characterized by two general types of disorders.

Hyperkinetic disorder: Showing excessive abnormal involuntary movements as seen in chorea, athetosis and
ballism (ballismus).
Hypokinetic disorder: Presenting slow and sluggish abnormal involuntary movements.
Parkinson disease is characterized of course, by both types of disorders.
CHOREA
The patient of chorea presents nonrepetitive irregular, quick and jerky movements.
Swift and sudden movements of head and limbs are good examples which exhibits typical dancing gait.
Two different forms of choreiform disease are as follows.
Huntington Disease (Huntington Chorea)
It is an autosomal dominant inherited disease due to single gene defect on chromosome 4. Onset of disease is in
adult life. Prognosis is bad as death occurs by 15– 20 years after onset. Males and females are equally affected.
At the onset muscles of limbs and face are affected. This results in choreiform movements with twitching of face
characterized by facial grimacing. Later on more muscles are affected. So patient ultimately becomes confined and
swallowing and speaking become difficult.
Sydenham Chorea
This disorder is infective in origin. Children suffering from rheumatic fever due to streptococcal infection are
affected. Streptococcal antigen attacks the neurons of basal ganglia. The disease is characterized by rapid
involuntary and irregular movements of limb, trunk and face which is characterized by choreiform movements.
However, prognosis of the disease is good as patient gets a full recovery.
BALLISMUS
It is the disorder caused due to vascular lesion of subthalamic nucleus.
Subthalamic nucleus functions for integration of smooth movements of different parts of body. Ballismus due to
lesion in subthalamic nucleus is characterized by small strokes of sudden outburst of violent involuntary movements
affecting trunk, girdle and proximal part of limb of opposite half of body. Usually both upper as well as lower limbs
of contralateral side are affected, for which disorder is known as hemiballismus. If restricted to one limb, it is called
monoballismus.
ATHETOSIS
This is a degenerative disease of globus pallidus. Degeneration of neurons of globus pallidus leads to ‘breakdown’ of
neurocircuit, globus pallidus– thalamus–cerebral cortex. The disorder is characterized by slow, sinuous writhing
movements of distal part of limbs affecting muscles of fingers and toes.
PARKINSON DISEASE
Parkinson disease is also known as Parkinsonism or paralysis agitans.
It is a progressive degenerative disease of unknown cause.
The disease starts between the age of 45 years to 55 years. It is the result of degeneration of neurons of substantia
nigra and to a lesser extent, those of globus pallidus, putamen and caudate nucleus.
Substantia nigra contains melanin pigment containing neurons. These neurons release dopamine through their
axons (nigrostriate fibers) to corpus striatum. Dopamine exerts inhibitory effect on striatal neurons. So, reduction of
dopamine due to lesion of neurons of substantia nigra causes loss of inhibitory effect on function of neurons of corpus
striatum. Clinically it is characterized by Release phenomenon.
Patient of Parkinson disease presents following clinical manifestations.
183
184
1. Tremor: This is repetitive alternating, involuntary movement of agonists and antagonists of limbs. This
movement is observed in resting condition of patient and disappears when he or she performs a voluntary
movement. That is why it is called static tremor or resting tremor. It is to be remembered here that, patient
of cerebellar disease present intention tremor which is observed when the patient intends to perform a
movement.
2. Hypokinesia:Parkinsondiseaseischaracterized by combination of both hyperkinetic and hypokinetic

disorder. Tremor is a manifestation of hyperkinetic disorder. In Parkinson disease features of hypokinesia are
also observed. Akinesia is lack of initiation of movement. Bradykinesia is slowness in performance of movement.
Face is found to be expressionless. Voice is slurred and its modulation is absent. While walking, swinging of
arm is absent.
3. Rigidity: Rigidity of muscles is elicited by passive movement of a joint, when a resistance is felt. Unlike
rigidity in pyramidal tract lesion, in
Parkinson disease rigidity is present in opposing muscle groups to an equal extent. Again nature of rigidity
varies depending upon presence or absence of tremor. If tremor is present, uniform and sustained resistance
during passive movement of limb joint is overcome by a series of jerky movement. Resistance and jerky
movement occurring alternately is like movement of cogwheel of a watch. That is why it is called ‘Cog-wheel
rigidity’. In absence of tremor, uniform and sustained resistance during passive movement shows plastic
rigidity on lead-pipe rigidity.
4. Postural disorder: Patient of Parkinson disease presents a stooping 􏲄for􏲄ard bend􏲄 posture with knee and
elbow joints flexed partially which are due to rigidity of muscles of trunk and limbs respectively.
5. Disorder in gait: Patient walks slowly in short steps and may run to maintain balance and may be unable
to stop when starts walking which is due to loss of limitation of voluntary movement. The typical style of
walking is called s􏲄uf􏲄ing gait.
Lateral Ventricle of Brain
Lateral ventricle of brain is the cavity of telencephalon. So it is the cavity of ventricular system present in cerebral
hemisphere.
Lateral ventricles are two in number, right and left, present inside the respective cerebral hemisphere.
Lateral ventricle presents ‘C’-shaped curvature with a short variable posterior prolongation (Fig. 11.1). The
concavity of the ventricle curves round thalamus and caudate nucleus. Central parts of the ventricles of both sides
are just paramedian in position where they are separated by a midline septum called septum pellucidum.
Parts of Lateral Ventricle (Fig. 11.2)
Lateral ventricle presents four parts. Each of the four parts of the ventricle coincides with the position of four lobes
of cerebral hemisphere.
Interventricular foramen of Monro
Third ventricle Cerebral aqueduct of Sylvius
Fourth ventricle Central canal
1. Anterior horn – in frontal lobe

2. Central part of body – in parietal lobe 3. Posterior horn – in occipital lobe
4. Inferior horn – in temporal lobe.
Out of three horns, inferior horn is largest. Poste- rior horn is not only smallest, it is also variable and very often
asymmetrical in two sides.
Ventricular System (Fig. 11.3)
Ventricles of brain are developmentally derived from cavity of neural tube. Ventricles are four fluid- filled cavities
located inside different parts of brain. They are intercommunicating with each other and other parts of cavity of
central nervous system. The ventricles are therefore lined with ependyma and contain cerebrospinal fluid.
Ventricles are four in number.
Anterior horn
Central part Inferior horn
Posterior horn
Lateral ventricle
Fig. 11.1 Two lateral ventricles in superior view with other parts of ventricular system
11
Anterior horn
Central part or body
186
FL
PL
OL
Inferior horn
Third ventricle

Central canal of lower half of medulla oblongata
Central canal of upper end of spinal cord
Posterior horn
Body of lateral ventricle
Fourth ventricle
Fig. 11.2 Parts of lateral ventricle in relation to four lobes of cerebral hemisphere
TL
1. Lateralventricle:Twoinnumber,rightandleft, present on either side of midline. They are cavities of

telencephalon (cerebral hemisphere).
2. Third ventricle: Narrow, single midline cavity of diencephalon, situated between the thalamus of two sides.
Superiorly, on either side of midline it communicates with lateral ventricle through interventricular foramen of
Monro.
3. Fourth ventricle: It is the cavity of rhombencephalon (hindbrain) located between cerebellum behind, and
pons and medulla oblongata in front. Cavity of fourth ventricle communicates with third ventricle above
through aqueduct of midbrain (of Sylvius), and with narrow central canal of spinal cord through central canal of
lower-half of medulla oblongata below. Lower part of ependymal roof of
Fig. 11.3 Lateral ventricle inrelation to complete ventricular system

fourth ventricle presents foramen of Magendie in the midline, and foramen of Luschka on either side, through
which ventricular cavity communicates with subarachnoid space. Choroid plexus of ventricles liberate
cerebrospinal fluid which freely circulates in subarachnoid space through foramen of Magendie and foramen of
Luschka. Constant secretion of cerebrospinal fluid is balanced by its constant absorption by arachnoid
granulations projecting in intracranial venous sinus from arachnoid mater.
Different Parts of Lateral Ventricle
Anterior horn
It is the anterior most part of lateral ventricle projecting into frontal lobe. Its anterior end is blind and
posteriorly it becomes continuous with central part or body of lateral ventricle at the level of interventricular
foramen of Monro.
Genu of Corpus callosum
Rastrum of Corpus callosum
Boundaries
Anteriorly: Anterior horn is limited by posterior surface of genu of corpus callosum (Fig. 11.4A).
Posteriorly: Anterior horn is continuous with central part of lateral ventricle (Fig. 11.4A). 187
Superiorly: Roof is formed by inferior surface of anterior part of body of corpus callosum (Fig. 11.4B).
Inferiorly: Floor of anterior horn is formed medially by superior surface of rostrum of corpus callosum and
laterally by head of caudate nucleus (Fig. 11.4B).
Medially: Septum pellucidum intervens anterior horn of both sides.
Central Part or Body
Central part or body of lateral ventricle coincides with the position of central core of parietal lobe below central
part (trunk) or body of corpus callosum.
Extent: From the landmark of interventricular foramen of Monro to the level of splenium of corpus
callosum.
Body of Corpus callosum

Fig. 11.4A Lateral ventricle is sagittal section. Anterior horn is bounded by body, genu and rostrum of corpus callosum superiorly,
anteriorly and inferiorly respectively
Septum pellucidum
Cavity of anterior horn of lateral ventricle
Rostrum of corpus callosum

Fig. 11.4B Boundaries of anterior horn of lateral ventricle on coronal section
Communications: Central part of lateral ventricle communicates with all the three horns of lateral
ventricle.
Anteriorly: With anterior horn infront of interventricular foramen of Monro.
Posteriorly: Beyond (posterior to) splenium of corpus callosum, central part of body communicates with
188 posterior horn.
Inferiorly: Below splenium, central part communicates anterioinferiorly with inferior horn.
Besides, it has alread been learnt that junction of anterior horn and body of lateral ventricle communicates
with third ventricle through foramen of Monro.
Boundaries (Fig. 11.5)
Central part or body of lateral ventricle is triangular on coronal section having following walls.
Medial wall is formed by a thin bilaminar membrane which is vertically suspended in midsagittal plane from
undersurface of corpus callosum. It is called septum pellucidum. Lower margin of septum pellucidum is
attached to superior aspect of body of fornix.
Floor is formed by the following structures from lateral to medial direction.
1. Body of caudal nucleus

2. Stria terminalis
3. Thalamostriate vein
4. Superior surface of thalamus which is covered by
fringe of choroid plexus.

Superolateral wall is arched downwards and late-
rally forming roof as well as lateral wall. It is formed by mediolateral concavity of undersurface of body of
corpus callosum.
Coronal section through body of corpus callosum
Septum pellucidum Fornix
Fissure between thalamus and fornix for invagination of tela choroidea
Cavity of third ventricle
􏲄􏲄oroid fissure is a curved slit seen from medial side of cerebral hemisphere. It is between inferior aspect of
body of fornix and superior surface of thalamus.
Tela choroidea: A thin layer of ependyma projects through the choroid fissure over the superior surface of
thalamus to carry a fringe-like fine network of blood vessels to form choroid plexus. Tela choroidea carrying the
network of choroid plexus invaginating ependyma through choroid fissure is common for the lateral ventricles
and third ventricle (Fig. 11.6).
Posterior horn (Fig. 11.7)
Posterior horn is a small backward prolongation from body of lateral ventricle to the occipital lobe of cerebral
hemisphere.
It can be considered as backward continuation of central part of body beyond splenium of corpus callosum.
Variations
1. Posterior horn may be absent in any side.

2. Ifpresentinbothsides,itmaybeasymmetricalin
size.
Posterior horn project backwards bisecting the fibers of splenium and posterior end of body of corpus callosum.
That is why it is smallest among three horns and its walls are minimum. The walls are inferomedial and
superolateral.
Inferomedial wall is also considered as medial wall. This wall presents two bulges towards the cavity. Upper
bulge is called bulb of posterior 􏲄orn which is raised by the fibers of forceps major running
Cavity of central part or body of lateral ventricle
Thalamus
Hypothalamus
Fig. 11.5 Boundaries of central part or body of lateral ventricle
189
Tela choroidea for lateral ventricle
Choroid plexus of third ventricle

Choroid plexus of lateral ventricle
Fig. 11.6 Common invagination of tela choroidea for lateral as well as third ventricles
Forceps major
Calcarine sulcus
Optic radiation
Tapetum
Bulb of posterior horn
Calcar avis
backwards from splenium of corpus callosum. Lower elevation is caused due to invagination of calcarine sulcus
which produces indentation in the inferomedial wall of posterior horn called calcar avis. That is why calcarine
sulcus is an example of complete sulcus.
Superolaterally, posterior horn is bounded by posteriorly running fibers of body of corpus callosum. It is called
tapetum which separates ventricular wall from optic radiation.
Inferior horn
Inferior horn of lateral ventricle is the largest among three horns.
It projects into the temporal lobe curving downwards and forwards around posterior end of thalamus from the
junction of body and posterior horn.
Triangular area of junction of body, posterior horn and inferior horn is known as collateral trigone which is
widest area of the ventricular cavity.
Inferior horn roughly corresponds to the level of superior temporal sulcus.

Fig. 11.7 Boundaries of posterior horn of lateral ventricle
In coronal section, inferior horn looks like a concavo- convex transverse slit presenting a roof and floor.
Roof
Roof is convex in outline. Its medial part is related to stria terminalis and tail of caudate nucleus
mediolaterally positioned. Lateral part of roof is formed by tapetum of corpus callosum which are the fibers
arching backwards from splenium and posterior end of body. Anterior end of roof is also related to amygdaloid
body attached to the tail of caudate nucleus.
Outside tapetum, fibers of optic radiation are superimposed.
Floor
Lateral part of floor presents an elevation called collateral eminence which is the indentation caused by bottom
of collateral sulcus, which is an example of complete sulcus of cerebral cortex.
Medial part of floor is formed by 􏲄ippocampus which is a mass of gray matter. Anterior end of hippocampus
2. Communicating hydrocephalus: In this variety, there is no blockage anywhere between site of formation and
exit of cerebrospinal fluid from ventricular system to subarachnoid space. So it is the effect of either overproduction
or impaired absorption of fluid.
Causes of Hydrocephalus
1. Abnormal increase in formation of cerebrospinal fluid is a rare condition which occurs in case of tumor of
choroid plexus.
2. Blockage in circulation of cerebrospinal 􏱧ui􏱧– Obstruction may be at different level leading to
different types of manifestations.
a) Tumor adjacent to interventricular for-
amen of Monro: It will cause unilateral obst􏲄 ruction of lateral ventricle of one side leading to its
dilatation. It will ultimately cause atrophy of surrounding neural tissue.
b) Obstruction anywhere beyond interventricular foramen, e.g. in third ventricle, cerebral aqueduct
or foramen of Magendie and foramen of Luschka will cause s􏲄mmetrical distension of bot􏲄 lateral ventricles
along with distension of t􏲄ird ventricle.
Obstruction of foramen of Magendie and foramen of Luschka may occur due to e􏲄panding tumor or
in􏲄ammator􏲄 e􏲄udate, e.g. in case of meningitis.
3. 􏱧􏱧􏱧􏱧ire􏱧 􏱧bsor􏱧􏱧io􏱧 o􏱧 􏱧erebros􏱧i􏱧􏱧l 􏱧ui􏱧 through arachnoid granulations may be due to

following causes.
a) Inflammatory exudate
CLINICAL ANATOMY
Ventricular system so also subarachnoid space contain normally an optimum quantity of cereb-rospinal fluid due to
balance maintained between its secretion by choroid plexus of ventricles and absorption by arachnoid granulations
in subarachnoid space. In pathological conditions there may be overaccumulation of cerebrospinal fluid which is
known as hydrocephalus. Hydrocephalus is associated with raised intracranial pressure.
Varieties of Hydrocephalus
1. Noncommunicating hydrocephalus: In this case, blockage in flow of cerebrospinal fluid may be at any point
between its formation at choroid plexus and its exit from ventricular system through the foramina at the roof of
fourth ventricle.
190
Tela choroidea
Fimbria Hippocampus
Dentate gyrus
Stria terminalis
Tapetum
Collateral eminence
Alveus
is expanded and slightly furrowed at its anterior end which is called pes 􏲄ippocampus. Ventricular surface of
hippocampus is covered by a thin layer of white matter called alveus. Alveus is formed by axons of the neurons
present in hippocampus. The axons converge on the medial side of hippocampus to form a band of white matter
called fimbria. Fiber bundle of fimbria is continuous posteriorly as posterior column of fornix.
Choroid fissure
Choroid fissure of the inferior horn is a slit on medial side in the interval between stria terminalis of roof and
fimbria of the floor. Choroid plexus of lateral ventricle turns round posterior end of thalamus to invaginate
ependyma through choroid fissure of inferior horn from medial side.
Fig. 11.8 Boundaries of inferior horn of lateral ventricle
Collateral sulcus
i. Expanding tumor
ii. Intracerebral hemorrhage which may be ext-
radural, subdural or intracerebral.

Lesion in one side will cause deviation of brain with lateral ventricle to the opposite side which
neurologically termed as ‘midline s􏲄ifting’. Assessment of these types of pathology of lateral ventricle and also
different areas of brain in different levels are done by two easy and safe radiological
investigations which are known as – 191
i. Computed tomography scanning (CT Scan)

ii. Magnetic resonance imaging (MRI).
Pneumoventriculography is another radiological

investigation in which case straight X-ray of cranium is taken after injecting oxygen or air inside cavity of
lateral ventricle which will replace cerebrospinal fluid.
2. b) Pressure or thrombosis of venous sinuses

3. c) Obstruction of internal jugular vein.
In these cases distension of lateral ventricles with
other ventricles is secondary to overaccumulation of cerebrospinal fluid in subarachnoid space.
Radiological Investigation of Lateral Ventricle
Size, shape and situation of lateral ventricle are assessed by radiological investigations for its—
a) Distension as a result of obstruction in ventricular system or subarachnoid space
b) Distortion
c) Displacement (shifting).
These types of abnormality in outline of lateral ventricle may be due to—
Diencephalon is the central midline portion of forebrain (prosencephalon).
Superolaterally it is continuous with telencephalon on either side which forms cerebral hemispheres. Inferiorly, it
merges with midbrain component of brainstem.
Main mass of diencephalon (the thalamus) is divided into two identical halves which are separated by a narrow
midline cleft which is the cavity of diencephalon called third ventricle of brain.
Diencephalon is primarily divided into dorsal diencephalon and ventral diencephalon by a narrow sulcus called
hypothalamic sulcus which extends from interventricular foramen of Monro to upper end of aqueduct of Sylvius (Fig.
12.1).
Corpus callosum
Septum pellucidum
Hypothalamic sulcus
􏱺art of hypothalamus in floor of third ventricle
Pons
Medulla oblongata
Parts of diencephalon: These are five in number.

Dorsal diencephalon (above hypothalamic sulcus) 1. The thalamus (dorsal thalamus)
2. Metathalamus
3. Epithalamus.
Ventraldiencephalon(belowhypothalamicsulcus) 4. Subthalamus
5. Hypothalamus.
The thalamus is the main mass of diencephalon.
Metathalamus is made up of lateral and medial geniculate bodies.
Epithalamus is the pineal gland connected to posterior pole of thalamus by proximal and distal laminae of pineal
stalk. Unlike other components of
Interthalamic adhesion
Metathalamus
Epithalamus (pineal gland) Subthalamus
Cerebellum Fourth ventricle
Diencephalon
Fig. 12.1 Diencephalon in midsagittal section with structures around it
12
Cavity of lateral ventricle
Thalamus
Subthalamic nucleus
Subthalamus Hypothalamus
Diencephalon
193
diencephalon it is not bilateral structure, but single midline component.
Subthalamus is posterior part of ventral diencephalon which is continuous with brainstem below. It contains
subthalamic nucleus (Fig. 12.2).
Hypothalamus is anterior part of ventral diencephalon which is divided into upper and lower part. Upper part
forms lowermost portion of lateral wall of third ventricle. Lower part forms floor of third ventricle, so from outer
aspect it forms base of brain (Figs 12.1 and 12.2).
THALAMUS
It is the thalamus component of dorsal diencephalon, which merges with the two components of ventral
diencephalon as follows (Fig. 12.1).
i. In anterior plane: Merges with hypothalamus. ii. In posterior plane: Merges with subthalamus.
Ovoid mass of thalamus is anteroposteriorly elongated with following dimensions.

Anteroposterior measurement – 3.5 cm Transverse measurement – 1.5 cm
Longer anteroposterior axis is directed forwards and medially.
Features of Thalamus
Poles
Anterior pole is narrower and more close to the midline. It forms posterior boundary of interventricular fora-
men of Monro.
Posterior pole is broader. It is known as Pulvinar. Pulvinars of both side are separated by a narrow interval
which lodges pineal gland. Pulvinar is the part of thalamus which overhangs lateral geniculate body of
metathalamus (Fig. 12.3).
Fig. 12.2 Diencephalon in coronal section

Thalamusisthelargestcomponentofdiencephalon. It is an egg-shaped ovoid mass of gray matter, one
on either side of midline.

A narrow midline cleft between thalami of two
sides is third ventricle of brain.

Gray mass of thalamus forming different nuclei
forms the cell stations for all contralateral sensory
pathways of body except the olfactory pathway.

Two thalami are interconnected by a compact band of white matter crossing midline. It is called
interthalamic adhesion.
194
Anterior pole
Lateral surface covered by a thin layer of white matter (external medullary lamina)
Surfaces
Superior surface covered by a thin lamina of white matter (stratum zonale)
Posterior pole (pulvinar)

Lateral geniculate body
Fig. 12.3 Lateral view of left thalamus Subdivisions of Thalamus
1. Superior surface: It forms the floor of central part or body of lateral ventricle along with thalamostriate
vein, stria terminalis and body of caudate nucleus which are mediolaterally placed (Fig. 12.2). Superior
surface of thalamus is covered by thin layer of white matter called stratum zonale (Fig. 12.3).
2. Medial surface: It forms lateral boundary of third ventricle. Medial surfaces of both thalami are connected
by interthalamic adhesion (Fig. 12.2).
3. Lateral surface: It is immediately covered by a thin lamina of white matter called external medullary
lamina (Fig. 12.3). Beyond this, lateral surface is related to thick compact fibrous band of posterior limb of
internal capsule.
Superior and medial surfaces are covered by ependyma lining the cavity of lateral ventricle and third ventricle
respectively (Fig. 12.2).
Internal medullary lamina
Thalamus is grossly subdivided by a vertical ‘Y’ shaped lamina of white matter, called internal medullary
lamina. Three parts of thalamus demarcated from each other by the lamina are, (Fig. 12.4)—
1. Anterior part 2. Medial part 3. Lateral part.
White Matter of Thalamus
Thalamus is a condensed mass of gray matter with minimum amount of white matter as following.
1. Stratum zonale: It is a thin lamina of white
matter covering superior surface.
2. Externalmedullarylamina:Itisathinlamina
of white matter covering lateral surface.
3. Internal medullary lamina: It is a ‘Y’ shaped vertical lamina inside thalamus dividing it into
anterior, medial and lateral part.
Anterior part Medial part
Lateral part
Pulvinar
Fig. 12.4 Internal medullary lamina dividing thalamus into anterior, medial and lateral parts
4. Interthalamic adhesion: It is a very narrow but compact bundle of white matter, round on cross section,
connecting medial surface of both thalami. Though the band crosses the midline to link two thalami, but fibers
truly do not cross the midline. Fibers, though may cross midline, but return back to the same sided thalamic
nuclei. So fibers of interthalamic adhesion are not true commissure (Figs 12.1 and 12.2).
Nuclei of Thalamus
1. Larger nuclei: Larger nuclei of thalamus are subdivided into three groups which lie in—
a) Anterior part
b) Medial part
c) Lateral part.
2. Smaller nuclei: These nuclei are related to surf-
ace or white matter lamina of thalamus. These are smaller collection of nerve cells as following –
a) Intralaminar nuclei
b) Midline nuclei or paraventricular nuclei
c) Reticular nuclei.
Nuclei related to anterior and medial parts of thalamus constitute paleothalamus and those of lateral part are 195
considered as neothalamus.
Anterior part (Fig. 12.5)
This part contains anterior thalamic nuclei. These nuclei is concerned with.
1. Function which is associated with that of limbic
system.
2. Emotional tone.
3. Mechanism of recent memory.
Medial part (Fig. 12.5)
Medial part of thalamus contains many smaller nuclei and a large medial dorsal or dorsomedial nucleus. The
dorsomedial nucleus is made up of anteromedial magnocellular and posterolateral parvocellular parts.
Medial part of thalamus is concerned with integration of large number of sensory informations (somatic as well
as visceral) and correlation with emotional feelings.
Lateral part (Fig. 12.5)
Nuclei of lateral part are divided into a dorsal tier and a ventral tier.
Dorsal tier nuclei are – (from anterior to posterior)
1. Lateral dorsal nucleus

2. Lateral posterior nucleus
3. Pulvinar.
Ventral tier nuclei are following from before back-
wards.
1. Ventralanteriornucleus:Itinfluencesactivities
2. 3.
of motor system.
Ventral lateral nucleus: This nucleus also influences motor activities.
Ventral posterior nucleus: It is divided into ventroposteromedial and ventroposterolateral nuclei. These
nuclei receive various sensory inputs (somatic as well as visceral) and convey these to sensory areas of cerebral
cortex.
Anterior thalamic nucleus (anterior zone)
Dorsal medial nucleus (medial zone)
Lateral dorsal nucleus
Diencephalon
Ventral anterior nucleus
Ventral lateral nucleus
Lateral posterior
}
nucleus Pulvinar
Medial geniculate body Lateral geniculate body

Ventral tier of lateral
Dorsal tier of lateral zone
Ventroposterolateral zone nucleus
Ventroposteromedial nucleus
Fig. 12.5 Nuclei of different zones of thalamus
196
Internal medullary lamina
Ependyma on medial surface
Midline (paraventricular) nuclei

Intralaminar nuclei
Reticular nuclei on lateral surface
Other Nuclei of Thalamus (Fig. 12.6)
Intralaminar nuclei
These are small collections of neurons which are present in internal medullary lamina.
These nuclei influence level of consciousness and alertness of an individual.
Midline nuclei (paraventricular nuclei)
These group of neurons are situated in the lateral wall of third ventricle beneath ependyma and some are also
scattered in interthalamic adhesion.
Function of these nuclei are not clearly known.
Reticular nucleus
This is a thin layer of nerve cells which are interposed between external medullary lamina and posterior limb of
internal capsule. It means that this thin lamina of nucleus is situated on lateral surface of thalamus.
Through this nucleus, cerebral cortex regulates thalamic activity.
GENICULATE BODIES: Lateral and medial geniculate bodies are together known as metathalamus. These
two small round elevations are overhung by pulvinar and nowadays are considered as components of
thalamus. Lateral and medial geniculate bodies are diencephalic level relay stations of visual end cochlear
pathways respectively.
Connections of Thalamus (Fig. 12.7)
Connections of thalamus is better understood and remembered if Figure no. 12.7 is consulted along with study
of under-mentioned text.
Anterior part
Medial part
Lateral part 􏱧 􏱧ors􏱧l 􏱧ier
􏱧 􏱧e􏱧􏱧r􏱧l 􏱧ier
Fig. 12.6 Smaller nuclei of thalamus
Name of nucleus Afferent Efferent

Dorsomedial nucleus Amygdaloid body 1. Prefrontal cortex 2. Hypothalamus

Medial nucleus of thalamus Other thalamic Cingulate gyrus
Lateral dorsal nucleus nuclei
Lateral posterior nucleus
Pulvinar Superior parietal lobule (Area 5) Inferior parietal lobule
Other thalamic nuclei (Area 7)
1. Globus pallidus 2. Substantia Premotor cortex (Area 6)
nigra
Ventral anterior nucleus
1. Globus pallidus 2. Substantia nigra 3. Dentate
nucleus 4. Red nucleus Motor and premotor cortex (Area
Ventral lateral nucleus 4 and 6)
1. Spinal lemniscus 2. Medial lemniscus 1. Trigeminal

Ventroposterolateral nucleus lemniscus Postcentral gyrus (Area 3, 1, 2)
Ventroposteromedial nucleus
2. Solitariothalamic tract Postcentral gyrus (Area 3, 1, 2)
Metathalamus

Lateral geniculate
body Optic tract of visual pathway Lateral lemniscus and inferior Primary visual cortex Area 17 Auditory cortex (Area 41
Medial geniculate colliculus and 42)
body

Anterior thalamic nuclei Mammillary body 1. Cingulate gyrus 2. Hypothalamus
Mammillary body
Globus pallidus substantia nigra
Premotor cortex (area 6)
Globus pallidus, substantia nigra, dentate nucleus and red nucleus
Premotor and motor areas (area 6 and area 4)
Spinal lemniscus, medial lemniscus
VA LD VL
AN
LP VPL
Connection of laminar nuclei Intralaminar nuclei 197

Afferent:
1. Reticular formation
2. Spinal lemniscus
3. Trigeminal lemniscus
Efferent: Via other thalamic nuclei to–
1. Cerebral cortex
2. Corpus striatum
Midline (Paraventricular) nuclei

Afferent: Reticular formation
Efferent: Not clearly known Reticular nucleus
Afferent:
1. Reticular formation
2. Cerebral cortex
Efferent:
Other thalamus nuclei.
Functions of Thalamus
1. In connection with functions of thalamus the first and foremost point is to note that, thalamus is made
up of a complex collection of nerve cells which are centrally placed in brain and are interconnected with
various motor and sensory centers.
2. Thalamusisthecentralsensorycellstationwhere all kinds of sensory pathways (except olfactory pathway)
relay on their way to concerned sensory areas of cerebral cortex for perception and integration.
3. Probably olfactory sensation is indirectly related to thalamus. Possibly olfactory sensation from amygdaloid
nucleus and hippocampus is integrated in lower level in mammillary body along with taste sensation. Finally
information passes to the thalamus through mammillothalamic tract.
4. For perception of moderate degree of pain and temperature sensation, ventroposterior nuclei of thalamus are
highest center.
5. It is known that, final order of neurons for all kinds of sensory inputs passes from thalamus to sensory
cortex. But for any kind of crude sensations, thalamus itself can appreciate it. But for interpretation of
sensations based in past experience, functional integrity of thalamocortical connection is required. It can be
understood by an example. If sensory cortex is destroyed, one can appreciate presence of a hot object in hand,
but appreciation of approximate temperature, shape and weight of the object will be impaired.
6. Ventral anterior and ventral lateral nuclei of thalamus receive inputs from globus pallidus, substantia nigra
and cerebellar dentate nucleus. These nuclei discharge outflow to motor and premotor areas of cerebral cortex.
So this thalamic circuit regulate voluntary movement with harmony in right direction and to a right extent. So
lesion of these thalamic nuclei will cause various kinds of abnormal involuntary movements.
7. Dorsomedial nucleus of thalamus connects hypothalamus and prefrontal cortex of frontal lobe.
Postcentral gyrus (area 3, 1, 2)
Trigeminal lemniscus, solitariothalamic tract
Prefrontal cortex and hypothalamus
Fig. 12.7 Connections of thalamic nuclei
VPM
Diencephalon
Cingulate gyrus Hypothalamus
Amygdaloid body
DM PUL
Superior parietal lobule (area 5)
Other thalamic nuclei
Inferior parietal lobule (area 7)
Lateral lemniscus inferior colliculus
Auditory cortex (area 41, 42)
Optic tract
Primary visual cortex (area 17)

globus pallidus, substantia nigra, dentate nucleus with cerebral cortex. Ataxia is due to loss of appreciation of
movements of muscles and joints.
Thalamic hand: Contralateral hand is held in an abnormal position. Forearm is pronated with flexed wrist and
metacarpophalangeal joint and extended interphalangeal joint. This deformity is due to altered tone in different
groups of muscle.
3. Altered higher function: Lesion of anterior nucleus will cause loss of alertness or attentiveness and loss of
recent memory.
Medial dorsal nucleus is concerned with mainten-
ance of mood and emotional balance of an individual. It is, of course, related to nature of sensory input as well as the
past experience gathered. Lesion of this nucleus will cause alteration of mood which ranges from a simple ‘sense of
well being’ or euphoria to mental depression.
Thalamic Syndrome
Features of thalamic syndromes is absolutely different from clinical manifestations of thalamic lesion which has
been described above. Findings of thalamic syndrome appear during the stage of recovery of a patient getting
thalamic infarct. In this case, sensory perception threshold for touch, pain, temperature is lowered. It means,
stimulation of lower intensity gives rise to higher feelings. For example, a simple pin prick on body surface will give
the feeling of burning sensation. Light touch on body surface may even give rise to feeling of excruciating pain.
Similar effect is observed in relation to special sensory inputs. For example, a melodious musical sound may be
heard by the patient very loud and disagreeable.
CLINICAL ANATOMY
Thalamus is centrally placed important relay station and center for integration of various types of inputs to central
nervous system. So disease of this gray matter mass will produce profound effect.
Cause of thalamic lesion is mostly vascular as a result of thrombosis or hemorrhage of posteromedial sets of
ganglionic or central branches of circle of Willis. The artery is named as thalamogeniculate branch. Sometimes
thalamic lesion may be neoplastic or degenerative in origin.
Clinical manifestations of thalamic lesion is fundamentally based on two principles:

1. Effectoflesionwilldependuponlossoffunctionof
different nuclei of thalamus.

2. As the thalamus is centrally placed and closely
approximated to many other important areas or centers of brain, associated lesion of adjacent structures may
overshadow the effect of thalamic lesion. Example is lesion of internal capsule, corpus striatum or midbrain.
Some Important Effects of Thalamic Lesion
1. Sensoryimpairment:Onceventroposteromedial and ventroposterolateral nuclei of thalamus are

affected, it will present grossly noticeable sensory impairment. Ventroposteromedial nucleus
receives exteroceptive as well as proprioceptive sensations from opposite half of face through
trigeminal lemniscus and taste sensation through solitariothalamic tract. So these sensations
will be impaired. Again lesion of ventroposterolateral nucleus, which receives spinal lemniscus
and medial lemniscus, will cause loss of exteroceptive sensation including pain, temperature,
touch (including discriminative touch) and pressure sensation, proprioceptive sensations from
muscles and joints, sense of vibration of opposite half of body.
2. Motor dysfunction:
Abnormalinvoluntarymovement:Thesechore-
iform movements or athetosis with ataxia are due to lesion of ventral anterior and ventral
lateral nuclei which link a neurocircuit of
198
This pathway is concerned with maintenance of personality and subjective feeling (mood), and emotion of an
individual.
8. Anterior nucleus of thalamus is concerned with mental attention and memory of recent events.
9. Reticular laminar nuclei between external medullary lamina and posterior limb of internal capsule are required
for alertness and wakefulness of an individual.
METATHALAMUS
Metathalamus is the component of dorsal diencephalon. These are two oval elevations lateralo- medially placed
and connected to posterior aspect of thalamus, underneath the projected posterior pole called pulvinar. These are
called medial and lateral geniculate bodies. They are so named because they are bend on themselves giving a
geniculate appearance. Both the geniculate bodies are grouped together under metathalamus. But, because of their
functional relationship they are nowadays incorporated in dorsal thalamus.
Medial Geniculate Body
This oval body is placed underneath pulvinar of thalamus lateral to superior colliculus. Inferior coll-
iculus is connected to medial geniculate body by a band known as inferior brachium. Medial geniculate body is
the diencephalic relay station of cochlear pathway for hearing. So afferent fibers reach this nuclear mass
coming from below and efferent fibers go upto the auditory cortex. 199
Afferent: These are narrow compact ascending fiber bundle called lateral lemniscus which are axons of
nerve cells from superior olivary nucleus and nucleus of trapezoid body in lower end of pons. Some of the fibers
pass to medial geniculate body after relaying in inferior colliculus. Beyond inferior colliculus, fibers enter
medial geniculate body through inferior brachium.
Efferent: 􏲠fferent fibers are axons of nerve cells in medial geniculate body. These fibers form auditory
radiation. These form sublentiform part of internal capsule to end in auditory cortex which is present in the
form of transverse gyri on upper surface of superior temporal gyrus (Area 41 and 42).
Lateral Geniculate Body
This is positioned also underneath pulvinar of thalamus and lateral to medial geniculate body and smaller in
size. It is connected to superior colliculus
Diencephalon
of midbrain by superior brachium. Lateral geniculate body is the diencephalic relay station of visual pathway.
Lateral geniculate body of one side receives visual information of ipsilateral half (right or left) of bot􏲄 retina􏲄 so
form contralateral 􏲄alf of field of vision of both eyes.
Afferent: Neurons of lateral geniculate body are arranged in six layers which are numbered one to six from
ventral to dorsal aspects. Afferent fibers reach lateral geniculate body via optic tract. The axons of multipolar
ganglionic neurons of retina leave eyeball through optic nerve, optic chiasma and then through optic tract to
relay in lateral geniculate body. Lateral geniculate body receives almost all the fibers of optic tract except some,
which go to pretectal nucleus for light reflex. It is known that lateral geniculate body of one side receive fibers
from same half (right or left) of both retina. Laminae 1, 4 and 6 of lateral geniculate body receive fibers of retina
of opposite side and laminae 2, 3 and 5 receive fibers of retina of same side (Fig. 12.8).
Efferent: 􏲠fferent fibers from all the layers of lateral geniculate body form geniculocalcarine tract. It is also
known as optic radiation which is the thalamocortical (corticopetal) component of posterior thalamic radiation.
These fibers pass through retrolentiform part of internal capsule.
Right half of right retina Right half of left retina
Fibers from same half (right) of contralateral retina end in layers 1, 4 and 6 of LGB (Red)
Right optic tract
Right lateral geniculate body
Fibers from same half (right) of ipsilateral retina end in layers 2, 3 and 5 of LGB (Blue)
65
4 32 1
Fig. 12.8 Layers 1, 􏲠 and 􏲠 of right lateral geniculate body receive fibers from right half of opposite retina and layers 2, 3, 5 receive fibers
from same half (right half) of same retina
EPITHALAMUS
Epithalamus is the part of dorsal diencephalon which is posterosuperior to the thalamus. In this connection, it
200 is to be noted that metathalamus is posteroinferior to the thalamus. Epithalamus is a composite structure
which lies in relation to posterior part of roof and adjacent part of posterior walls of third ventricle.
Composition of Epithalamus:
1. Pineal gland.
2. Paraventricular nuclei (anterior and posterior).
These are quite different from paraventricular
nucleus of hypothalamus.
3. Habenular nuclei: Medial and lateral, with Habe-
nular commissure.
4. Stria medullaris thalami.

5. Posterior commissure.
Pineal gland (Fig. 12.9)

Pineal gland is also known as epiphysis cerebri. It is a small, reddish gray midline sessile organ placed
posterosuperior to the main thalamic mass.
Evolution
In some classes of fishes and amphibian, this structure used to represent dorsal third eye. In higher animals
and in the past in case of human, this organ was considered as vestigial organ. That is why it is used to be
termed more commonly as pineal body.
Tela choroidea Pineal recess
Recent identity
Nowadays this is more popularly termed as pineal gland as it is very highly evolved endocrine gland exerting
influence in activities of so many endocrine glands of body including hypophysis cerebri (pituitary gland).
Special characteristics
Following are very special characteristics of pineal gland.

1. Pineal gland, an endocrine gland, though present
2. 3.
in the brain, does not contain nerve cells, but
contains neuroglia 􏲄astroc􏲄tes􏲄 and modified neurons. Theglandreceivessomenervefiberscallednervus conarii,

which are postganglionic sympathetic fibers coming from superior cervical ganglion.
After two decades of life, pineal gland may show some age changes characterized by deposition of calcium salts.
Calcification will show tiny opaque shadow in radiological imaging. This is called ‘Brainsand’.
Gross anatomy
Pineal gland is a small, reddish gray, sessile, conical organ, lying posterosuperior to main thalamic mass and it
is lodged in a small depression between two superior colliculi. Above it is related to splenium of corpus
callosum. Anteroposteriorly it measure 8 mm with the base directed forwards. Base of the gland is
pedunculated. Peduncle of pineal gland (pineal stalk) is split up to form proximal (superior) and distal (inferior)
laminae. In between two laminae, a small
Splenium of corpus callosum
Habenular commissure
Pineal gland Posterior commissure
Superior colliculus
Fig. 12.9 Pineal gland with structures around it
201
conical outpouching of third ventricle of brain forms its pineal recess. Both the laminae of pineal stalk present
transversely running fibers forming commissures. Fibers passing through upper lamina form Habenular
commissure and fibers through lower lamina form posterior commissure. Some fibers invading the gland are
called aberrant commissure which of course, do not terminate in cells of pineal gland.
Reader is suggested to consult the chapter of white matter of Brain for further details about the commissures.
Important relations (Fig. 12.9)
Superiorly pineal gland is related to splenium of corpus callosum. Tela choroidea of third ventricle of brain
invaginates between splenium and the gland.
Inferiorly pineal gland is related to tectum of midbrain.
Pineal gland is covered by an envelope of pia mater derived from inferior layer of tela choroidea which is
ultimately continuous over tectum.
Anteriorly, base of pineal gland presents the peduncle (pineal stalk). In between two laminae of the stalk is the
pineal recess of third ventricle of brain.
Structure
Diencephalon
laries or ependymal lining. Dense core vesicles of bulbous expansions of pinealocytes release the hormone
melatonin. Melatonin and its precursor serotonin are synthesized from tryptophan. The released hormone
melatonin is transported through bloodstream and also alternative medium of cerebrospinal fluid passing
through capillaries or ependyma of pineal recess respectively.
2. Neuroglia: These are astrocytes, interstitial in position and posses supportive function. Cells in the laminae
of pineal stalk are mostly neuroglial cells.
Noncellular element
1. Pineal gland does not contain nerve cells. But it contain fine unmyelinated fibers which are the axons
arising from superior cervical ganglion. These are called nervus conarii. These sympathetic nerve fibers
reach the gland along the course of blood vessels.
2. Aftertwodecadesoflife,inorganicsalt,e.g.calcium phosphate and calcium carbonate may be deposited
inside the gland. Through radiological imaging, these particles are evidenced as radioopaque dots. This
is known as corpus arenacea or brain sand.
Functions
Number of indoleamine and polypeptide hormones, including melatonin are secreted by pinealocytes. These
hormones exert widespread regulatory effect on many endocrine glands of body, e.g.
1. Both adenohypophysis and neurohypophysis 2. Islets of pancreas

3. Parathyroid gland
4. Adrenal cortex as well as medulla
5. Gonads.
Effects on all these endocrine glands are inhibitory.
Inhibitory effect on pituitary gland is either direct or it may be indirect through inhibitory effect on hormone
releasing factors liberated by hypothalamus.
Melatonin on reproductive system: Melatonin has got inhibitory effect on gonadotrophins. During
prepubertal life, inhibitory effect of melatonin on gonadotrophic hormones exerts a temporary hault on
development of reproductive system and maturity of reproductive activity until optimum period is being
reached.
Pineal gland acting as a biological clock: Secretion of indoleamine hormones including melatonin and
enzymes responsible for synthesis of these hormones show variation in blood concentration in day and night.
The level of concentration of hormones increases in darkness and falls during day time. The reduced
concentration of day time is due to inhibition
Pineal gland is classically known as neuroendocrine gland. Pia mater from inferior layer of tela choroidea of
third ventricle forms an envelope of the gland. From this pial capsule, number of septae enter inside the gland
to divide it into number of lobules. The septae also carry blood vessels and thin unmyelinated s􏲄mpat􏲄etic nerve
fibers arising from superior cervical ganglion.
Blood vessels
The gland is richly supplied by arteries which are
branches of medial division of posterior choroidal branch of posterior cerebral arteries. Capillaries end in
numerous pineal veins which finally come out to drain into internal cerebral vein and/or great cerebral vein of
Galen.
Cell structure
Pineal gland contain two kinds of cells which are pinealocytes and neuroglia.
1. Pinealocytes: These are parenchymal cells of
the gland. These are not nerve cells but may be considered as modified neurons. Pinealocytes present inside the
lobule in the form of clusters on cords which are endocrine cells. Multiple processes (two or more) extend from
the cell body. These processes end in bulbous expansions which are packed with rough endoplasmic reticulum,
mitochondria and dense core vesicles. The terminal expansions are approximated to fenestrated capil-
1. Hypothalamus
2. Propyriform cortex
3. Septal nuclei
4. Basal nucleus of Meynert.
Afferent fibers from above mentioned areas pass to Habenular nucleus through stria medullaris thalami. Stria
medullaris thalami is a well-defined band of white matter being considered as an important constituent of
epithalamus. It extends from anterior pole of thalamus, along the line of demarcation between superior and medial
surfaces of thalamus to reach habenular nucleus.
Other afferents are—
5. Noradrenergicandserotoninergicfibersfrombrai-
nstem.
6. Substantia nigra
7. Globus pallidus.
Efferent:
1. To pineal gland through habenulopineal tract.

2. To interpeduncular nucleus and reticular form-
ation through habenulopeduncular tract or fasciculus retroflexus.

Habenular Commissure
These are commissural fibers connecting 􏲠abenular nucleus of both sides. The fibers pass through proximal
(upper) lamina of pineal stalk.
Functions of habenular nucleus
1. Habenularnucleus,beingpartoflimbicsystem,is considered as cell station in olfactory and visceral pathways.

2. 􏲠abenular nucleus influences other neuronal groups which influence various endocrine and visceral
functions.
3. It is also thought that habenular nucleus, if not directly but indirectly, possesses influence on sleep and
temperature regulation.
Posterior Commissure (Consult Figure

of Commissure in Chapter of White Matter of Brain)
Posterior commissure is one of the components of epithalamus. But, as it is named commissure, it is composed of
fibers only. These commissural fibers pass across the midline through distal (lower) lamina of peduncle of pineal
gland.
The areas of both sides connected by fibers of posterior commissure are—

1. Medial longitudinal fasciculus
2. Pretectal nucleus
3. Superior colliculi
4. Interstitial nucleus of Cajal.
CLINICAL ANATOMY
Selective lesion of pineal gland is rare. Lesion, if occurs, will lead to release of inhibitory effect of pineal gland
hormone on other endocrine glands. Release or withdrawal of inhibitory influence on gonads, will cause loss of
normal inhibition on sexual activity.
Calcification of pineal gland with advancement of age is found in more than 50% of normal adult persons.
Radiological investigation will show its shadow in midsagittal plane 5 cm above the shadow of external auditory
meatus. Deviation of shadow of calcified pineal gland from midline is important diagnostic point in case of any space
occupying lesion of brain which may be hemorrhagic, hydrocephalic or neoplastic in origin.
PARAVENTRICULAR NUCLEI OF EPITHALAMUS
These are different from paraventricular nuclei of thalamus. But both the groups are very close to each other
beneath the ependyma of third ventricle. Paraventricular nuclei of epithalamus are situated deep to ependyma
dorsal part of third ventricle.
Connections of Paraventricular Nuclei
Afferent:
1. Hypothalamus
2. Hippocampal formation
3. Locus coeruleus.
Efferent:
1. Amygdaloid body
2. Hippocampal formation.
HABENULAR NUCLEUS AND HABENULAR COMMI- SSURE (CONSULT FIGURES OF COMMISSURE IN CHAPTER
OF WHITE MATTER OF BRAIN)
Habenular nucleus: These are collection of neurons forming an important component of epithalamus. Groups
of neurons forming Habenular nucleus is placed beneath a triangular area called Habenular trigone. The triangle is
bounded by—
Pineal gland – medial

Posterior end of thalamus – superolaterally Superior colliculus – inferolaterally.
Connections of Habenular Nucleus
Afferent: Habenular nucleus forming part of limbic system, is connected to several area through afferent fibers
which are as follows–
202
of secretion as a result of activity of sympathetic fibers in pineal gland. As the hormonal concentration show a
circadian rhythm, it is told that pineal gland acting as biological clock through which physiological activities of life is
regulated.
SUBTHALAMUS
Subthalamus is the posterior smaller part of ventral diencephalons (Fig. 12.1).

Position and relation: Subthalamus is posterior to hypothalamus. This narrow part of diencephalon is
compressed between thalamus and midbrain. Above it is demarcated from thalamus (dorsal thalamus) by
posteroinferior part of hypothalamic sulcus. Below it merges with tegmentum of midbrain.
Subthalamic nucleus: This is a small biconvex mass of gray matter present in subthalamus (Fig. 12.10). In
coronal section of brain, subthalamic nucleus is superomedially related to thalamus from which it is separated 203
by another smaller biconvex mass of gray matter called Zona incerta. Inferolaterally subthalamic nucleus is
related to lentiform nucleus from which it is separated by descending fibers of internal capsule.
Connections: Subthalamic nucleus is connected to globus pallidus in bothway direction. Other fibers
related to subthalamic nucleus are pallidothalamic fibers. Fibers of ansa lenticularis are posteroinferior to the
nucleus while passing around posterior limb of internal capsule. Anterosuperior to the nucleus pass the fibers of
lenticular fasciculus.
Other Components of Subthalamus
Apart from subthalamic nucleus and related fiber bundles mentioned above, it is considered that cranial end of
red nucleus and substantia nigra are also incorporated in subthalamus.
Function of Subthalamus
Though subthalamus is anatomically a component of diencephalons, but functionally it is related to basal

ganglia. Apart from its connection with globus
Zona incerta
Thalamus
Subthalamic nucleus
Internal capsule
Diencephalon
pallidus, it is believed that it has connections with red nucleus and substantia nigra. Through this circuit,
subthalamic nucleus also controls muscular activity. The neurons of subthalamic nucleus is glutaminergic and
excitatory in nature.
HYPOTHALAMUS
General Consideration (Fig. 12.11)
Hypothalamus is lower and anterior part of diencephalon.
It is the anterior part of ventral diencephalon, posteriorly merging with subthalamus.
Hypothalamic sulcus, extending from interventricular foramen of Monro to upper end of aqueduct of Sylvius
demarcates hypothalamus from dorsal diencephalon above it.
Hypothalamus being very essential for life, is centrally placed in limbic system below thalamus and overhung
by both cerebral hemispheres.
Hypothalamus forms the lower part of lateral wall and also the floor of third ventricle of brain which is a
central midline cleft.
Part of hypothalamus forming floor of third ventricle of brain forms the components of interpeduncular fossa
of base of brain when seen from below. Anteroposteriorly these structures are – 1. Optic chiasma 2. Tuber
cinereum with infundibulum of pituitary gland (not the gland itself) and 3. Mammillary body.
How small is hypothalamus:
1. Hypothalamus is 10 gm in weight.
2. It constitutes only 0.3% of total body mass.
How much important hypothalamus is functionally:
Hypothalamus is very essential for life because almost all the functions of body are controlled by it either
directly or indirectly.
Lenticular fasciculus
Fig. 12.10 Subthalamic nucleus with gray and white matters around it
Ansa lenticularis
Lentiform nucleus
Bothway connection of subthalamic nucleus with globus pallidus (Subthalamic fasciculus)

Hypothalamus sulcus
204
Thalamus
Hypothalamus Preoptic area
Optic chiasma
Tuber cinereum with infundibulum
Fig. 12.11 Hypothalamus in sagittal plane with surrounding structures
Epithalamus Subthalamus
Mammillary body
Broadly, functions of hypothalamus can be stated as—
1. It controls activities of autonomic nervous system. Being the supreme center for regulation of auto-
nomic nervous system, hypothalamus had been referred by Sherington as ‘head-ganglion’ of auton-
omic nervous system.
2. It controls functions of endocrine system.
Thus controlling both autonomic nervous system and endocrine system, hypothalamus maintains body
homeostasis.
3. Hypothalamus plays an important role in emotional activities through its influence on limbic system.
Relations of Hypothalamus
In coronal section, hypothalamus can be simulated with the capital letter ‘U’. Intermediate part of ‘U’ form the
floor and, both the limbs form lower part of lateral wall of third ventricle.
So relations of four aspects of hypothalamus are following (Fig. 12.12)—

Superiorly: Thalamus, demarcated by hypothal-
amic sulcus.
Inferiorly: It is free and form components of
interpeduncular fossa of base of the brain. It forms
the floor of third ventricle.

Medially: Cavity of third ventricle of brain (lower
part).
Laterally: Internal capsule of brain.
Anteroposterior extent
Anteriorly, hypothalamus merges with an area known as preoptic area which extends from optic chiasma to
lamina terminalis. Anatomically preoptic area is a part of telencephalon. But functionally it is considered as
anteriormost part of hypothalamus containing one of its nuclei called preoptic nucleus.
Posteriorly, hypothalamus merges with subthalamus which becomes continuous below with tegmentum of
midbrain.
Fundamental Subdivision of Hypothalamus
Mediolateral subdivision (Fig. 12.13)
Anterior column of fornix ends in mammillary body. Mammillothalamic tract extends from mammillary body to
anterior nucleus of thalamus. These two bands of fibers divide hypothalamus primarily into medial and lateral
zones. Subependymal surface (medial surface) of medial zone presents a thin strip which is differentiated from
main part of medial zone. This thin medialmost lamina of hypothalamus possesses its own identity as
paraventricular zone.
So, from lateral to medial, hypothalamus is ultimately divided into following three zones.
1. Lateral zone
2. Intermediate zone
3. Paraventricular
or subependymal zone (also called medial zone)
}
No. 2 and No. 3 zone together actually
Anteroposterior subdivision (Fig. 12.11)
1. Preoptic region: It is the part of brain behind lamina terminalis, extending inferiorly
forms medial zone
205
Thalamus
Diencephalon

Hypothalamus sulcus
Hypothalamus forming lower part of lateral wall of third ventricle
Hypothalamus forming floor of third ventricle
upto optic chiasma. Anatomically it is part of telencephalon. But for functional reason it has been incorporated
into hypothalamus of diencephalon.
Body of fornix
Anterior column of fornix
Fibers of internal capsule related lateral to hypothalamus
Hypothalamus forming base of brain
2. Supraopticregion:Itisthepartofhypothalamus above optic chiasma.
3. Tuberal region: It is the part adjoining tuber cinereum and infundibulum of pituitary gland.
Thalamus
Mammillothalamic tract Mammillary body

Fig. 12.12 Hypothalamus on coronal section
Lateral zone
Intermediate zone
Paraventricular or subependymal zone of hypothalamus
Fig. 12.13 Mediolateral subdivision of hypothalamus
206
4. Mammillary region: It is the part where mammillary body is situated.
Nuclei of Hypothalamus
1. Hypothalamus is composed of small nerve cells which are arranged in groups called hypothalamic
nuclei.
2. Many of these nuclei are not clearly demarcated from each other. Even some may show overlapping.
3. A group of neurons, known as preoptic area, situated between lamina terminalis and optic chiasma, is
anatomically part of telencephalon. But from functional point of view, the area forming a nucleus,
preoptic nucleus is incorporated in
hypothalamus (diencephalon).
4. Various nuclei of hypothalamus are divided
into three zones already stated. These zones are
lateral, intermediate and paraventricular or subependymal. The last group is also known as
medial zone.
5. Some of the nuclei are bisected, thereby falling in two adjacent zones. These are – preoptic, supraoptic
and tuberal nuclei.
􏲠. Nuclei which are anatomically classified, are not often grouped physiologically. It means that nuclei of two
different anatomical zones may be physiologically identical in function.
7. For more academic interest, very often, nuclei are classified in a complex manner. But simplest, conventional
and mediolateral subdivision of nuclei of hypothalamus is mentioned below.
Nuclei of lateral zone (Fig. 12.14)
Lateral nucleus: This nucleus is made up of large sized and loosely packed neurons which occupies whole
anteroposterior extent of lateral zone. Lateral nuclear zone is also associated with abundance of fibers.
Lateral nucleus
Fig. 12.14 Nucleus of lateral zone of hypothalamus

Preoptic nucleus Supraoptic nucleus
Tuberoinfundibular nucleus Mammillary nucleus
Fig. 12.15 Nuclei of hypothalamus bisected for both lateral and intermediate zone
Nuclei common for lateral and intermediate zones (Fig. 12.15)
1. Preoptic nucleus
2. Supraoptic nucleus
3. Tuberoinfundibular nucleus 4. Mammillary nucleus.
Intermediate zone (Fig. 12.16)
1. Anterior nucleus
2. Ventromedial nucleus 3. Dorsomedial nucleus 4. Posterior nucleus.
Anterior nucleus
Ventromedial nucleus
Dorsomedial nucleus
Posterior nucleus
Fig. 12.16 Nuclei of intermediate zone of hypothalamus Paraventricular or subependymal zone (Fig. 12.17)
It is a thin strip-like zone just beneath the ependyma of lateral wall third ventricle at the level of
hypothalamus. The nucleus is known as para-
207
Paraventricular nucleus
Fig. 12.17 Paraventricular nucleus of hypothalamus ventricular nucleus. This nucleus is medialmost in
position among all hypothalamic nuclei.
Connections of Hypothalamus
Hypothalamus situated at the center of limbic system present connections with various areas of brain.
Afferent connections
1. Somatic afferent: Exteroceptive sensations, e.g. touch/pressure and pain/temperature sensations are
carried via ventral and lateral spinothalamic tracts respectively. To pass through the brainstem, before
reaching their primary destination to thalamus, the tracts present compact bundle known as spinal lemniscus.
Similarly, medial lemniscus is another compact bundle destined to thalamus while passing through brainstem.
This carries proprioceptive sensations from muscles and joints, sense of vibration and discriminative touch.
Before terminating in thalamus, these lemnisci send collaterals to hypothalamus.
2. Specialvisceralafferent:Thesearetheafferent fibers from the gustatory pathway. Axons of nucleus tractus

solitarius ascend to ventroposteromedial nucleus of thalamus as solitariothalamic tract. Collaterals from this
tract reach hypothalamus.
3. General visceral afferent: General sensations from viscera, sense of stretch, compression or distension and
pain sensation due to lack of oxygen following ischemia, primarily reach the autonomic center of brain (dorsal
nucleus of vagus) and spinal cord (T1 – L2 and S2 – S4 segments). But finally afferent fiber from these centers
ascend through reticular formation to reach hypothalamus which is considered as headganglion of autonomic
nervous system.
Diencephalon
4. Visualafferent:Afferentfibersfromvisualpath- way pass from opticchiasma to supraoptic

nucleus of hypothalamus via retinohypothalamic tract.
5. Olfactory afferent: Fibers from olfactory pathway pass to hypothalamus as medial
forebrain bundle.
6. Auditory afferent: This connection has not been clearly established. But it has been proved
experimentally that sound stimulating cochlear pathway stimulates activity of
hypothalamus.
7. Descendingcorticalafferent:Thesearecortico- 􏱴􏱴pot􏱴alamic fibers descending from frontal
lobe of cerebral cortex directly to hypothalamus.
8. Hippocampal afferent: Fibers from hippocampus pass along the curved course of fornix to
reach mammillary body. It is considered by many neurologists that hypothalamus is the
main output path of limbic system.
9. Afferent from amygdaloid body: These are the fibers of stria terminalis which extend from
amygdaloid body around the curve of thalamus to reach hypothalamus.
10. Afferent from thalamus: These are fibers reaching hypothalamus from dorsomedial, anterior and
midline nuclei of thalamus.
11. Afferent from midbrain: These are the fibers from tegmentum of midbrain.
Efferent connections
1. Descending efferent (to autonomic centers of brainstem and spinal cord): These fibers descend via
brainstem reticular formation.
a) Terminationinbrainstem:Thesefibersend
in following parasympathetic cranial nerve
nuclei.
i. Edinger Westphal nucleus (IIIrd)

ii. Superior salivatory nucleus (VIIth )
iii. Interior salivatory nucleus (IXth)

iv. Dorsal nucleus of vagus (Xth).
b) Termination in spinal cord:
i. Sympathetic: Fibers from posterior part of hyp-
othalamus pass to sympathetic neurons in lateral gray horns of 1st thoracic to 1st/2nd lumbar segments of
spinal cord.
ii. Parasympathetic: Fibers from anterior half of hypothalamus pass to parasympathetic neurons of
intermediate area of 2nd, 3rd and 4th sacral segments of spinal cord.
2. Efferent to thalamus (mammillothalamic tract): These fibers pass from hypothalamic nucleus of
mammillary region to anterior nucleus of thalamus.
3. Efferents to hypophysis cerebri (pituitary gland): a) Efferent to neurohypophysis (posterior pituitary)

(Fig. 12.18): Axons of supra-
208
Supraoptic nucleus
Adenohypophysis (anterior pituitary)
Paraventricular nucleus
Mammillary body Hypothalamohypophyseal tract

Venules
Neurohypophysis (posterior pituitary)
Venules
Fig. 12.18 Efferent connection of hypothalamic nuclei with neurohypophysis to form hypothalamohypophyseal tract
optic and paraventricular nuclei of hypothalamus extend upto posterior pituitary (neurohypophysis). These
fiber bundles are known as hypothalamohypophyseal tract. Neurons of supraoptic and paraventricular nuclei
possessing secretory functions liberate hormones vasopressin and oxytocin respectively. These hormones
released from neurons of hypothalamus are transported though the axoplasm of the hypothalamo– hypophyseal
tract to neurohypophysis (posterior pituitary). Finally the hormones circulate in the general bloodstream
through the venules of posterior pituitary.
Vasopressin (antidiuretic hormones) is vasoconstrictor in nature and causes reabsorption of water from distal
convoluted tubules and collecting tubules of kidney. Oxytocin stimulates contraction of uterine musculature
and myoepithelial cells of alveoli of mammary gland.
b) Efferent for adenohypophysis (anterior pituitary) (Fig. 12.19): Neurons of tuberal nucleus of
hypothalamus send axons to infundibulum of pituitary gland. These axon bundles are known as
tuberoinfundibular tract which transports two hormones liberated by neurons of tuberal nucleus. The hormones
are named as hormone releasing factors and
Tuberal nucleus
Tuberoinfundibular tract (superior) Hypophyseal artery
Capillaries
Neurohypophysis
Sinusoids in adenohypophysis
Hypophyseal vein Adenohypophysis
Fig. 12.19 Efferent connection from tuberal nucleus of hypothalamus for adenohypophysis
Diencephalon
hormone release inhibiting factors. These substances reach through tuberoinfundibular tract to infundibulum
of pituitary gland from hypothalamus. Through hypophyseal portal system capillaries at both ends the hormone
releasing factors and hormone release inhibiting factors reach the adenohypophysis (anterior pituitary) to
produce in􏲄uence on t􏲄e endocrine cells.
􏲄pecific functions of t􏲄o 􏲄ormones:

1. Hormone releasing factors: These stimulate
release of following hormones from the concerned cells of adenohypophysis.
1. a) Growth hormones (GH)

2. b) Adrenocorticotrophic hormone (ACTH)
3. c) Thyroid stimulating hormones (TSH)
4. d) Follicle stimulating hormones (FSH)
5. e) Luteinizing hormones (LH).
2. Hormonereleaseinhibitingfactors:Theseinh- ibit release of following hormones from concerned cells of

adenohypophysis.
1. a) Melanocyte stimulating hormones (MSH)

2. b) Lactogenic hormones (Prolactin).
Functions of Hypothalamus
209
􏲠ypothalamus exerts its influence on almost every function of body. Only the important and better studied
functions are discussed below.
Autonomic control
Hypothalamus is primarily considered as ‘higher autonomic center’ to have a control on lower autonomic center
for both parasympathetic and sympathetic system present is brainstem and spinal cord.
Beside this, hypothalamus is also considered as a center for integration of both autonomic nervous system and
endocrine system, thus maintaining body homeostasis.
Parasympathetic and sympathetic components of autonomic nervous system are controlled by anterior and
posterior parts of hypothalamus respectively. It is also proved experimentally. Electrical stimulation of anterior
and preoptic nuclei of hypothalamus leads to increased parasympathetic activities, e.g. lowering of blood
pressure, decreased heart rate, hyperperistalsis, contraction of bladder wall, increased salivation and gastric
juice and constriction of pupil.
Stimulation of posterior and lateral nuclei causes hyperactivity of sympathetic system which is manifested by
rise of blood pressure, increased heart rate, diminished intestinal peristalsis and dilatation of pupil.
Neurosecretion
Supraoptic and paraventricular nuclei of hypothalamus are concerned with liberation of vasopressin and
oxytocin respectively. Vasopressin basically being selective vasoconstrictor in nature, causes reabsorption of
water from distal convoluted tubules and collecting tubules of kidney. Oxytocin increases contractility of uterine
musculature and myoepithelial cells in the alveolar wall of mammary gland.
Endocrine control
Tuberoinfundibular nucleus of hypothalamus libe- rates two hormones called hormone releasing factor and
hormone release inhibiting factor. Initially these hormones reach infundibulum of pituitary gland via
tuberoinfundibular tract. But finally through the vascular portal system of pituitary gland hormones reach
adenohypophysis (anterior pituitary) to exert regulations on different endocrine cells liberating respective
hormones. Hormones releasing factor stimulates release of growth hormones, adrenocorticotrophic hormone,
thyroid stimulating hormone, follicle stimulating hormone and luteinizing hormone. Hormone release inhibiting
factor inhibits release of melanocyte stimulating hormone and lactogenic hormone (prolactin).
Control of body temperature
Normal body temperature is maintained due to balance of function of anterior and posterior part of
hypothalamus. Anterior part is concerned for heat loss by cutaneous vasodilation and sweating which result in
lowering of body temperature. Posterior part of hypothalamus, if activated, causes vasoconstriction of skin and
inhibition of sweating with no heat loss. Skeletal muscle is also responsible for production of heat which results
in shivering.
Control of food and water intake
Food intake: Intake of food by an individual is regulated by two centers of hypothalamus called Hunger
center and satiety center. Hunger center is present in lateral part of hypothalamus, whereas medial part lodges
satiety center. Stimulation of lateral part results in increase in food intake. Lesion of this area will lead to
anorexia and subsequent loss of body weight. Stimulation of medial part of hypothalamus containing satiety
center inhibits intake of food. Obviously lesion in this area will results in uncontrolled voracious appetite which
finally causes excessive obesity.
Obesity and Wasting
These are two opposite indirect manifestations of lesion of satiety and hunger center of hypothalamus. Medial zone
contain the satiety center and the hunger center is present in lateral zone. Usually severe obesity is the common
manifestation of hypothalamic lesion which is associated with genital hypoplasia. Wasting is rare in occurrence.
Hyperthermia and Hypothermia
These manifestations are the result of imbalance in normal body temperature regulation due to lesion in
hypothalamus. Hyperthermia is commoner than hypothermia. It may result following head injury or neurosurgical
operation in the area adjacent to hypothalamus. Patient of hyperthermia is otherwise normal, because patient is not
suffering from headache or malaise which are the effect of pyrexia following any infection.
Diabetes Insipidus
This clinical condition is characterized by passage of large volume of urine with low specific gravity. As a result
patient remains severely thirsty and frequently drinks large quantity of water. This effect is due to lesion of
supraoptic nucleus of hypothalamus or hypothalamohypophyseal tract with impairment of secretion of vasopressin
or antidiuretic hormone (ADH).
Sexual Disorder
Craniopharyngioma is a congenital tumor arising from remnants of Rathke’s pouch. In children, its pressure effect
on hypothalamus may show sign of sexual retardation along with other clinical manifestation of hypothalamic
lesion. After puberty, the patient suffers from impotence or menstrual disorder.
Sleep Disorder
Patient suffers from disorder of circadian rhythm of sleep and wakefulness. Typically patient may suffer from
insomnia or frequent short period sleep during the hours of waking.
Emotion Disorder
In patient of hypothalamic lesion, various kinds of emotional outbursts are observed. It may be unexplained weeping
or laughter. Patient may show uncontrollable rage. Sometimes there may be features of mental depression.
CLINICAL ANATOMY
Although hypothalamus is a very tiny area of central nervous system, its immense clinical importance should never
be ignored. Because, hardly there is a tissue of body which is not under the influence of hypothalamus.
Hypothalamus is the principal outlet of limbic system which in􏲄uences t􏲄ree important aspects of daily life, which
are autonomic function, endocrine function and emotional activities.
Lesion of hypothalamus may be due to direct reason like vascular and in􏲄ammator􏲄, or indirect pressure effect, e.g.
neoplasm or internal hydrocephalus adjacent to it.
Important clinical manifestations of hypothalamic syndrome are following:
Water intake: Some area of lateral zone of hypothalamus is known as thirst center. Stimulation of this area
makes an individual thirsty with severe urge to drink water. Again, supraoptic nucleus, through its influence on
liberation of vasopressin (antidiuretic hormone), maintains optimum osmol- arity of blood, thus maintains water
balance of body.
Regulation of emotion and behavior
Hypothalamus is considered as principal outlet for action of limbic system for emotion and behavior of an individual
through prefrontal cortex. Rage and passivity are two opposite poles of emotion and behavior. These are again
dependent upon effect of surrounding environment. Hypothalamus acts as an integrator for various informations
received from different areas of nervous system and leads to manifestations of emotion.
Lateral nuclei of hypothalamus are considered as the center for rage and ventromedial nucleus is the center for
passivity. Tuberal nucleus by synthesis of hormone releasing factors exert in􏲄uence on secretion of gonadotrophins,
thus has an effect indirectly on sexual behavior.
Relation of circadian rhythm
Hypothalamus acts as biological clock through regulation of circadian rhythm. Along with thalamus, limbic system
and reticular activating system, hypothalamus regulates cycle of sleeping and waking. Supraoptic nucleus, which
receives afferent impulse from retina through optic chiasma, plays an important role in the biological rhythm of
sleeping and waking.
Circadian rhythm controlled by hypothalamus, also includes body temperature, adrenocortical activity, eosinophil
count and renal excretion.
Identity
Third ventricle of brain is a narrow midline cavity of diencephalon.
Morphologically, it is central midline part of cavity of forebrain vesicle. Two lateral extensions are lateral ventricle.
Third ventricle is slit-like cleft between two thalami. It is limited below by hypothalamus forming base of the
brain.
Communications (Fig. 13.1)
1. Proximal: On either side of midline, third ventricle communicates anterolaterally with lateral ventricle through
a narrow slit, called interventricular foramen of Monro which is bounded anteriorly by anterior end of anterior
column of fornix and transversely running fibers of anterior commissure, and posteriorly by anterior pole of
thalamus.
Interventricular foramen is directed forwards, upwards and laterally.

2. Distal: Third ventricular cavity communicates
distally in the midline. It is posteroinferior in direction where the cavity is continuous with narrow passage of
cerebral aqueduct of Sylvius passing through midbrain. Aqueduct distally leads to cavity of fourth ventricle of
brain.
Boundaries (Figs 13.1 and 13.2)
It has already been mentioned that third ventricle is a narrow midline cleft between medial surfaces of
two thalami and upper part of hypothalamus. So, its four walls, anterior, posterior, superior and inferior, are
narrow. Both the lateral walls are wider which are clearly demonstrated in midsagittal section of brain.
Lateral Wall
Larger upper part of lateral wall is formed by medial surface of thalamus. Lower part is formed by hypothalamus
below hypothalamic sulcus. Surfaces of thalamus and hypothalamus forming lateral wall are lined by ventricular
ependyma.
Important features of lateral wall
1. Stria medullaris thalami (Fig. 13.2)
It is a subependymal thin band of white matter that extends anteroposteriorly along the line of demarcation
between medial surface and superior surface of thalamus, thus indicating upper extent of lateral wall of third
ventricle. Stria medullaris thalami extends from anterior pole of thalamus to Habenular nucleus.
2. Hypothalamic sulcus (Figs 13.1 and 13.2)
It is a narrow and shallow sulcus which extends from interventricular foramen of Monro to upper end of cerebral
aqueduct of Sylvius. The sulcus demarcates medial surfaces of thalamus and hypothalamus.
Third Ventricle of Brain
13
Anterior commissure
212
Hypothalamic sulcus
Fornix
Lamina terminalis
Infundibulum of pituitary gland Mammillary body
Tela choroidea
Suprapineal recess Pineal recess
Cerebral aqueduct of Sylvius

Optic recess
Infundibular recess Optic chiasma
Fig. 13.1 Third ventricle of brain viewed in midsagittal diagram with its boundaries, recesses and communications
3. Interthalamic adhesion (Figs 13.1 and 13.2)
It is a short, narrow and compact band crossing the midline which connects very closely apposed medial
surfaces of both thalami. It is round on cross-section visible on medial surface of thalamus. It is made up of both
white as well as gray matter.
White matter: These fibers arising from thalamic nuclei of one side cross the midline. But these are not
Stria medullaris thalami
Interthalamic adhesion Hypothalamic sulcus
true commissural fibers, as instead of reaching nuclei of opposite thalamus, they return back to the same side
(Fig. 13.2).
Graymatter:Interthalamicadhesionalsocontain some scattered neurons which are considered to be detached
cells of paraventricular or midline nuclei of thalamus.
Tela choroidea Choroid plexus
Ependymal roof of third ventricle
Thalamus
Hypothalamus
Fig. 13.2 Third ventricle of brain on coronal section
Fornix
Third Ventricle of Brain

213
Corpus callosum Cavity of lateral ventricle
Stria terminalis Thalamostriate vein Thalamus
Hypothalamus
Anterior Wall (Fig. 13.1)
It is formed by following structures from above downwards.

Anterior column of fornix.
Anterior commissure: Its fibers cross transversely in front of lower end of anterior column of fornix.
Lamina terminalis: A thin layer of gray matter extending from lower end of rostrum of corpus callosum to
optic chiasma.
Posterior Wall (Fig. 13.1)
It is shorter than anterior wall and formed by –

Pineal gland
Two laminae of pineal stalk called Habenular
commissure — proximal posterior commissure — distal.
Floor (Fig. 13.1)
From before backwards structures forming the floor are—

Optic chiasma
Tuber cinereum with infundibulum of pituitary
gland (not the gland itself)

Mammillary bodies – which is bilateral Posterior perforated substance
Tegmentum of midbrain.
Roof
This wall is lined only by ependyma which extends from upper border of medial surface of one thalamus along
the length of stria medullaris thalami to that of other.
Tela choroidea
Choroid plexus
Ependymal roof of third ventricle
Roof is therefore narrow having the breadth between two thalami and anteroposteriorly extends from the level
of interventricular foramen to superior lamina of pineal stalk forming Habenular commissure.
Recesses of Third Ventricle (Fig. 13.1)
Recesses are mostly small angular pockets of cavity of the ventricle in relation to the structures forming its
boundary.
The recesses are following:

Optic recess: It is an angular pocket of the cavity
above optic chiasma which lies on the anterior end of the floor. The recess is at the junction of anterior wall and
floor of the ventricle.
Infundibularrecess:Thisrecessiscomparatively deeper which is tubular in shape with pointed lower end. It
extends through tuber cinereum into the stalk (infundibulum) of pituitary gland.
Pineal recess: It is a small angular recess on the posterosuperior aspect of the cavity which is bounded by
superior and inferior stalks of pineal gland.
Suprapineal recess: It is wider and blunt recess which is obviously above pineal gland but below tela
choroidea which is below splenium of corpus callosum.
Besides these four well-defined recesses, another triangular recess is found in relation to the anterior wall.
It is between two diverging anterior column of fornix, in front of interventricular foramen and behind
anterior commissure. It is called anterior recess of third ventricle.
Fig. 13.3 Tela choroidea in relation to roof of third ventricle

CLINICAL ANATOMY
In normal individual, third ventricle of brain is a narrow midline cleft of ventricular system. But its cavity is dilated
in case of hydrocephalus which is a
214
Anterior apical end of tela choroidea at the level of interventricular foramen of Monro
Superior layer of tela choroidea

Choroid plexus of third ventricle
Inferior layer of tela choroidea
Posterior basal end of tela choroidea between splenium and pineal gland
TELA CHOROIDEA AND CHOROID PLEXUS (FIGS 13.3 AND 13.4)
Splenium of corpus callosum and fornix lie above the ependymal roof of third ventricle but do not form the boundary
of roof. Through the gap between splenium and pineal gland, pia mater, invaginates forward over the ependyma of
roof. As the pial fold invaginates forwards, it extends from the level of splenium and pineal gland upto anterior blind
end at the level of interventricular foramen. This pial reflexion presents two characteristics:
1. It is double layered, one layer is reflected back as second layer from anterior end.
2. Itistriangularinoutline.Posteriorbasalendlies in the interval between splenium and pineal gland. Anterior apical
end extends upto interventricular foramen (Fig. 13.4).
This is known as tela choroidea.
Choroid plexus: Tuft of finer blood vessels which are anterioposteriorly linear and fringe-like invaginates
between two layers of tela choroidea from behind forwards. The choroid plexus contains four anteroposterior
running components parallel to each other. Central two belong to third ventricle. Outer two form choroid plexus of
lateral ventricle which protrude outwards through the slit between fornix and thalamus (Figs 13.3 and 13.4).
clinical condition characterized by overaccumulation of cerebrospinal fluid in its cavity. Normally a balance is
maintained between secretion of cerebrospinal fluid by choroid plexus of ventricles and its absorption by arachnoid
granulations. Hydrocephalus may develop due to any of following causes –
1. Oversecretion of cerebrospinal fluid.

2. Impaired abosorption of cerebrospinal fluid.
3. Obstruction in ventricular system anywhere upto
communication with subarachnoid space through foramen of Magendie and foramen of Luschka. Dilatation of third
ventricle in a case of hydrocephalus
will occur if the obstruction is distal to interventricular foramen of Monro. This obstruction occurs due to any
expanding tumor close to wall of the ventricle. Cranio- pharyngioma is a common supratentorial congenital tumor in
children. It is the benign neoplasm arising from remnants of Rathke’s pouch.
Dilatation of third ventricle in a patient of hydrocephalus secondarily may cause pressure effect on structures of
the floor the ventricle.
The manifestations commonly observed are—
1. Bitemporal hemianopia: That is loss temporal field of vision of both eyes due to pressure effect on decussating
nasal fibers of optic chiasma.
2. Hypothalamicsyndrome:Itischaracterizedby obesity, diabetes insipidus, hyperthermia or hypothermia,

disorder in sexual activity, emotional and sleep disturbances.
The site of obstruction and nature of dilatation can be detected through radiological investigation like
ventriculography, Computed Tomography Scanning (CT Scan) and Magnetic Resonance Imaging (MRI).
Fig. 13.4 Tela choroidea taken out from roof of third ventricle
Brain, being the part of central nervous system is made up of very delicate and sensitive tissue. It needs adequate
protection. For this, brain is primarily encased within the cranium. In addition, following are two additional factors
which help to keep brain in safe and secured position.
1. Brain is covered by three membranes called meninges, of different thickness, transparency and
stretchibility. From outside inwards these are—
Dura mater: Its most characteristic feature is
its toughness.
Arachnoid mater: It is transparent and elastic. Pia mater: It is thinnest, most delicate, inti-
mately related to surface upto bottoms of fossa,
sulci and fissures.

2. Spacebeneatharachnoidmater,calledsubarachn-
oid space is filled up with thin watery cerebrospinal fluid which acts as a cushion around brain. Spinal
meninges has been described in the chapter
of spinal cord. DURA MATER
Dura mater of brain, as it is inside the cranium, is called cranial dura. It is made up of two layers, outer endosteal
and inner meningeal layer.
Endosteal layer: This layer of cranial dura is nothing but periosteum lining inner surface of cranium which is
also called endosteum. Through the sutures of cranial bones, endosteal layer of dura
(endosteum) is fused with the periosteum outside cranium.

Meningeal layer: It is the true meninx (sing.) or covering of brain. It is a dense, opaque fibrous membrane
which possesses maximum protective power.
It is to be noted here that, spinal cord is covered by single meningeal layer with which meningeal layer of cranial
dura is continuous through foramen magnum. Endosteal layer of cranial dura ends being attached at the margin of
foramen magnum.
Normally, endosteal and meningeal layers are firmly adherent to each other except –
1. Insomesiteswheremeningeallayerisinfoldedto
form some dural septae.
2. In some areas two layers of dura are separated to
lodge intracranial venous sinuses.
Any trauma, leading to head injury may lead to
formation of blood clot (hematoma) outside dura (extradural hematoma). It will then separate meningeal layer
from endosteal layer.
Dura mater is discussed below on following two fundamental headings—

Dural folds or septae.
Intracranial venous sinuses between two layers of
dura.
Folds of Dura Mater
These are formed when meningeal layer gets separated from endosteal layer to invaginate in the gaps (sulci or
fissures) between adjacent parts of brain.
Meninges of Brain and Cerebrospinal Fluid

14
216
Superior sagittal sinus

Crista galli giving attachment to anterior end of falx cerebri
Falx cerebelli
Important dural septae or fold are—
1. Falx cerebri
2. Tentorium cerebelli
3. Falx cerebelli
4. Diaphragma sellae.
Falx cerebri (Figs 14.1 and 14.2)
It is a sickle-shaped fold of dura mater which extends anteroposteriorly, through midsagittal plane and dips in
median longitudinal fissure of brain between two cerebral hemispheres.
Endosteal layer of dura
Meningeal layer of dura
Falx cerebri
Right transverse sinus
Straight sinus
Left transverse sinus
Tentorium cerebelli
Fig. 14.1 Folds of dura mater
Ends: Anterior apical end is attached to crista galli of ethomoid and adjacent part of internal crest of frontal
bone.
Posterior basal end is anteroposteriorly running straight border which is attached to midline of superior
surface of tentorium cerebelli.
Borders: Superior border is convex and attached to margins of a narrow linear sulcus on the inner surface
of median sagittal sutures connecting two parietal bones.
Inferior border is concave and comparatively sharper free border which comes in relation to ante-
Supratentorial compartment
Infratentorial compartment
Falx cerebri Inferior sagittal sinus
Tentorium cerebelli Transverse sinus
Foramen magnum
Meningeal layer of cranial dura continues as spinal dura
Fig. 14.2 Dural folds on coronal section of cranium are found to form compartments
roposteriorly convex superior surface of corpus callosum.
Venous sinuses related
It is already known that intracranial venous sinuses lies between endosteal and meningeal layers of dura
mater. Venous sinuses related to falx cerebri are followings– 217
1. Superior sagittal sinus: Runs from before backwards along upper convex border of the falx.
2. Inferior sagittal sinus: It runs also anteroposteriorly, but along the lower free concave
margin of falx cerebri.
3. Straightsinus:Itisanteroposteriorlystraightin direction, present along the line of attachment
of falx cerebri and tentorium cerebelli in the median plane.
Tentorium cerebelli (Figs 14.1 and 14.2)
It is a double fold of dura mater which invaginates horizontally forwards through the gap between the occipital
lobes of cerebrum and cerebellum (Fig. 14.3).
Tentorium cerebelli is so called because from midline it slopes on either side downwards and laterally to
adjust the slopes from raised superior vermis to superior surface of cerebellar hemispheres on either side (Fig.
14.2).
Surface
Superior surface is related to inferior surface of occipital lobe of cerebrum.
Inferior surface is related to superior surface of cerebellum.
Margins
1. Posteriormargin:Itisactuallyperipheral,conv- e􏲄 and fi􏲄ed margin which is attached on either side of

midline and from behind forwards to—
Two lips of transverse sulcus of occipital bone. Superior border of petrous part of temporal
bone.
Anterior end of this margin is attached to posterior
clinoid process of sphenoid bone.

2. Anterior margin: It is the inner central free
margin of the dural fold. Free margin of both sides together forms a concavity which is called tentorial notch. In
front of this notch passes brainstem from supratentorial compartment to infratentorial compartment of
cranial cavity to pass through foramen magnum.
Anterior end of free margin is attached to anterior clinoid process of sphenoid bone.
Venous sinuses related
Anterior part of peripheral margin attached to superior margin of petrous part temporal bone is related to
superior petrosal sinus.
Posterior part of peripheral margin related to transverse sulcus of occipital bone is related to transverse sinus.
Function of tentorium cerebelli
Horizontal shelf of tentorium cerebelli holds on it the occipital lobes of cerebrum in supratentorial
Endosteal layer of dura Occipital lobe
Meningeal layer of dura hori􏱺ontally reflected forwards to form tentorium cerebelli

Cerebellum
Fig. 14.3 Horizontal shelf of tentorium cerebelli separating occipital lobe of cerebrum from cerebellum
218
compartment and prevents its pressure unduely to be applied on cerebellum in the infratentorial com-
partment.
Falx cerebelli (Fig. 14.1)
It is a small, crescentic fold of dura mater which extends along the midline vertical plane forwards between two
cerebellar hemisphere bellow tentorium cerebelli.
Margins
Superior margin is anteroposteriorly straight. It runs along midline being attached on the undersurface of
tentorium cerebelli.
Posterior margin is convex and attached to internal occipital crest. This margin lodges occipital sinus.
Anterior margin is concave and free. It invaginates through the gap between posteroinferior aspect of two
cerebellar hemispheres. Occipital sinus is lodged between right and left layers of this dura fold (Fig. 14.1).
Diaphragma sellae (Fig. 14.4)
It is a small, round and horizontal fold of dura mater whose peripheral margin is attached to the outline of
hypophyseal fossa (sella turcica) of superior surface of body of sphenoid on middle cranial fossa. It presents a
central circular aperture through which infundibulum (stalk) of pituitary gland passes upwards to be attached
to the base of brain.
Arterial Supply of Dura Mater
Dura mater is supplied meningeal branches of so many arteries. These meningeal branches are divided into
following three sets.
1. Anterior: For anterior cranial fossa.
2. Middle: For middle cranial fossa.

3. Posterior: For posterior cranial fossa.
Anterior meningeal branches

These branches arise from –
1. Anterior and posterior ethmoidal arteries.
Optic chiasma
Infundibulum of pituitary gland
2. Internal carotid artery.

3. A branch from middle meningeal artery.
Middle meningeal branches
1. Middle meningeal artery: It is a branch from maxillary artery. It is the largest of the meningeal arteries.
Entering through foramen spinosum it lies deep to pterion. This landmark of the artery is clinically important
for neurosurgeons. Here it divides into anterior frontal and posterior parietal branches. Some of the branches
may ascend upto vertex and anastomose with the corresponding branches of other side.
2. Accessory meningeal artery: It is also branch of maxillary artery and it enters cranium through foramen
ovale.
3. A branch from ascending pharyngeal artery enters through foramen lacerum.
Posterior meningeal branches
1. Meningeal branch of occipital artery. It may be two. One enters through jugular foramen and
another through mastoid foramen.
2. Multiple meningeal branches of vertebral artery.
Apart from very fine branches from all of the above meningeal arteries distributed to dura mater,
branches are also distributed to periosteum (endosteum), bone and bone marrow.
Nerve Supply of Dura Mater
Sensory nerves for cranial dura mater are also divided like arteries into three sets for anterior, middle and
posterior cranial fossae. These are as following:
Anterior cranial fossa
1. Anterior ethmoidal nerve. 2. Posterior ethmoidal nerve.
Mammillary body
Diaphragma sellae
Pituitary gland
Fig. 14.4 Diaphragma sellae related to pituitary gland at the base of brain
3. Meningeal branch of maxillary nerve (Nervus meningeus medius).

4. Recurrent meningeal branch of mandibular nerve (Nervus spinosus).
Middle cranial fossa
1. Nervus meningeus medius.

2. Nervus spinosus: Which also carries sympathetic
fibers from middle meningeal plexus. 219

Nervus spinosus divides into anterior and post-
erior divisions which follow the course of anterior
and posterior divisions of middle meningeal artery.
3. A recurrent tentorial branch from ophthalmic
nerve which supplies tentorium cerebelli.
Posterior cranial fossa
1. Ascending meningeal branches from upper three cervical nerves. They enter through foramen magnum.
2. Recurrentmeningealbranchofhypoglossalnerve. It is actually made up of fibers of first cervical nerve
and reenters cranium through hypoglossal canal.
3. Meningeal branch may arise from vagus nerve at the site of its superior ganglion.
In addition, meningeal branches are also given
from facial nerve and glossopharyngeal nerve.

It is important to notice at this stage that arachnoid mater and pia mater do not receive any sensory nerve.
These are restricted to dura mater only. Sympathetic fibers from cervical s􏲄mpat􏲄etic trun􏲄 are vasomotor
in nature.
Venous Sinuses of Dura Mater
These are intracranial venous channels between endosteal and meningeal layer of cranial dura mater. These
are formed due to separation of two layers or invagination of meningeal layer from endosteal layer of dura
mater.
Characteristics of venous sinuses
1. These are thin-walled with absence of muscle fibers in their wall.

2. Theyaredevoidofvalves,sobloodcanflowinboth directions.
3. Walls are formed by dura mater with inner endothelial lining.
4. The venous sinuses communicate with the veins outside cranium through emissary veins which adjust
intracranial venous pressure.
5. Venous sinuses receive venous blood from brain, meninges, bones of the cranium.
􏲠. Circulated cerebrospinal fluid also finally drains into venous sinuses.
7. Blood from all venous sinuses finall􏲄 drains through internal jugular vein.
Names of dural venous sinuses
Unpaired Paired
1. Superior sagittal sinus 1. Cavernous sinus
2. Inferior sagittal sinus 2. Superior petrosal sinus
3. Straight sinus 3. Inferior petrosal sinus
4. Occipital sinus 4. Transverse sinus
5. Anterior intercavernous sinus 5. Sigmoid sinus
6. Posterior intercavernous sinus 6. Petrosquamous sinus
7. Basilar venous plexus 7. Middle meningeal sinus
8. Sphenoparietal sinus
Some important venous sinuses (Fig. 14.5)
It is anteroposteriorly directed along the superior convex margin of falx cerebri. Narrower anterior end
communicate with nasal veins through foramen cecum. Posteriorly at the level of internal occipital
protuberance it usually turns to the right to become continuous with right transverse sinus. Cerebrospinal fluid
is absorbed through arachnoid villi projecting to the wall of this sinus.
It also runs anteroposteriorly along the lower concave free margin of falx cerebri.
It joins with great cerebral vein of Galen to form straight sinus.
Straight sinus
It is so called because of its straight anteroposterior midline direction along the line of attachment of falx
cerebri and tentorium cerebelli.
It is formed by union of inferior sagittal sinus and great cerebral vein. Its posterior end turns to the left to
become continuous with left transverse sinus.
Occipital sinus
It is small in size and runs downwards and forwards along the posterior, attached, convex margin of falx
cerebelli.
It starts from con􏲄uence of sinus which is mee- ting point of following venous sinuses at the level of internal
occipital protuberance.
220

Anterior intercavernous sinus
Left sphenoparietal sinus
Left cavernous sinus Left superior petrosal sinus
Left inferior petrosal sinus
1. Superior sagittal sinus

2. Straight sinus
3. Two transverse sinuses.
Occipital sinus ends in internal vertebral venous
plexus beyond posterior margin of foramen magnum.
Cavernous sinus
This is a paired venous sinus present in middle cranial fossa in relation to lateral surface of body of sphenoid. It
extends from apex of petrous part of temporal
bone to superior orbital fissure.

Lateral wall of the sinus is related to oculomotor,
trochlear, ophthalmic and maxillary nerves from above downwards. Medially it is related to pituitary gland in
hypophyseal fossa. Inferomedial to the sinus lie internal carotid artery and abducent nerve.
Cavernous sinus has many important tributaries and communications. It communicates through emissary
veins at base of skull with pterygoid venous plexus which is clinically important.
For detailed study of this sinus, reader is advised to consult Textbook of Gross Anatomy.
Transverse sinus
This paired sinus is lodged in the transverse sulcus on either side of internal occipital protuberance, at the
posterior part of peripheral fixed margin of tentorium cerebelli.
Right transverse sinus is formed usually as a continuation of posterior end of superior sagittal sinus and
posterior end of straight sinus usually continues as left transverse sinus.
Right transverse sinus
Confluence of sinus Straight sinus
Great cerebral vein of Galen Left transverse sinus
Sigmoid sinus
Internal jugular vein

Fig. 14.5 Important dural venous sinuses
Both transverse sinuses are continuous, at its lateral end, as sigmoid sinus on inner aspect mastoid part of
temporal bone.
Sigmoid sinus
It is so called because of its sinuous or S-shaped appearance. It is lodged on a deep groove on inner aspect of
mastoid part of temporal bone. Sigmoid sinus on either side starts as a continuation of transverse sinus and
continues as upper end (superior bulb) of internal jugular vein just beyond the level of jugular foramen.
Superior petrosal sinus
Superior petrosal sinus is also bilateral sinus. It is situated along the superior border of petrous part of
temporal bone at the anterior part of peripheral fixed border of tentorium cerebelli.
It extends from posterior end of cavernous sinus to lateral end of transverse sinus at its junction with sigmoid
sinus.
Blood is drained in anteroposterior direction from cavernous sinus towards transverse sinus.
Inferior petrosal sinus
This paired sinus extends from before backwards along the groove between inferior border of petrous part of
temporal bone and clivus of sphenoid bone. It drains blood from cavernous sinus to bulb of internal jugular vein
passing through anterior compartment of jugular foramen.
221
Sphenoparietal sinus
It is a bilateral narrow and small venous sinus running along posterior border of lesser wing of sphenoid to
drain into cavernous sinus.
ARACHNOID MATER
Arachnoid mater is a thin, delicate, impermeable transparent membrane which wraps over brain (as well as
spinal cord). It is placed in the plane between dura mater outside and pia mater inside.
Arachnoid mater invests the surface of brain and does not dips into any depression, fossa, sulcus or fissure on
the surface of brain except in following two sites.
1. Insidethemedianlongitudinalfissureofcerebrum,
arachnoid mater is taken inside by the meningeal dura to the bottom of fissure through the formation of falx
cerebri.
2. Insidethestemoflateralsulcusofbrain,arachnoid mater is pushed by posterior free margin of lesser wing of

sphenoid.
Investing the brain arachnoid mater is continuous
below foramen magnum to cover spinal cord and ends along with spinal dura at the level of lower border of body
of second sacral vertebra.
Spaces Related to Arachnoid Mater
Arachnoid mater is closely related to dura mater from which it is separated by a thin potential space called
subdural space which contains a thin layer of fluid.
Beneath arachnoid a noticeable space is there between it and pia mater called subarachnoid space. The
subarachnoid space is much wider in some sites.
Contents of Subarachnoid Space
Subarachnoid space contains following –
1. 􏱧erebros􏱧i􏱧􏱧l 􏱧ui􏱧 which, after being secreted by choroid plexus of ventricle and circulated in
ventricular system, is transported into subarachnoid space, through apertures of roof of fourth
ventricle.
2. Blood vessels of brain before they enter inside
or come out of brain substance.
3. Cranial nerves after they exit out of the brain
and before come out through foramen of skull.
4. 􏱧fi􏱧e􏱧e􏱧􏱧or􏱧o􏱧re􏱧i􏱧ul􏱧rfiberstraversingsub-

lubricated by fluid of subdural and subarachnoid space.
Prolongations of Arachnoid Mater
1. Alongthenerves:Whencranialnervearisefrom surface of brain, so also spinal nerve arising from spinal cord,
they take a sleeve of meningeal dura as well as arachnoid mater. Dura stops at the margin of foramina through
which the nerves come out. But arachnoid continues for a short distance over the perineural sheath.
2. Along the blood vessels: When arteries from subarachnoid space penetrate brain substance, they take
prolongation of arachnoid along with pia to form perivascular sheath.
Processes of Arachnoid (Fig. 14.6)
1. Arachnoid villi: These are multiple, short finger-like prolongations of arachnoid mater
which invaginate the wall of intracranial venous sinuses. These villi perforate the dural wall
of venous sinus while pushing through it and come in contact with endothelial wall of the
sinus. The specialized mesothelial cells of the arachnoid villi is concerned with transport of
cerebrospinal fluid from subarachnoid space to venous sinus.
Maximum number of arachnoid villi are found in relation to wall of superior sagittal sinus.
2. Arachnoidgranulations:Thesearenothingbut 􏱧o􏱧ifie􏱧 􏱧or􏱧s o􏱧 􏱧r􏱧􏱧􏱧􏱧oi􏱧 􏱧illi. With adva-

ncement of age, arachnoid villi are enlarged in size, becomes pedunculated and clumped
together to form arachnoid granulations whose function is same, i.e. as absorption of
cerebrospinal fluid from subarachnoid space into venous blood.
Prominent arachnoid granulations, in old age, produce impressions in the form of multiple
pits on the inner surface of bones of vault of skull adjacent to the sulcus for superior sagittal
sinus.
Subarachnoid Space
It is the space beneath arachnoid mater, so between it and pia mater. Subarachnoid space of brain is
continuous with that around spinal cord through foramen magnum.
Contents
1. 􏱧erebros􏱧i􏱧􏱧l 􏱧ui􏱧: Which flows freely around the surface of brain.

arachnoid space binds arachnoid with pia mater.
Surface lining
Both superficial and deep surfaces of arachnoid mater are covered by a layer of mesothelial cells which are
Outer periosteum
Bone of cranial vault
Endosteal layer of dura

222
Meningeal layer of dura
Arachnoid villi
Emissary vein
Arachnoid mater
Fig. 14.6 Arachnoid villi invaginating dura and endothelial wall of dural venous sinus
2. Blood vessels: Main arteries and veins supplying or draining brain lie in the plane of subarachnoid space.
3. Cranial nerves: After exit from brain, cranial nerves initially lie in the subarachnoid space before they
leave cranium through corresponding foramina.
4. Subarachnoid space is 􏱧r􏱧􏱧erse􏱧 b􏱧 fi􏱧e 􏱧e􏱧􏱧 􏱧or􏱧 o􏱧 re􏱧i􏱧ul􏱧r fibers binding arachnoid and pia
together. This fibrous network looks like a spider web. That is why arachnoid is no named, as it means
s􏱧i􏱧er􏱧􏱧eb.
The network of fibers with cerebrospinal fluid in subarachnoid space appears like a water-filled sponge acting
as a cushion around brain having significant protective function.
Communication
Interpeduncular cistern Cisterna pontis
Subarachnoid space communicates with ventricular system through foramen of Magendie and foramen o􏱧
􏱧us􏱧􏱧􏱧􏱧 on the lower ependymal roof of fourth ventricle.
Prolongations of subarachnoid space
1. Along cranial nerve, for a short distance outside cranium beyond foramina of cranial bones forming
perineural space.
2. Along blood vessels, inside brain forming perivascular space.
Subarachnoid Cisterns (Fig. 14.7)
As arachnoid mater straightway sweeps over the surface of the brain, in some areas, where brain
Cisterna ambiens (cistern of great cerebral vein)
Fourth ventricle of brain Cerebellomedullary cistern
Fig. 14.7 Subarachnoid cisterns
surface presents a marked depression, fossa or notch, subarachnoid space is found to be much more spacious.
These roomy areas of subarachnoid space are known as subarachnoid cisterns. These cisterns are filled with
adequate quantity of cerebrospinal fluid. Some cistern again contains many of the arteries which gives secondary
branches to brain.
Some important cisterns
1. Cerebellomedullary cistern (cisterna magna)
It is the largest cistern present in the angle between dorsal surface of medulla oblongata and anteroinferior aspect of
cerebellum. It is the area of subarachnoid space which directly communicates with cavity of fourth ventricle through
the foramina at its roof. Inferiorly it is continuous with spinal subarachnoid space.
2. Interpeduncular cistern
It is the cistern formed due to sweep of arachnoid mater over interpeduncular fossa. As this prominent cistern is
situated on base of brain, it is also called cisterna basalis. This cistern is important because, 1. It lodges arterial
circle of Willis.
2. It is related to important structures of interpeduncular fossa, e.g. optic chiasma, infundibulum with pituitary
gland, mammillary bodies.
3. Pontine cistern (cisterna pontis)

It is another prominent cistern in front of basilar part of pons.
It lodges basilar artery with its many important branches.
This cistern is continuous—

Above – With interpeduncular cistern.
Below – With spinal subarachnoid space. Posteriorly – With cerebellomedullary cistern.
4. Cistern of lateral sulcus
It is also called Sylvian cistern. This cistern is actually situated in front of stem of lateral sulcus, between temporal
pole and frontal lobe of cerebral hemisphere. It contains middle cerebral artery.
5. Cistern of great cerebral vein
This cistern is also known as cisterna ambiens. It is situated between splenium of corpus callosum and superior
surface of cerebellum. It contains great cerebral vein of Galen and pineal gland.
PIA MATER
Pia mater is thinnest and innermost covering of brain. It is transparent and vascular membrane.
Its surface is lined by a layer of mesothelial cells.
Pia mater is closely related to the surface of brain everywhere.
It lines the walls and also the bottom of all sulci of brain. However in cerebellum, it is not that much intimate to all
the fissure. It lines mainly the larger cerebellar fissure. Blood vessels while penetrating through the surface of
brain, take a sleeve of pia mater (along with arachnoid) inside the brain. It forms there the perivascular sheath.
Space underneath is called perivascular space.
CLINICAL ANATOMY
Functional Importance of the Meninges

Tough membrane of dura mater encasing the brain has got the vital protective role. Apart from this, dural folds,
mainly falx cerebri and tentorium cerebelli limit e􏲄cessive movements of brain 􏲄it􏲄in t􏲄e s􏲄ull.
Arachnoid mater binds the subarachnoid space containing cerebrospinal fluid and meshwork of delicate fibers
which together act as a cushion around brain.
Pia mater is the vascular membrane which acts as a media for penetration of blood vessels inside the brain.
Disharmony Between Excessive Movement of Brain and Skull with Meninges
In an individual subjected to head injury with a moving head, momentum of brain strikes it against skull and also
dural folds. It may cause tear of fragile cortical veins draining into dural venous sinus. Consequence may be
subdural or subarachnoid hemorrhage.
Intracranial Hemorrhages Related to Dura
Epidural Hemorrhage Resulting Extradural Hematoma
Epidural hemorrhage results from injury to meningeal artery or vein. The most common blood vessel affected is the
anterior (frontal) division of middle meningeal artery. A minor degree of head injury may lead to fracture of
anteroinferior part of parietal bone or squamous part of temporal bone. As a result of hematoma, meningeal layer of
dura will be stripped off from inner surface of skull. Intracranial pressure will be raised and enlarging hematoma
exerts pressure over motor area of precentral gyrus.
Subdural Hemorrhage
Subdural hemorrhage result in case of injury to superior cerebral vein at its site of drainage in superior sagittal
sinus.
223
224
It is interesting to note here the differential findings in Computed Tomography Scan (CT Scan) in epidural and
subdural hematoma. In case of epidural hemorrhage, meningeal layer of dura is stripped up from endosteal
layer visualizing a biconvex lens shaped hyperdense area. In patient with subdural hematoma, blood
accumulates in extensive potential space between meningeal dura and arachnoid mater producing a long
crescentic hyperdense area.
Meningeal Headache
Dura mater is mainly supplied by different branches of trigeminal nerve and ascending meningeal branches of
upper three cervical nerves.
Headache related to supratentorial part of dura, supplied by branches of trigeminal nerve, is referred to
forehead. Whereas, headache related to infratentorial part of dura supplied by branches of upper three
cervical nerves, is referred to occipital region.
In case of meningitis, or inflammation of meninges, headache is experienced over the entire head and back of
the neck.
In this connection, it is to be noted here that arachnoid mater and pia mater do not have any sensory nerve
fibers. Sensory nerves are only restricted to dura mater.
Meningioma
Meningiomas are one of the types of intracranial tumors which arise from arachnoid villi which are most
commonly related to superior sagittal sinus.
Thrombosis of Dural Venous Sinus
Superior sagittal sinus receives communications from veins of scalp through emissary veins and from veins of
nose. So infection from this areas may spread through venous communication to superior sagittal sinus.
Complication may lead to venous sinus thrombosis.
Cavernous sinus communicates with veins draining dangerous area of face through emissary veins at base of
skull, pterygoid venous plexus and deep facial veins. Neglected infection of this area of face may cause spread of
infection in cavernous sinus with a serious complication like cavernous sinus thrombosis.
Sigmoid sinus is separated from mastoid air cells by a thin plate of bone on the floor of sigmoid sulcus of
mastoid part of temporal bone. Mastoiditis, resulting from middle ear infection (otitis media) may lead to
spread of infection to sigmoid sinus following erosion of thin plate of bone. Infection may lead to thrombosis of
sigmoid sinus.
Pulsating Exophthalmos
Cavernous sinus is related to internal carotid artery on its inferomedial aspect. Violent head injury may cause
fracture of middle cranial fossa with rupture of internal carotid artery at this site. A communication is
established between cavernous sinus and internal carotid artery. So arterial blood is pushed in cavernous
sinus engorging communicating veins. Eyeball becomes engorged and protrudes forwards (exophthalmos). The
protruded eye is found to be pulsatile synchronizing with every systole so also pulse. That is why the clinical
condition is called pulsating exophthalmos.
CEREBROSPINAL FLUID
Cerebrospinal fluid is a modified tissue fluid which is present in ventricular system of central nervous system
and whole of subarachnoid space around brain and spinal cord.
Cerebrospinal fluid is constantly synthesized by choroid plexus of ventricle. After being circulated, it is also
constantly absorbed through arachnoid villi of subarachnoid space. While circulated, in between secretion and
absorption, its volume and pressure are also kept constant in normal individual. Its volume is 15􏲠 ml and
pressure ranges between 􏲠􏲠–15􏲠 mm of water.
Physical Property
Cerebrospinal fluid is a clear, colorless fluid being slightly alkaline in nature.
Its specific gravity is 1􏲠􏲠5–1􏲠􏲠8.

It contains inorganic salts in similar concentration
as blood plasma.
Chloride content is half the amount as compared
to blood plasma.
It contains traces of protein.
Microscopic study shows only a few lymphocytes
(up to 3 cells per cubic millimeter).
Formation
Cerebrospinal fluid (CSF) is synthesized at the rate of 200 ml per hour or 5000 ml per day.
CSF is formed by choroid plexus of all the three ventricles. 8􏲠–􏲠􏲠􏲠 is formed by choroid plexus of lateral
ventricle. Remaining is by that of third and fourth ventricles.
A very small quantity of the fluid is formed by capillaries related to the surface of brain and spinal cord.
Secretion of cerebrospinal fluid is an active process and it creates a small pressure gradient. It is important to
realize that synthesis of cerebrospinal fluid is not pressure regulated as it occurs in case of blood pressure.
Cerebrospinal fluid acts as a medium for transport of metabolites from nervous tissue to blood. Lower
concentration of potassium, calcium, magnesium, bicarbonate and glucose than in blood plasma explains active
transport.
Circulation
8􏲠–􏲠􏲠􏲠 of cerebrospinal fluid is secreted by choroid plexus of lateral ventricle. Remaining smaller amount is 225
synthesized from choroid plexus of third and fourth ventricle and from smaller blood vessels of brain surface.
Circulation of cerebrospinal fluid is a continuous process like its synthesis. From lateral ventricle the fluid
passes to third ventricle through interventricular foramen of Monro. From third ventricle CSF enters fourth
ventricle through cerebral aqueduct of Sylvius. Following two factors facilitate this circulation.
1. Arterial pulsation of choroid plexus.

2. Movement of cilia of the ependymal cells lining
ventricles.
Fluid is then squeezed slowly through fora-
men of Magendie and two lateral foramina of Luschka of ependymal roof of fourth ventricle to
cerebellomedullary cistern of subarachnoid space. Then it passes to pontine cistern from where it ascends
through tentorial notch to reach inferior surface of cerebrum.
Then pulsations of cerebral arteries help to propel the fluid upwards along superolateral surface of cerebral
hemisphere. It is from this stage some amount of cerebrospinal fluid descends through subarachnoid space of
spinal cord and further lower down around cauda equina upto the level of second sacral vertebra.
At the bottom of spinal subarachnoid space, cerebrospinal fluid flow depends upon following factors —
1. Pulsation of spinal arteries

2. Movements of spinal column
3. Respiration
4. Coughing
5. Change of posture of body.
Absorption
Principal sites of absorption of cerebrospinal fluid are the arachnoid villi. These are finger-like projections from
the arachnoid mater lining which project into
the dural venous sinuses. Mainly they project into the wall of superior sagittal sinus. Clusters of villi grouped
together form elevations which are known as arachnoid granulations.
Structurally, arachnoid villi is a diverticulum from the arachnoid mater which pierces dura mater to invaginate
the wall of venous sinus. The diverticulum is covered by a thin cellular layer which are the mesothelium of
arachnoid, being capped on its outer surface by endothelium of venous sinus.
The arachnoid granulations increase in number and size with advancement of age. Sometimes these become
calcified in old age.
Other way of absorption
Small quantity of cerebrospinal fluid is absorbed through following alternate routes.
1. Directly through some veins in subarachnoid
space.
2. Throughperineurallymphvesselsfollowingcranial
and spinal nerves.
Regulation of absorption
When the pressure of cerebrospinal fluid rises more than venous pressure in venous sinuses, absorption of
cerebrospinal fluid is facilitated. 􏲠lectron microscopic studies show that tips of arachnoid villi presents minute
tubules connecting venous sinus and are lined with endothelium. Flow of cerebrospinal fluid into venous sinus
is regulated by rise of venous pressure. When the pressure inside the venous sinus rises more than
cerebrospinal fluid pressure, tubules at the tips of arachnoid villi are closed and thus reflux of blood back into
the subarachnoid space is prevented. So arachnoid villi act as one-way valve.
􏱽loo􏱽 􏱽 cere􏱽ros􏱽inal 􏱽ui􏱽 􏱽arrier 􏱽􏱽i􏱽. 􏱽4.􏱽􏱽
It is a partition or demarcation which form barrier between blood and ventricular cerebrospinal fluid existing in
relation to choroid plexus.
Structure
It is the structure of a villus of a choroid plexus. It is the wall of villus of choroid plexus which separates lumen
of capillary from cavity of ventricle. It is made up of following elements.
1. Very thin lining of endothelial cells of capillaries which do not show true fenestration. The fenestration
areas are bridged by thin diaphragm.
2. A continuous layer of basement membrane outside capillary endothelial lining.
3. Some scattered 􏲄attened pale cells.

226
Tight junction
Pale cell
Choroidal epithelial cells
Epithelial basement membrane
Endothelial basement membrane
Endothelial cell
4. A continuous basement membrane of choroidal epithelial cells.

5. Layerofchoroidepithelialcells.Theadjacentepit- helial cells are joined by tight junctions. These tight
junctions acts as barrier.
Water, gases and lipid-soluble substances are able
to pass through the barrier from blood to cerebrospinal fluid. Macromolecules like protein are unable to pass
through.
􏱽unctional si􏱽nificance
Blood–Cerebrospinal fluid barrier is an important semipermeable membrane which prevents entry of many
potentially harmful substances into the brain and spinal cord. But it permits entry of gases and nutrients
inside the nervous tissue.
􏱽unctions of cere􏱽ros􏱽inal 􏱽ui􏱽
1. Cerebrospinalfluidcirculatedasathinfilmoffluid act as support and protective factor in addition to the

meninges.
2. Along with meshwork of fibers extending from arachnoid to pia mater, cerebrospinal fluid acts as a
cushion around the brain like a sponge soaked with water.
3. Cerebrospinalfluidispartlyconcernedwithnour- ishment of central nervous system tissue.
􏲠. Cerebrospinal fluid, as comes in direct relation with central nervous system, helps to drain metabolites.
5. As brain floats on surrounding cerebrospinal fluid encased by arachnoid as well as tough dura, weight of the
brain is felt lighter.
􏲠. As cerebrospinal fluid comes in close contact with blood at the site of venous sinuses, pressure gradient helps
for absorption of cerebrospinal fluid to a variable extent as per situation.
Fig. 14.8 Blood–Cerebrospinal fluid barrier
CLINICAL ANATOMY
Effect of Increased Cerebrospinal Fluid Pressure
In normal healthy individual, cerebrospinal fluid pressure is 􏲠􏲠–15􏲠 mm of water. If the pressure rises due to
any reason, it will lead to some effect also beyond subarachnoid space of brain. For example subarachnoid space
continues beneath arachnoid around optic nerve upto its attachment at posterior pole of retina. Pressure of
cerebrospinal fluid will exert pressure at optic disk which will compress thin- walled retinal vein producing
congestion with swelling (edema) of optic disk. It is known as papilledema.
Obstruction in Flow of Cerebrospinal Fluid at Subarachnoid Space
Normal cerebrospinal fluid pressure is 􏲠􏲠–15􏲠 mm of water. If pressure is applied on internal jugular vein at
neck, pressure of intracranial venous sinus rises which will retard the flow of cerebrospinal fluid to venous
sinuses with consequent rise in CSF pressure. In normal healthy individual this rise of pressure is observed
with the help of manometer placed through spinal tap (lumbar puncture). In case of obstruction in spinal
subarachnoid space by tumors of meninges or spinal cord, this rise of cerebrospinal fluid pressure fails to be
observed. It is known as positive 􏱧ue􏱧􏱧e􏱧s􏱧e􏱧􏱧 si􏱧􏱧.
In case of blockage of flow of cerebrospinal fluid anywhere in subarachnoid space of spinal cord, fluid below the
level of obstruction, collected by lumbar puncture, exhibits following characteristics.
1. Astheamountofproteinisincreasedremarkably, fluid drained out coagulate 􏲄uic􏲄l􏲄.

2. Fluid looks yellowish in color (Xanthochromia) due to presence of altered blood pigment.
This condition is known as Froin’s syndrome.
Hydrocephalus
Hydrocephalus is a clinical condition which is characterized by abnormal increase in quantity of cere-
brospinal fluid inside cranium. 􏲠ydrocephalus with raised intracranial pressure may be due to one of the
following causes.
1. Abnormal increase in formation of the fluid.

2. Obstructionanywhereinthepathwayofcirculation
227
of fluid.
3. Impaired absorption through arachnoid villi into
venous sinus.
If the hydrocephalus develops due to oversecretion and/or reduced absorption, with no blockage, it is called
communicating hydrocephalus where subarachnoid space along with ventricular system is dilated because
of patency of foramina at the roof of fourth ventricle. But if there is obstruction anywhere between
intraventricular foramen of Monro and, foramen of Magendie and foramina of Luschka at fourth ventricular
roof, hydrocephalus is characterized by dilatation of ventricular system only. It is called noncommunicating
hydrocephalus.
􏲠xcessive formation of cerebrospinal fluid is very rare which occurs in tumors arising from choroid plexus.
Impaired absorption of the fluid from arachnoid villi leading to hydrocephalus may be due to any of following
reasons.
1. Inflammatory exudate related to arachnoid villi. 2. Venous sinus thrombosis.
3. Increased pressure of venous sinus, when it exc- eeds the pressure of cerebrospinal fluid.
4. Compression of internal jugular vein.
Study of Cerebrospinal Fluid in Different Diseases
Physical, chemical with biochemical, microbiological and histological (pathological) examinations are done for
the purpose of detection of so many neurological diseases.
The fluid is withdrawn from spinal subarachnoid space through the process of a clinical investigation called
lumbar puncture (spinal tap) which has been described in the chapter of spinal cord.
Increased pressure of cerebrospinal fluid occurs in case of meningitis, or in case cerebral edema, cerebral
tumors, or formation intracranial hematoma or abscess.
Gross appearance of normal cerebrospinal fluid is colorless, clear and watery. Turbid or cloudy appearance
indicates presence of polymorphonuclear leukocytes or excess of proteins. Leukocyte count increases in
meningitis and encephalitis. In case of tuberculous meningitis and poliomyelitis, protein content is increased
because of increased vascular permeability.
Normal cerebrospinal fluid does not contain red blood cells. Gross appearance of blood is due to fault in lumbar
puncture when vertebral veins are punctured by spinal tap needle. Cerebrospinal fluid may be uniformly
stained with blood in subarachnoid hemorrhage. However, after some hours of subarachnoid hemorrhage,
yellowish coloration (xanthochromia) will be observed due to presence of oxyhemoglobin.
Blood Supply of Brain and Spinal Cord
Brain and spinal cord, constituting central nervous system, have high metabolic demand as these are made up of
very sensitive and delicate nervous tissue. This demand is fulfilled by aerobic combustion of glucose. For this, there
is very much necessity of adequate and continuous supply of glucose and oxygen which are transported through
bloodstream.
It is interesting to note that, though central nervous system (brain and spinal cord) constitutes only 2% of body
weight, it receives 17% of cardiac output and utilizes 20% of total oxygen utilized by body.
Central nervous system tissue is very much sensitive and highly vulnerable to injury due to lack of blood supply, so
lack of oxygen (hypoxia). Experimental studies as well as clinical observation established that, in case of arrest of
blood supply to the brain for 10 seconds, there occurs loss of consciousness and if it continues for 10 minutes for even
a tiny area of the tissue, it leads to irreversible damage.
BLOOD SUPPLY OF BRAIN
Arteries of Brain
Brain is richly supplied by arteries. Brain is encased inside cranial cavity and covered by meninges.
Source of the arteries are from outside the cranium so these arteries will have to enter the cranium.
Entering the cranium the arteries and their main branches pierce dura mater and then arachnoid mater and are
initially placed in subarachnoid space.
Final sets of branches penetrate brain tissue in the form of two groups which are—
1. 􏱧u􏱧erfi􏱧i􏱧l 􏱧􏱧or􏱧i􏱧􏱧l􏱧: Which have two characte-
ristics.
a) They supply superficial cortical part of brain. b) They form anastomosis on the surface of the
brain which will help in collateral circulation. 2. 􏱧ee􏱧 􏱧􏱧e􏱧􏱧r􏱧l􏱧 􏱧􏱧􏱧􏱧lio􏱧i􏱧 or 􏱧u􏱧le􏱧r􏱧: Which
have two characteristics—

a) They supply deeper part of brain, e.g. white
matter (fiber bundles) and deep-seated mass
of gray matter like basal nuclei.

b) These branches are end arteries which do not
have any anastomosis before capillary level.

􏱧our􏱧es o􏱧 􏱧r􏱧eries: Sources of arteries to the brain are from two bilateral arterial systems which are–
1. Vertebrobasilar arterial system.
2. Carotid arterial system.
Vertebrobasilar arterial system
This arterial system is formed by two vertebral arteries. Vertebral artery originates at scelenoverte- bral triangle of
root of neck. But it is the fourth part of vertebral artery which becomes intracranial entering through foramen
magnum to supply brain (with spinal cord).
Fourth part of vertebral artery pierces dura mater and then arachnoid mater inside the cranium. Arteries of both
sides run upwards, forwards and medially over anterolateral aspect of medulla oblongata and converge towards
midline. Uniting with each other in midline at pontomedullary junction both vertebral
15
Basilar artery
Vertebral artery
arteries from basilar artery. Basilar artery runs upwards along basilar sulcus of pons. At the upper end of
basilar sulcus basilar artery bifurcates into posterior cerebral arteries (Figs 15.1 and 15.2).
So, branches from vertebrobasilar system are divided into two groups—
1. Branches from vertebral artery.

2. Branches from basilar artery.
Branches from vertebral artery (Fig. 15.1) 229
These are five sets of branches—
1. 􏱧e􏱧ull􏱧r􏱧 􏱧r􏱧eries: These are minute, multiple
and medial branches of vertebral artery. These short branches pierce medulla oblongata.
These are called paramedian branches by clinician.
2. 􏱧e􏱧i􏱧􏱧e􏱧l 􏱧r􏱧eries: These are also minute and multiple but lateral set of branches. The
branches supply dura mater and bone of posterior cranial fossa.
3. 􏱧􏱧􏱧eriors􏱧i􏱧􏱧l􏱧r􏱧er􏱧:Thisissingleandmidline artery which is formed by union of one
contributory branches of each of the vertebral arteries. Each of the branches runs
downwards and medially, and adjoin with each other in the midline to descend vertically
along the anterior median fissure of spinal cord. Anterior spinal artery though single,
supplies anterior two-thirds of spinal cord.
4. 􏱧os􏱧eriors􏱧i􏱧􏱧l􏱧r􏱧er􏱧:Thisisbilateralbranch which arises from lateral side of vertebral
artery. Posterior spinal artery also descends vertically, but along posterolateral sulcus of
spinal cord which coincides with the line of attachment of posterior root of spinal nerves.
Meningeal arteries
Medullary arteries
Anterior spinal artery Posterior spinal artery
Though posterior spinal arteries are two in number, they supply posterior one-third of spinal cord.
Distribution of both anterior as well as posterior spinal arteries are discussed in details in connection with
blood supply of spinal cord.
5. 􏱧os􏱧erior i􏱧􏱧erior 􏱧erebell􏱧r 􏱧r􏱧er􏱧: It is the largest branch of intracranial part of vertebral artery
and presents an irregular course from side of medulla at the level of olive towards cerebellum. This artery is so
named because it is posterior in position among two inferior cerebellar arteries (Fig. 15.3). The artery runs
backwards winding round medulla to supply inferior aspect of cerebellum, both vermis as well as hemisphere. It
also gives branches to posterolateral aspect of medulla oblongata.
􏱧r􏱧􏱧􏱧􏱧es 􏱧or 􏱧􏱧oroi􏱧 􏱧le􏱧us: Choroid plexus of fourth ventricle is formed by branches of posterior
inferior cerebellar artery.
Branches of basilar artery (Fig. 15.2)
Basilar artery is formed by union of two vertebral arteries in the midline of pontomedullary junction.
The artery runs upwards along basilar sulcus of pons and at its upper end it bifurcates into right and left
posterior cerebral arteries.
Branches of basilar artery are of five groups like those of vertebral artery.
1. 􏱧o􏱧􏱧i􏱧e 􏱧r􏱧eries: These are short, narrow and
multiple branches, being paramedian in position. Just after origin, these branches penetrates through basilar
part of pons.
2. 􏱧􏱧b􏱧ri􏱧􏱧􏱧i􏱧e 􏱧r􏱧er􏱧: It is so called because it supplies labyrinth of internal ear. It is a long

􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Branches of vertebral artery
230
Posterior cerebellar artery
Basilar artery
Vertebral artery
Superior cerebellar artery Pontine arteries
Labyrinthine artery
narrow branch which accompanies facial and vestibulocochlear nerves to enter through internal acoustic
meatus and supplies internal ear.
3. 􏱧􏱧􏱧erior i􏱧􏱧erior 􏱧erebell􏱧r 􏱧r􏱧er􏱧 􏱧􏱧i􏱧s 􏱧􏱧􏱧􏱧 􏱧􏱧􏱧 􏱧􏱧􏱧􏱧􏱧: It is so named because it is the
anterior of the two inferior cerebellar arteries. It may be recalled that posterior one arises from vertebral
artery. This branch of basilar artery passes backwards and laterally to supply anterior part of inferior aspect of
cerebellum. It also gives short branches to posterolateral part of medulla oblongata and pons.
Sometimes labyrinthine artery arises from anterior inferior cerebellar artery.
Posterior cerebellar artery
Basilar artery
Vertebral artery
4. 􏱧u􏱧erior 􏱧erebell􏱧r 􏱧r􏱧er􏱧: It arises from terminal part of basilar artery close to its bifurcation.
Initially it curves around cerebral peduncle and finally reaches superior aspect of cerebellum (Fig. 15.3). It is
the artery to supply mainly superior aspect of cerebellum (vermis as well as hemispheres), but branches are
also distributed to pons, pineal gland and superior medullary velum.
5. 􏱧os􏱧erior 􏱧erebr􏱧l 􏱧r􏱧er􏱧: These are two terminal branches (right and left) of basilar artery arising at
upper end of basilar sulcus. The artery runs upwards, backwards and laterally winding round cerebral peduncle
to approach posterior part
Superior cerebellar artery
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Branches from basilar artery
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Three cerebellar arteries arising from vertebrobasilar system

of medial surface of cerebral hemisphere. It is the artery mainly to supply cerebral hemisphere as it is named
‘Cerebral”. Its distribution in detail will be discussed later, but at this stage it is to be noted that it gives
following three types of branches.
1. a) Cortical branches: These supply parts of temporal and occipital cortex.
2. b) Central branches: These branches penetrates deep into the substance of brain as end arteries to
supply midbrain, pineal gland, thalamus and lentiform nucleus.
3. c) Choroidal branches: It takes part in formation of choroid plexus of inferior horn of lateral ventricle.
Vertebrobasilar system of arteries approaching brain from behind supplies – 231

1. Hindbrain: Pons, medulla oblongata and cere-
bellum
2. Midbrain
3. Posterior part of:
a) Diencephalon: Geniculate bodies, pineal gland
and posterior part of thalamus.

b) Telencephalon: Smaller posterior part of cere-
bral hemisphere.
Carotid arterial system
Carotid arterial system is formed by intracranial portion of internal carotid artery and its branches.
Internal carotid artery enters cranial cavity through carotid canal at the base of skull. Entering inside cranium
it first lies in middle cranial fossa where it follows the following course.
Optic nerve
Optic chiasma
Optic tract Posterior cerebral artery

Basilar artery
The artery runs forwards along carotid sulcus in relation to inferomedial wall of cavernous sinus. Medial to
anterior clinoid process it turns upwards. Here it pierces dura mater and then arachnoid mater to reach the
plane of subarachnoid space. Internal carotid artery finally turns upwards and backwards lateral to optic
chiasma below anterior perforated substance where it divides into its two terminal branches — Anterior and
middle cerebral arteries.
Branches from intracranial carotid arterial system (Fig. 15.4)
Same as vertebral artery and basilar artery of vertebrobasilar system—Five branches arise from carotid
system.
1. 􏱧􏱧􏱧􏱧􏱧􏱧l􏱧i􏱧􏱧r􏱧er􏱧:Itarisesfrominternalcaro-
tid artery when it emerges from cavernous sinus to pass upwards medial to anterior clinoid process.
Ophthalmic artery arises inside cranium but it is destined to orbital cavity. It leaves cranium through optic
canal being inferolateral to optic nerve. In the orbit it supplies eyeball and other related structures.
2. 􏱧os􏱧erior􏱧o􏱧􏱧u􏱧i􏱧􏱧􏱧i􏱧􏱧􏱧r􏱧er􏱧:Itisanarrow branch which arises from the site of bifurcation of

internal carotid artery. It runs backwards and communicates with posterior cerebral artery. On either side
posterior communicating artery plays an important role to establish communication between carotid system
and vertebrobasilar system.
3. 􏱧􏱧􏱧erior 􏱧􏱧oroi􏱧􏱧l 􏱧r􏱧er􏱧: It is a long narrow branch arising from internal carotid artery, close
Anterior cerebral artery Anterior communicating artery
Ophthalmic artery Middle cerebral artery
Internal carotid artery Anterior choroidal artery
Posterior communicating artery communicates with posterior cerebral artery of vertebrobasilar system
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Branches of carotid arterial system for brain, viewed from inferior aspect (base) of the brain
to its bifurcation into two cerebral arteries. It runs backwards along the direction of optic tract and enters
through the choroid fissure of inferior horn of lateral ventricle. It takes part in formation of choroid plexus and
also gives branches to important structures like crus cerebri, optic tract, lateral geniculate body and internal
capsule.
4. 􏱧􏱧􏱧erior 􏱧erebr􏱧l 􏱧r􏱧er􏱧: It is the narrower terminal branch of internal carotid artery.
It runs forwards and medially above optic nerve.

232
Then it reaches median longitudinal fissure of brain.
Here it is joined to the anterior cerebral artery of opposite side by anterior communicating artery which may be
double or absent in some cases.
Finally anterior cerebral artery approaches the medial surface of cerebral hemisphere where it divides into two
terminal branches called pericallosal artery and callosomarginal artery.
Anterior cerebral artery itself gives rise to two sets of branches called cortical and central (nuclear or
ganglionic) branches.
5. 􏱧i􏱧􏱧le􏱧erebr􏱧l􏱧r􏱧er􏱧:Itisthelargerterminal branch of internal carotid artery and looks to be the

continuation of parent arterial trunk after anterior cerebral branch is given out. It is also the largest branch of
internal carotid artery. Middle cerebral artery, after its origin at the base of brain near anterior perforated
substance, runs upwards backwards and laterally to reach stem of lateral sulcus of cerebrum.
Like posterior and anterior cerebral arteries, middle cerebral artery also gives out following two sets of
branches.
a) Central branches: These branches arise from
middle cerebral artery while it is in base of brain near anterior perforated substance.
b) Cortical branches: These branches arise while the parent trunk approaches superolateral surface of cerebral
hemisphere.
Communication Between Vertebrobasilar and Carotid Arterial Systems (Fig. 15.5)
It has already been noticed that at the base of the brain arteries of vertebrobasilar system approach from
behind and those of carotid system proceed from the front. But a communication is established among branches
of two systems of both sides. This arterial communication is called 􏱧ir􏱧le o􏱧 􏱧illis or 􏱧ir􏱧ulus 􏱧r􏱧eriosus
(Fig. 15.5). This arterial circle is situated on interpeduncular fossa of base of the brain in the plane of
interpeduncular cistern of subarachnoid space.
Though it is called arterial ‘circle’ of Willis, it is not circular but polygonal (hexagonal) in outline. Arteries
forming the circle of Willis are—
1. Anterior communicating artery
2. Anterior cerebral artery
3. Internal carotid artery, continued as middle cere-
bral artery
4. Posterior communicating artery 5. Posterior cerebral artery
6. Basilar artery.
VARIATIONS OF CIRCLE OF WILLIS
1. Commonest variation is in relation to anterior communicating artery. Very often it may be double.
Sometimes it is absent.
2. Incompletecircle:Posteriorcommunicatingartery of one side or even of both sides may be absent making
the arterial circle incomplete.
1. Anterior communicating artery 2. Anterior cerebral artery
3. Internal carotid artery continued as middle cerebral artery
4. Posterior communicating artery 5. Posterior cerebral artery
6. Basilar artery
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Circle of Willis to establish communication between vertebrobasilar system and carotid system
􏱪􏱪nctional 􏱪i􏱪nificanc􏱪 of Ci􏱪cl􏱪 of 􏱪illis
Parent arteries which contribute to formation of circle of Willis are divided in following four units.
1. Right internal carotid artery
2. Left internal carotid artery
3. Right vertebral artery 4. Left vertebral artery.
In normal healthy individual, because of uniformity of arterial pressure in four units, blood from one unit is not
at all mixed up with blood of other unit, neither side to side, nor anteroposteriorly. It is important as well as 233
interesting to note that, even in basilar artery blood from two vertebral arteries are not admixtured. So, it is
very clear that in normal person, anatomical anastomosis of circle of Willis is not physiologically active. But in
pathological condition, if any one of the arteries forming the arterial circle is blocked, collateral circulation is
established. So depending on the site and nature of occlusion, blood from one arterial unit may flow to any part
of brain.
􏱪􏱪anc􏱪􏱪s of Ci􏱪cl􏱪 of 􏱪illis 􏱪􏱪i􏱪􏱪 􏱪􏱪􏱪􏱪􏱪
It has already been learnt that, brain receives two sets of branches from arteries of both vertebrobasilar and
carotid system. These are cortical and central.
Branches from circle of Willis are all central. These are also called nuclear or ganglionic branches which are
example of end arteries.
Branches are divided into following four groups.
1. Anteromedial—Median
2. Anterolateral—Right and left
3. Posteromedial—Median
4. Posterolateral—Right and left.
Anteromedial branches
These branches arise from anterior communicating and anterior cerebral arteries. One of the branches
Anterior cerebral artery Recurrent artery of Heubner

Middle cerebral artery
Internal carotid artery Posterior communicating artery
Posterior cerebral artery Basilar artery
arise from anterior cerebral artery which presents a recurrent course. This is called re􏱧urre􏱧􏱧 􏱧r􏱧er􏱧 o􏱧
􏱧eub􏱧er. Anteromedial set of branches supply—
Anterior half of anterior limb of internal capsule Putamen
Head of caudate nucleus. Anterolateral branches
These are called striate arteries which arise from site of origin of middle cerebral artery.
These branches penetrate through anterior perforated substance and are divided into two groups called lateral
and medial striate arteries.
Lateral striate arteries ascend along lateral surface of lentiform nucleus. These arteries supply— Posterior
half of anterior limb and anterior two- thirds of posterior limb of internal capsule—
Lentiform nucleus
Caudate nucleus
Thalamus.
One of the lateral striate arteries supplying posterior limb of internal capsule presents a long course. It is called
􏱧􏱧􏱧r􏱧o􏱧􏱧s 􏱧r􏱧er􏱧 o􏱧 􏱧erebr􏱧l 􏱧e􏱧orr􏱧􏱧􏱧e. Because of its length, it is more prone to be damaged in
cerebrovascular accident.
Medial striate arteries ascend medial to lentiform nucleus and supply—
Caudate nucleus Internal capsule.
Posteromedial branches
These branches are median in position and originate from posterior communicating and posterior cerebral
arteries.
They penetrate through posterior perforated substance and give branches to—
Anterolateral (striate) branches
Charcot’s artery of cerebral hemorrhage Anteromedial branches
Posterolateral branches Posteromedial branches

􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Central branches of circle of Willis
234
Anteromedial part of cerebral peduncle
Hypothalamus forming floor of third ventricle
Medial part of thalamus forming lateral wall of third ventricle.
Posterolateral branches
These branches arise from posterior cerebral artery lateral to its junction with posterior communicating artery.
Posterolateral branches are bilateral to supply: Posterior part of thalamus
Geniculate bodies
Posterior part of cerebral peduncle Pineal gland
Tactum of midbrain.
Central branches of circle of Willis are also known as ganglionic or nuclear branches, because in the central core
of brain, these branches not only supply important fiber bundles like internal capsule, but also many of them
supply submerged collection of gray matter which are called basal ganglia or basal nuclei. All the central
branches are example of e􏱧􏱧 􏱧r􏱧eries having no anastomosis in precapillary level. So, once one of these
arteries are affected due to hemorrhage, thrombosis or embolism, area of brain supplied by that artery will
suffer from irreversible damage.
CORTICAL BRANCHES SUPPLYING DIFFERENT SURFACES OF CEREBRAL HEMISPHERE
Superficial gray matter of cerebral hemisphere (cerebral cortex) is supplied by cortical branches of anterior,
middle and posterior cerebral arteries. Before these cortical branches penetrate into the cortex, they
anastomose freely on the surface of the brain. So, if any branch is occluded, the area will receive blood supply
through collateral circulation.
It is important to note that three cerebral arteries are concerned with arterial supply of three surfaces of
cerebral hemisphere. It means, each of the surfaces receive branches from all the three cerebral arteries, but
with variations in their share.
Superolateral Surface (Fig. 15.7A)
Middle cerebral artery is the main artery for superolateral surface. It supplies most of the area of this surface.
Important areas supplied by middle cerebral artery includes, major parts of primary motor and primary sensory
area, frontal eye field, motor speech area, auditory area.
The areas of superolateral surface not supplied by middle cerebral artery are –
1. A narrow strip of area of about 2.5 cm breadth
below and parallel to superomedial border, from frontal pole upto parietooccipital sulcus, which is supplied by
bran-ches of anterior cerebral artery. It includes ‘leg area’ of primary motor and primary sensory cortex.
2. Occipital lobe and a narrow strip above and parallel to lower border of temporal lobe (except temporal pole)
which is supplied by branches of posterior cerebral artery.
Medial Surface (Fig. 15.7B)
Maximum area of medial surface (anterior two-thirds) is supplied by branches of anterior cerebral artery which
covers paracentral lobule.
Areas of medial surface not supplied by anterior cerebral artery are—

1. Temporal pole which is supplied by middle cerebral
artery.
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Areas of superolateral surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Areas of medical surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
2. Occipital lobe and medial surface of temporal lobe (except temporal pole) which is supplied by posterior
cerebral artery which therefore supplies visual area.
Inferior Surface (Fig. 15.7C)
Tentorial surface area (except temporal pole) is supplied by posterior cerebral artery.
Tentorial surface of temporal pole is supplied by middle cerebral artery.
Larger lateral part of orbital surface of frontal lobe (Fig. 15.7C) is supplied by middle cerebral artery.
Smaller medial part of orbital surface of frontal lobe is supplied by anterior cerebral artery.
􏲄􏲄􏲄siological control of blood 􏲄o􏲄 in cerebral arteries– 235

1. Cerebral arteries are richly supplied by postga-
nglionic sympathetic fibers which arise from superior cervical sympathetic ganglion. Stimulation of these
fibers causes cerebral vasoconstriction.
2. However, in normal condition, cerebral blood flow is under chemical regulation rather than nervous control.
Arterial blood flow to the brain is dependent upon concentration of carbon dioxide, hydrogen ion and oxygen
present in nervous tissue. Increase in carbon dioxide and hydrogen ion concentration and lowering of oxygen
tension causes cerebral vasodilatation.


􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Areas of inferior surface of cerebral hemisphere supplied by cortical branches of three cerebral arteries
VENOUS DRAINAGE OF BRAIN
At the beginning it is to be noted that veins draining brain are quite different from intracranial venous sinuses.
236 Characteristics
1. Veins of the brain are thin-walled due to absence of muscles in the walls.
2. These veins are devoid of valves, so blood does not have unidirectional flow.
3. Arrangement of veins does not follow the arterial pattern.
4. All the veins of brain ultimately drain in intracranial venous sinus.
5. Veins are situated initially in subarachnoid space. But ultimately they pierce arachnoid mater and
meningeal layer of dura mater to drain into venous sinuses.
6. To maintain the patency, some of the veins drains against the direction of blood flow through the sinus.
Groups of Veins
Broadly veins of the brain are divided into following three groups—
External cerebral veins
Internal cerebral veins
Terminal veins. External Cerebral Veins
Superior cerebral veins (Fig. 15.8)
These veins are 6–12 in number. They are shorter in length and parallel to each other. Superior cerebral
Superior cerebral vein
Inferior cerebral vein
Superficial middle cerebral vein
veins drain the upper halves of both superolateral as well as medial surfaces of cerebrum. They drain in
superior sagittal sinus. Anterior group opens at right angle but posterior group of veins opens obliquely
against the direction of blood flow (anterior to posterior) in superior sagittal sinus. This will maintain their
patency even when CSF pressure is increased.
􏱽u􏱽erficial 􏱽i􏱽􏱽le cere􏱽ral 􏱽eins 􏱽􏱽i􏱽. 􏱽􏱽.􏱽􏱽
It runs downwards, forwards and medially along the length of posterior ramus and then stem of lateral sulcus
of brain. This vein will receive tributaries from the area of superolateral surface around posterior ramus of
lateral sulcus.
Superficial middle cerebral vein drains into cavernous sinus or sometimes into sphenoparietal sinus.
Communications
Superficial middle cerebral vein communicates with – Superior sagittal sinus: Through superior ana-
stomotic vein.
Transversesinus:Throughinferioranastomotic
veins.
Deep middle cerebral vein: Present deep to it
on insular cortex.
Deep middle cerebral vein
It is situated very deep in lateral sulcus on the surface of insular cortex and coupled with middle cerebral
artery.
It runs downwards and forwards to form basal vein joining with anterior cerebral vein.
Superior anastomotic vein
Inferior anastomotic vein
Transverse sinus Sigmoid sinus
Superior bulb of internal jugular vein

􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Veins in relation to superolateral surface of cerebral hemisphere
237
Anterior cerebral vein (Fig. 15.9)
It is the only vein which is the companion of corresponding artery, i.e. anterior cerebral artery.
It runs over the surface of corpus callosum and approaches towards base of the brain curving genu. It receives
small tributaries from the area of medial surface of cerebral hemisphere which is not drained by superior and
inferior sagittal sinuses. As mentioned earlier, anterior cerebral vein forms basal vein joining with deep middle
cerebral vein.
Inferior cerebral veins

These are multiple small veins draining inferior surface of cerebral hemisphere. They are divided into two
groups. Veins draining orbital surface converge and terminate into superior cerebral veins or directly into
superior sagittal sinus. Veins of tentorial surface drain into cavernous sinus.
Internal Cerebral Veins (Figs 15.9 and 15.10)
There are two internal cerebral veins, one on either side of midline.
Internal cerebral vein begins at the level of interventricular foramen of Monro at the apex of tela choroidea of
third ventricle.
This vein is formed by union of following veins.
1. 􏱧􏱧􏱧l􏱧􏱧os􏱧ri􏱧􏱧e􏱧ei􏱧:Drainsthalamusandbas-
al ganglion (corpus striatum).
2. 􏱧e􏱧􏱧􏱧l 􏱧ei􏱧: Drains septum pellucidum.

3. 􏱧􏱧oroi􏱧􏱧l 􏱧ei􏱧: Drains from choroid plexus.
The two internal cerebral veins, one on either side
of midline, run backwards between two layers of tela choroidea. Below splenium of corpus callosum two veins
join to form great cerebral vein of Gelen.
Straight sinus
Basal vein
Terminal Veins
Basal vein (Figs 15.9 and 15.10)
This vein is one on either side of midline. It is formed at anterior perforated substance by union of–
Deep middle cerebral vein
Anterior cerebral vein
Striate vein.
Besides the above mentioned tributaries of formation, basal vein also receives vein from–
Cerebral peduncle
Structures of interpeduncular fossa
Tectum of midbrain
Parahippocampal gyrus
Basal vein finally joins great cerebral vein of Galen.
Great cerebral vein (Figs 15.9 and 15.10)
Great cerebral vein of Galen is a single midline vein. It is formed by union of two internal cerebral veins below
splenium of corpus callosum. It receives basal veins from two sides. A little backwards it joins with inferior
sagittal sinus to form straight sinus (Fig. 15.9).
BLOOD SUPPLY OF SPINAL CORD
Arterial Supply (Fig. 15.11)
Spinal cord lies in upper two-thirds of vertebral canal extending from upper border of 1st cervical vertebra to
lower border of 1st (2nd) lumbar vertebra. Main arterial channels supplying spinal cord are called spinal
arteries. These are three vertical channels, which arise from intracranial part (4th part) of vertebral arteries.
After origin, spinal arteries come
Anterior cerebral vein
Internal cerebral vein
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧 Veins in relation to medial surface of cerebral hemisphere

Septal vein Thalamostriate vein
Choroidal vein
Septal vein, thalamostriate vein and choroidal vein join to form internal cerebral vein
Tela choroidea
Terminal part of great cerebral vein of Galen
238
Basal vein joining great cerebral vein

out of cranium through foramen magnum to enter vertebral canal. These three arteries are –
One anterior spinal artery
Two posterior spinal arteries.
Anterior spinal artery
Inside cranium, each of the vertebral arteries gives out one anterior spinal branch which descends downwards
and medially towards anterior median line where they meet each other to form single anterior spinal artery.
Anterior spinal artery so formed, runs downwards along anterior median fissure of spinal cord.
Branches
While running along anterior median fissure, at the level of every segment of spinal cord, anterior spinal artery
gives sulcal branches which penetrate through spinal cord to anterior two-thirds of spinal cord covering –
1. Anterior gray column, anterior gray commissure, (and lateral gray column)
2. Anterior and lateral white columns with anterior white commissure.

Sulcal branches supply anterior two-thirds of
spinal cord in alternate fashion to right and left side in successive spinal cord segment.
Channel of anterior spinal artery extends upto lower end of spinal cord but it may show some variations.
1. It may be prominent only upto cervical level beyond which it may be very slender.
2. In some cases, in upper thoracic level and in thor- acolumbar junction, anterior spinal artery may be very
narrow.
In any of the cases, where anterior spinal artery
is deficient, blood 􏲄o􏲄 to t􏲄e anterior spinal arter􏲄 is reinforced by segmental contribution of other arteries
(discussed below).
Posterior spinal arteries
Posterior spinal arteries are two in number, right and left. They arise from intracranial part of vertebral artery
or sometimes from posterior inferior cerebellar artery of respective side. Leaving cranial cavity through
foramen magnum, the arteries descend vertically along posterolateral sulcus of spinal cord at the line of
attachment of posterior roots of spinal nerves. Posterior spinal arteries give off branches in every segments
which enter the substance of spinal cord to supply its posterior one-third which includes –
1. Posterior gray column with posterior gray commissure.
2. Posterior white column.
Variations
Posterior spinal arteries may be very much narrow in upper thoracic level. It is very much vulnerable
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Terminal veins related to tela choroidea of third ventricle

to ischemia in upper three thoracic segments where
reinforcement of the artery is very much essential by segmental arteries.
Reinforcement of spinal arteries
It is already understood, though both anterior and posterior spinal arteries may be existent throughout whole
length of spinal cord, anatomically they are slender in different levels. This effect may interfare with adequate
blood flow in the affected segments of spinal cord. But it is compensated through reinforcement of the spinal
arteries by se􏱧􏱧e􏱧􏱧􏱧l 􏱧r􏱧eries at every segment throughout whole length of spinal cord.
239
Segmental arteries are horizontal in disposition and enter vertebral canal through intervertebral foramina.
Segmental arteries arise from the following regional arteries.
1. 􏱧􏱧􏱧er􏱧i􏱧􏱧lre􏱧io􏱧:Deepcervicalartery,ascending
cervical artery, and 2nd part of vertebral artery.
2. 􏱧􏱧􏱧􏱧or􏱧􏱧i􏱧re􏱧io􏱧:Posteriorintercostalarteries.
3. 􏱧􏱧 lu􏱧b􏱧r re􏱧io􏱧: Lumbar arteries, may be su-
pplemented by lateral sacral artery.
Course, distribution and communication of segmental arteries–
Segmental arteries enter vertebral canal through respective intervertebral foramen. It then divides into
anterior and posterior radicular arteries which approach respective aspect of spinal cord along the route of
anterior and posterior roots of spinal nerve. Primary role of the radicular arteries are to supply corresponding
nerve roots. But they continue to run
Posterior radicular artery
Arterial vasocorona
Branches supplying nerve roots

Anterior radicular artery
further towards the surface of spinal cord for two purposes.

1. They encircle spinal cord from anterior and poste-
rior aspects of both sides and communicate with each other. While doing so, along the length of spinal cord they
form a fine arterial reticulum or network called arterial vasocorona. Branches from it directly enter the
substance of spinal cord.
2. The radicular artery also communicates with the spinal arteries on the surface to reinforce spinal arteries.
This reinforcement is important for adequate blood flow through spinal arteries, particularly below cervical
level where spinal arteries are very thin. One of the anterior redicular artery may be very much prominent to
take the place of lower two-thirds of anterior spinal artery in case of its deficiency. It is called 􏱧r􏱧eri􏱧
r􏱧􏱧i􏱧ul􏱧ris 􏱧􏱧􏱧􏱧􏱧. Its position is variable from T1–T11 segment.
Additional feeder arteries: Additional feeder arteries enter the vertebral canal and anastomose with
anterior and posterior spinal arteries. But site of origin, number and size varies from one individual to another.
One of the large and important feeder artery is called 􏱧re􏱧􏱧 􏱧􏱧􏱧erior 􏱧e􏱧ull􏱧r􏱧 􏱧r􏱧er􏱧 o􏱧
􏱧􏱧􏱧􏱧􏱧ie􏱧i􏱧􏱧. It arises from aorta either in lower thoracic or upper lumbar level. It is unilateral and in most
of the cases if enters the spinal cord from left side. When this artery is present, it becomes the major source of
blood flow to lower two-thirds of spinal cord.
VENOUS DRAINAGE OF SPINAL CORD
All the venous channels of spinal cord, like arteries, are longitudinal in position being parallel to long-axis
Posterior spinal artery
Segmental artery
Spinal branch of segmental artery
Anterior spinal artery

􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Arterial supply of spinal cord
240
of spinal cord. These are six in number with fixed position as follows:
1. 􏱧􏱧e􏱧􏱧􏱧ero􏱧e􏱧i􏱧􏱧:Itrunalonganteriormedian
fissure of spinal cord.
2. 􏱧􏱧o􏱧􏱧􏱧erol􏱧􏱧er􏱧l:Theyrunalonganterolateral
sulcus in front of attachment of anterior nerve roots.

These three veins are named anterior spinal veins.
3. 􏱧􏱧e 􏱧os􏱧ero􏱧e􏱧i􏱧􏱧: It runs along posterior median sulcus of spinal cord.

4. 􏱧􏱧o 􏱧os􏱧erol􏱧􏱧er􏱧l: These veins run along posterolateral sulcus of spinal cord, posterior to
attachment of posterior roots of spinal nerve. These three veins are named as posterior
spinal veins.
Communication Network
All the six veins receive tributaries from spinal cord. These tributaries form a fine network on the pial surface
of spinal cord which is called venous vasocorona.
􏱧r􏱧i􏱧􏱧􏱧e:Spinalveinsformaplexusinsideverte- bral canal called i􏱧􏱧er􏱧􏱧l 􏱧er􏱧ebr􏱧l 􏱧e􏱧ous 􏱧le􏱧us.

Radicular veins arising from it join to form segmental veins which come out through intervertebral foramen to
drain in regional veins of cervical, thoracic and lumbar regions.
Communication with Intracranial Veins
Upper end of internal vertebral venous plexus ascend through foramen magnum to communicate with
basilar venous plexus which in turn, establishes communication with intracranial venous sinuses.
BLOOD-BRAIN BARRIER
Sensitive and delicate tissue of central nervous system (brain and spinal cord) needs suitable environment for
its normal activity. That is why in one side it needs selective transport of essential substances from blood
capillaries to extracellular space of nervous tissue and again it needs restriction of entry of some injurious and
toxic substances. This becomes possible only because of presence of a barrier between capillary lumen and
extracellular space of nervous tissue. This is called blood-brain barrier. Though it is called ‘blood-brain barrier’
it demarcates blood from brain as well as spinal cord.
Structure (Fig. 15.12)
Electron microscopic studies reveal following layers of blood-brain barrier—

1. 􏱧􏱧􏱧o􏱧􏱧eli􏱧l 􏱧ells o􏱧 􏱧􏱧ll o􏱧 􏱧􏱧􏱧ill􏱧r􏱧: Blood-
brain barrier is characterized by permeability restriction because endothelial lining presents ‘tight junction’ and
it is devoid of typical fenes- trations.
􏱧􏱧se􏱧e􏱧􏱧 􏱧e􏱧br􏱧􏱧e: Outside the endothelial cells, there is continuous layer of basement membrane.
Components forming blood-brain barrier
1. Capillary endothelium
2. Basement membrane
3. Foot process of astrocytes
Tight junction between endothelial cells
􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧 Blood-brain barrier
2. 􏱧oo􏱧 􏱧ro􏱧esses o􏱧 􏱧s􏱧ro􏱧􏱧􏱧es: Surrounding the capillary wall and closely apposed to it, there are
numerous foot processes of astrocytes.
Selective Permeability
Blood-brain barrier is impermeable to compound having molecular weight of 60,000 or more. It follows
241
transport of gases and water readily. Lipid-soluble substances are able to pass through. The barrier permits
transport of glucose, electrolytes, amino acids but prevents access of protein. Toxic materials are prevented
from passing through the barrier. Blood-brain barrier has got enormous importance in connection with drug
therapy and induction of anesthesia. To have an effect on central nervous system tissue, a drug for treatment of
a disease, must have ability to pass through blood-brain barrier.
Areas of Brain Devoid of Barrier
In some areas of brain, blood-brain barrier is not existent. Because selective permeability is not maintained in
those areas due to absence of tight junction in endothelial lining. These areas are –
1. Pineal gland
2. Neurohypophysis
3. Tuber cinereum
4. Walls of supraoptic recess of third ventricle
5. Area postrema in the floor of fourth ventricle.
Blood-brain barrier in newborn needs special
mention. Although it exists very well in newborn, there are evidences that it is more permeable to cert- ain
substances than in case of adults.
pressure (hypertension) and dyslipidemia reduced the incidence of cerebrovascular accidents.
Final distributing arteries are anterior, middle and posterior cerebral arteries. They present free anastomosis
on the surface of cerebral cortex. But the central branches via circle of Willis penetrate into the central core of
brain where they may branch further but no further anastomoses takes place. These central branches are
therefore end arteries.
Factors Responsible for Impairment of Cerebral Blood Flow
These factors may be many. But most important factors interfering with normal cerebral blood flow are— 1.
􏱧l􏱧er􏱧􏱧io􏱧 o􏱧 bloo􏱧 􏱧ressure: Hypertension or
hypotension
2. 􏱧ise􏱧seso􏱧􏱧r􏱧eries􏱧􏱧lls:Itistheformationof
atheroma which can occlude the lumen of artery.
It may cause formation of thrombus.

3. 􏱧ise􏱧ses􏱧􏱧i􏱧􏱧blo􏱧􏱧􏱧􏱧e􏱧r􏱧eri􏱧llu􏱧e􏱧. It may occur in following two forms—
a) Embolism by a dislodged thrombus.
b) Embolism by fat globules.
Cerebral Artery Syndromes
These are the syndromes which occur following occlusion of any of the three cerebral arteries. From knowledge
of anatomy it is well-understood that these kinds of occlusive disorder give rise to various neurological
manifestations. It is not possible as well as not desirable for the sake of common readers to discuss these
manifestations in detail. Interested readers may consult textbooks of neuromedicine. Salient features of
cerebral arterial syndromes are discussed below.
Anterior Cerebral Artery Occlusion
Occlusion of anterior cerebral artery distal to anterior communicating artery leads to following manifestations
–
1. Contralateral hemiparesis and hemianesthesia of
leg and foot area due to involvement of uppermost part of both primary motor as well as sensory areas adjacent
to superomedial border of cortex on lateral and medial surfaces of cerebral hemisphere which include
paracentral lobule.
2. Apathyandpersonalitychangeduetoinvolvement of frontal lobe area adjacent to superomedial border of

cerebral cortex.
3. Impairment of power of steriognosis: The patient will be unable to identify an object. It is due to lesion of
marginal part of superior parietal lobule adjacent to superomedial border, the area which is supplied by
anterior cerebral artery.
CLINICAL ANATOMY
Rich blood supply to brain and spinal cord is very much essential for its high metabolic demand fulfilled by
aerobic combustion of glucose. Both glucose and oxygen are carried to nervous tissue through the media of
bloodstream. Blood is carried through both vertebrobasilar system and carotid system. Internal carotid artery is
the major source of arterial blood flow. Arrest of blood supply to the brain for 10 seconds result is
unconsciousness. It is proved that, if complete arrest of blood flow continues beyond 1 minute, neuronal
function ceases. Irreversible neuronal tissue damage starts after 4 minutes and becomes complete by 10
minutes of vascular occlusion.
Cerebrovascular accidents are one of the most leading cause of morbidity and mortality in almost all the parts
of globe. It results from hemorrhage, thrombosis and embolism. In the recent days, awareness in the
community to control high blood
242
Middle Cerebral Artery Occlusion
Following are the clinical manifestations which will of course vary as per site of occlusion and degree of
collateral circulation.
1. Contralateral hemiplegia and hemianesthesia
except ‘leg and foot’ area and supranuclear paralysis of cranial nerve manifested by paralysis of lower half of
contralateral side of face. These losses are due to involvement of primary motor cortex and primary sensory
cortex on superolateral surface of brain except upper marginal part (con-trolling leg and foot area) which is
supplied by anterior cerebral artery.
2. Aphasia is noted when dominant left cerebral hemisphere is involved affecting motor and sensory area
for speech (Broca’s area or area 44, 45).
3. Contralateral homonymous hemianopia due to lesion of optic radiation which receives branches from
middle cerebral artery.
Auditory area (area 41 and 42) of superior temporal
gyrus also suffers from ischemia. But in case of unilateral vascular lesion, there is little impairment of hearing
due to bilateral cortical influence.
Posterior Cerebral Artery Occlusion
Occlusion of posterior cerebral artery leads to jeopardization of blood supply to visual area of occipital cortex
(area 17). It will cause visual defect called homonymous hemianopia with sparing of macular vision. The defect
is manifested by loss of contralateral half of field of vision. Macular vision is spared because macular area of
visual cortex on lateral surface receives collateral circulation from middle cerebral artery.
Lesion of Central Branches
Central branches from circle of Willis are end arteries. These arteries are divided into four sets. Many of them
penetrate into deeper central core of cerebral hemisphere to supply white matter like internal capsule and
masses of deep-seated gray matter, e.g. basal ganglia. Lateral striate branches of middle cerebral artery once
damaged, leads to lesion in posterior limb of internal capsule through which pass bundles of corticospinal tract.
It will therefore result in contralateral hemiplegia. If vascular lesion affects retrolentiform and sublentiform
part of internal capsule it will cause contralateral hemianopia and hemihypoacusis. Vascular lesion of basal
ganglia will lead to various manifestation of extrapyramidal disorder.
Thrombosis is most common in middle cerebral artery or its branches, because it is the direct continuation of
internal carotid artery.
Vascular Disorder Related to Vertebrobasilar System
Vertebrobasilar arterial system supplies the parts of brain situated in posterior cranial fossa. These are— 1.
Brainstem
2. Cerebellum
3. Occipital lobe of cerebrum.

Different branches of vertebrobasilar system are
concerned for feeding different component of brain. Some common types of vascular occlusive disorders are
mentioned below—
1. 􏱧e􏱧􏱧r􏱧l 􏱧􏱧e􏱧i􏱧l􏱧 􏱧e􏱧ull􏱧r􏱧 s􏱧􏱧􏱧ro􏱧e: Ven-
tral part of medulla oblongata is lesioned due to occlusion (thrombosis) of medullary branches of vertebral
artery. It causes crossed paralysis which is characterized by contralateral hemiplegia and ipsilateral paralysis
of muscles of tongue.
2. 􏱧􏱧􏱧er􏱧l 􏱧e􏱧ull􏱧r􏱧 􏱧􏱧􏱧lle􏱧ber􏱧􏱧 s􏱧􏱧􏱧ro􏱧e: Occlusion of posterior inferior cerebellar

artery leads to this condition where posterolateral part of medulla oblongata and
cerebellum is lesioned. It is manifested by—
1. a) Contralateral hemianesthesia of body and ipsilateral hemianesthesia of face.
2. b) Dysphagia and dysphonia due to paralysis of muscles of soft palate, pharynx and
larynx.
3. c) Cerebellar ataxia.
4. d) Vertigo, nausea, vomiting, nystagmus.
5. e) Horner’s syndrome.
3. 􏱧ill􏱧r􏱧 􏱧ubler 􏱧􏱧􏱧􏱧ro􏱧e: It results due to occlusion of paramedian pontine branches of
basilar artery supplying lower and ventral part of pons. In this case lesions of descending
fibers of corticospinal tract and emerging fibers of VIth and VIIth cranial nerve result in
following neurodeficits—
a) Contralateral hemiplegia
b) Ipsilateral facial paralysis
c) Ipsilateral medial strabismus (squint) due to
unopposed action of medial rectus muscle.
4. 􏱧o􏱧􏱧i􏱧e 􏱧e􏱧orr􏱧􏱧􏱧e: It is extensive and bilateral in nature so that clinical condition will
cause all bilateral manifestation due to lesion of pons. In addition the lesion will present
following two
specific features.
􏱧i􏱧􏱧oi􏱧􏱧 􏱧u􏱧il: Due to involvement of ocular sympathetic fibers.

􏱧􏱧􏱧er􏱧􏱧re􏱧i􏱧:Duetoseverelesioninponswhich disconnect the body from heat regulating center in
hypothalamus.
5. 􏱧eber s􏱧􏱧􏱧ro􏱧e: It occurs due to occlusion of
a branch of posterior cerebral artery supplying ventral part of cerebral peduncle. It results in lesion of
corticospinal and corticobulbar (corti-
conuclear) tracts and emerging fibers of oculomotor nerve. Clinical manifestations are contralateral hemiplegia,
paresis of contralateral lower half of face and tongue, with ptosis, lateral squint, dilatation of pupil with its no
reaction to light and accommodation.
Cerebral Aneurysms
Aneurysm is the condition which is characterized by abnormal dilatation of wall of any part of artery. Cerebral
aneurysms are mostly congenital in origin. Congenital cerebral aneurysm occurs mostly at the site where two
arteries join at the base of brain to from circle of Willis. This is due to congenital deficiency of muscle fibers at
that site of arterial wall. Multiple aneurysms giving ‘berry-like’ appearance in the arterial tree are called 243
􏱧err􏱧 􏱧􏱧eur􏱧s􏱧s. Congenital deficienc􏲄 of tunica media resulting ballooning of arterial wall is further
complicated by formation of atheroma.
Local dilatation may initially cause pressure effect on neighboring structure, such as optic nerve or the third,
fourth or sixth cranial nerve and so producing symptoms accordingly. Afterwards, aneurysms may suddenly
rupture in subarachnoid space. In this case there occurs sudden onset of intense headache followed by mental
confusion. Death may occur quickly or within a few days. Best chance of recovery is there following clipping or
ligation of neck of aneurysms.
Acquired cerebral aneurysms, though rare, occurs due to softening of arterial wall following lodgement of an
infected embolus. Acquired aneurysms may also occur in case of arterial disease like atheroma on normal
arterial wall. It may be a complication of damage of internal carotid artery where it lies in cavernous sinus.
Intracranial Hemorrhage
Apart from cerebrovascular lesion, intracranial hemorrhage may also result from trauma.
Four varieties of intracranial hemorrhage are following:
Epidural (Extradural) Hemorrhage
It usually occurs due to injuries to meningeal arteries or veins. Anterior division of middle meningeal artery is
commonly damaged, following a comparatively minor blow to the side of head which causes fracture of
anteroinferior part of parietal bone. It will injure the artery. Due to bleeding, extradural hematoma strips the
meningeal layer of dura from endosteum of skull. Gradually enlarging hematoma produces pressure effect on
the cortical areas, especially the
underlying precentral gyrus. Through the burr hole 4 cm above the midpoint of zygomatic arch, hematoma is
cleared out to release the pressure and the torn artery is ligated.
Subdural Hemorrhage
Subdural hemorrhage results from injury (tearing) of the superior cerebral veins. Close to the site of their entry
to superior sagittal sinus. It results from excessive anteroposterior movements of brain within the skull. This
occurs due to a blow on front or back of head. Tearing of superior cerebral vein resulting from repeated jerky
anteroposterior movements of brain within the skull may occur sometimes when a person crosses over a series
of high speed-breakers sitting in a speedy car.
When the vein is torn, blood under low pressure beigns to accumulate in the potential space between dura and
arachnoid. Depending upon the speed of accumulation of blood it may be of acute or chronic variety. Chronic
form may gradually progress over the period of several months. When a small blood clot attracts fluid by
osmosis, hematoma expands gradually and produce various pressure symptoms. In both the varieties, blood
clots are to be removed by ‘burr holes’.
Subarachnoid Hemorrhage
It may result from following causes –
1. Leakageorruptureofcongenitalaneurysmsinthe
circle of Willis.
2. Hemorrhage from angioma.

3. Contusion or laceration of brain and meninges
following head injury:
Clinical features are –
1. Sudden onset of intense headache

2. Stiffness of neck
3. Loss of consciousness.
􏲄iagnosis is confirmed b􏲄 –
1. Lumbarpuncture(spinaltap)showsheavilyblood-
stained cerebrospinal fluid.
2. Visualization of dense areas of blood through
computed tomography (CT) scan is more confir- matory.

Prognosis of this clinical condition is fatal and
death follows quickly. In some cases patient may withstand the first attack of bleeding but ultimately does not
survive for more than a few days.
Cerebral Hemorrhage
In hypertensive patients cerebral hemorrhage occurs due to rupture of atheromatous artery after middle
age. Very often thin-walled lenticulostriate branches of middle cerebral artery are affected. Corticospinal and
corticonuclear fibers of internal capsule are damaged leading to contralateral hemiplegia and supranuclear
lesion of cranial nerves.
Radiological Investigations of Detection of Cerebrovascular Disease
Cerebral angiography
This procedure is adopted for the following purposes: 1. Fordetectionofabnormalitiesofcerebralvascular

244
pattern, e.g. arteriovenous malformation.
2. For localization of space occupying lesion such as
tumors, hematomas, abscesses.
3. For detection of vascular patern of tumors for the
purpose of diagnosis of their pathology.
Investigation is done under general anesthesia.
Following rapid injection of a radiopaque medium, series of radiographs are taken quickly at the interval of 2
seconds. Injection is done either on vertebral artery, or indirectly through a catheter introduced into radial or
femoral artery.
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
CT and MRI are indispensable techniques for diagnosis of various cerebrovascular diseases. The diagnosis
can be made with speed, accuracy and safety. Intracranial blood clot can be detected by its density. These
techniques have remarkably replaced the cerebral angiography.
Vascular lesion of spinal cord
In comparison to the importance of nervous tissue of spinal cord, its arterial supply is not rich to that extent.
All the three spinal arteries are very slender and deficient in lower part. Anterior spinal artery narrows down
remarkably beyond cervical level. Again reinforcing segmental arteries also vary in number and prominence.
Anterior two-thirds of spinal cord covering the area of anterior (and lateral) gray column, anterior white column
and major anterior part of lateral white column is supplied by anterior spinal artery. Occlusion of anterior
spinal artery may produce following clinical manifestations.
1. Bilateral loss of motor function which usually affects lower limbs (paraplegia) is due to lesion corticospinal
tracts of both side.
2. Bilateral loss of pain and temperature sensations due to lesion of lateral spinothalamic tract in lateral
white column. This deficit is below the level lesion.
3. Weakness of muscles and loss of tendon jerks of
lower limb due to damage of neurons of anterior
gray column.
4. Loss of control on bladder and bowel function due
to damage of the descending autonomic fibers.
Sense of position and movements, touch sensation and sense of vibration are not affected as because blood
supply of posterior white column (by posterior spinal artery) is not jeopardized.
Clinical Anatomy of Blood Brain-barrier
Blood-brain barrier in fetus and newborn
In fetus, newborn baby and premature infants, blood- brain barrier is not fully developed. It results in entry of
toxic substance into the intercellular space of nervous tissue. For example bilirubin can readily pass through for
yellowing of brain with a complication called bilirubin encephalopathy (kernicterus).
Brain trauma and blood-brain barrier
Trauma, either physical or chemical, and inflammation (e.g. meningitis) may cause disruption of structure of
blood-brain barrier. It may either cause damage to the endothelium or disruption of tight junctions. It will lead
to free diffusion of large molecules which include toxic substance, into the nervous tissue.
Tumors and blood-brain barrier
Tumors like anaplastic malignant astrocytoma, gliob- lastoma and metastatic lesions in brain may present
excessive vascularization. These pathological blood vessels do not possess blood-brain barriers.
Drug and blood-brain barrier
In reference to their permeability through blood- brain barrier, drugs are classified into two groups. Some pass
through while some of them do not. In this context, it is interesting to note the following points. 1. Lipid-soluble
drugs possess the power of perme-
ability to pass through blood-brain barrier, e.g.
thiopental and atropine.
2. A drug like phenylbutazone which binds with
macromolecules of plasma protein is unable to
cross the barrier.

3. A drug like penicillin passes through blood-
brain barrier in small amount. It is matter of great advantage that this drug does not cross the barrier
in large concentration which is very toxic to nervous tissue.
4. Some drugs are not able to pass through the blood-brain barrier, like dopamine, deficiency of which is
the cause of disease, parkinsonism. But L-dopa, the precursor of domamine readily passes through the
barrier. Administration of L-dopa in Parkinsonism gives good result.
Reticular formation is defined as diffuse, ill-defined and scattered collections of neurons in central nervous system
which are intermingled with the network (reticulum) of nerve fibers.
Situation: Main part of reticular formation is present althrough the central core (tegmentum) of brainstem (Fig.
1􏲠.1).
Topographically this component of central nervous system is present in the areas of brainstem which are not
occupied by named and defined nuclei and fiber- bundles.
􏲠xtension of Brainstem Reticular Formation—
Midbrain
Brainstem
reticular Pons
1. Above:Itextendsintosubthalamus,hypothalamus and thalamus of diencephalon. Further, it has also been proved

that some areas of cerebrum and cerebellum are also closely related to brainstem reticular formation.
2. Below: It extends into the spinal cord, specially the cervical segments. 􏲠ere reticular formation is represented by
network (reticulum) of nerve cells and fibers on the lateral aspect of neck of dorsal gray horn.
Phylogenetic importance: Reticular formation is the very significant part of central nervous system
formation
Cerebellum
Reticular Formation
Medulla oblongata
Fig. 16.1 Brainstem reticular formation extends throughout central tegmental core
16
246
in lower vertebrates. There it possesses the vital centers like respiratory and cardiac, which actively controls
respiration, heart rate and blood pressure.
Principle of function:
1. It maintains the state or level of consciousness, alertness or awakefulness of an individual.

2. It also helps in arousal from sleep.
3. It contains respiratory and cardiac centers
through which it regulates respiration, heart rate
and blood pressure.
􏲠. It regulates receptive capacity of sensory end
organs and also having effect on sensory centers,
regulates threshold of various sensations.

5. It controls muscular activities through its influence on cerebral cortex, cerebellum, basal nuclei, red
nucleus, substantia nigra.

􏲠. It regulates visceral, endocrine and emotional acti-
vities through its connection with hypothalamus
and limbic system.

Architectural variation: Reticular formation is not only divided in various nuclear groups, but also shows
following variations of neurons.
i. Cell bodies show variations in size, e.g. large, medium and small.
ii. Variations in length of axons.
iii. Variations in ramification of dendrites.
Classifications of 􏱪􏱪ainst􏱪􏱪 􏱪􏱪tic􏱪la􏱪 􏱪􏱪cl􏱪i
􏱧ri􏱧􏱧r􏱧 􏱧l􏱧ssifi􏱧􏱧􏱧io􏱧 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧: Primarily, nuclei of brainstem reticular formation are divided
into three groups, from midline to lateral, they are named as—
1. Raphe nuclei: These are present in the midline of central core of brainstem. The cell bodies of neurons are
intermediate in size. Neurons of these nuclei liberate serotonin which acts as
neurotransmitter. Raphe nuclei is also known as
median column nuclei.

2. Medial column nuclei: From midline this column
is intermediate in position throughout tegmental core of brainstem. Neurons of this column are large sized,
hence this is called Magnocellular column.
3. Lateral column nuclei: Out of three columns, cells of this column are smallest in size. The word parvus
means small. That is why this column is called Parvocellular column.
􏱧ur􏱧􏱧er 􏱧l􏱧ssifi􏱧􏱧􏱧io􏱧 o􏱧 􏱧u􏱧lei 􏱧􏱧i􏱧􏱧 􏱧􏱧􏱧􏱧􏱧: The above mentioned three columns of nuclei of
brainstem reticular formation are divided into many nuclei. Memorization of all these nuclei by a reader at
this stage is not encouraged. The nuclei which are functionally important and clinically more significant are
only discussed below.
Median column nuclei (raphe nuclei) (Fig. 16.3)
As already mentioned, nuclei of this column are made up of medium sized neurons. These neurons produce a
neurotransmitter serotonin.
The nuclei are —
1. Dorsal raphe nucleus
This is present in midbrain. Axonal fibers from this nucleus descend as reticulospinal tract to spinal cord and
relay on sensory neurons of apex of posterior horn (Fig. 1􏲠.􏲠) which carry pain sensation from peripheral
sensory nerves via lateral spinothalamic tract. Transmission of pain sensation is inhibited as the posterior horn
sensory neurons are influenced by inhibitory effect of serotonin (neurotransmitter) released by neurons of
dorsal raphe nucleus of midbrain reticular formation.
Median (raphe) nuclear column Medial magnocellular column Lateral parvocellular column
Fig. 16.2 Primary subdivision of brainstem reticular nuclei
Reticular Formation
247
Dorsal raphe nucleus
Periaqueductal nucleus Cuneiform nucleus
Subcuneiform nucleus Oral pontine nucleus
Pedunculopontine nucleus
Medial column nuclei
Lateral column nuclei

Median column nuclei
Central nucleus of Pontine raphe nucleus pons
Magnus raphe nucleus
Central nucleus of medulla
Caudal pontine nucleus
Fig. 16.3 Important nuclei of brainstem reticular formation􏲠 Median column􏲠Red, Medial column􏲠 Blue and lateral column􏲠 Green
2. Pontine raphe nucleus
This midline nucleus is situated in dorsal part of tegmentum of pons and is in the same line with dorsal raphe
nucleus of midbrain.
3. Raphe nucleus magnus
This nucleus is longer and situated in the medulla oblongata. Nucleus of spinal tract of trigeminal nerve
present in medulla oblongata receives pain sensation
carrying fibers of trigeminal nerve from the same half of face. Axons of this nucleus, after decussation, carry
pain sensation upwards to thalamus through trigeminal lemniscus. Axons of raphe nucleus magnus relay in the
neurons of spinal nucleus (nucleus of spinal tract) of trigeminal nerve and through liberation of serotonin
(neurotransmitter) produce inhibitory influence on pain pathway from half of the face (Fig. 1􏲠.5).
Dorsal raphe nucleus in midbrain
Reticulospinal tract
􏱺eripheral nerve fibers carrying pain sensation
Free nerve ending
Gigantocellular nucleus
(pontine part) Medial column
Ventral ret. nucleus
nuclei
Gigantocellular nucleus (medullary part)
Fig. 16.4 Dorsal raphe nucleus exerts inhibitory effect, through release of serotonin, on pain fibers forming lateral spinothalamic tract
248
Pons
Magnus raphe nucleus of midline column of reticular nucleus
Axon of magnus raphe nucleus releases serotonin to exert inhibitory effect on nucleus of spinal tract of trigeminal nerve
Lower half of medulla oblongata
Trigeminal nerve
Upper half of medulla oblongata
􏱺ain fibers of trigeminal nerve relaying in spinal nucleus of trigeminal nerve
Spinal tract and

Spinal nucleus of trigeminal nerve
Fig. 16.5 Magnus raphe nucleus in medulla oblongata exerts inhibitory effect on spinal nucleus of trigeminal nerve from where pain
sensation is carried through trigeminal lemniscus from ipsilateral half of face
Medial column reticular nuclei
This column is intermediate in position. The cell- bodies of this column are large sized. That is why it is called
magnocellular column.
In three parts of brainstem important nuclei of this column are as follows. (Fig. 1􏲠.2)—
2. Oral pontine nucleus

3. Caudal pontine nucleus 􏲠. Gigantocellular nucleus (pontine part)
Medulla oblongata— 1. Gigantocellular nucleus (medullary part)
2. Ventral reticular nucleus Fundamentally, function of the nuclei of this group is to form polysynaptic pathway
by establishing
connections as follows (Fig. 1􏲠.􏲠)—
Ascending efferent
Afferents Descending efferent
Midbrain— Pons —
1. Periaqueductal nucleus 2. Cuneiform nucleus

3. Subcuneiform nucleus 1. Nucleus coeruleus
Horizontal efferents
Higher centers
Other reticular nuclei
Medial reticular nuclei
Fig. 16.6 Connections of medial column reticular nucleus
Lateral reticular nuclei

Lower centers
Nuclei of medial (intermediate) column receive afferents from lateral column.
Efferents go to following three destinations –
1. Ascending efferents – To higher centers

2. Descending efferents – To lower centers
3. 􏲠orizontal efferents – To other reticular nuclei.
Lateral column reticular nuclei 249
This is called parvocellular column as it is made up of small sized neurons.
Important nuclei of this column are as follows in different levels of brainstem.
Reticular Formation
Midbrain— 1. Pedunculopontine nucleus Pons— 1. Central nucleus of pons Medulla oblongata— 1. Central
nucleus of medulla
2. Lateral reticular nucleus
3. Ventral reticular nucleus Nuclei of lateral column of reticular formation are fundamentally association
component of brainstem reticular formation. These nuclei receive collaterals from ascending sensory pathway.
These send efferent
to medial column reticular nuclei.
Summary of nuclei of brainstem reticular formation

Median column nuclei
Medial column nuclei— Lateral column nuclei—
(raphe nuclei) – medium
Magnocellular, from Parvocellular– from
sized cells – liberate
polysynaptic connections Association components
serotonin
Periaqueductal nucleus
Midbrain Dorsal raphe nuclei Cuneiform nucleus Pedunculopontine nucleus
Subcuneiform nucleus
Nucleus coeruleus
Oral pontine nucleus Caudal
Pons Pontine raphe nuclei Central nucleus of pons
pontine nucleus Gigantocellular
nucleus (pontine part)
Gigantocellular nucleus Central nucleus of medulla
Medulla oblongata Raphe nucleus magnus (medullary part) Lateral reticular nucleus
Ventral reticular nucleus Ventral reticular nucleus
Conn􏱪ctions of 􏱪􏱪tic􏱪la􏱪 􏱪o􏱪􏱪ation
To develop clear concept about connections of reticular formation, it is important as well as interesting to
subdivide the functions of reticular formation into following two groups.
1. Reticular formation maintains the level of alertness or consciousness of an individual.

2. Reticular formation controls or regulates –
a) Autonomic functions like respiration, heart rate, blood pressure and also some other visc-
eral functions.
b) Muscular activities through its influence on
lower motor neuron, itself being influenced by cerebral cortex, cerebellum, basal nuclei, substantia
nigra, red nucleus.
c) Receptive capacity of sensory pathways through its projection on sensory neurons (tracts) of central
nervous system.
d) Endocrine and emotional activities through its connections with hypothalamus and limbic system.
Above mentioned two groups of functions are performed by two components of reticular formations which are
respectively as follows—
1. Ascending reticular activating system
􏱧􏱧s􏱧e􏱧􏱧i􏱧􏱧 re􏱧i􏱧ul􏱧r s􏱧s􏱧e􏱧􏱧: This part of reticular formation is principally lateral column reticular
nuclei. It receives inputs either directly or through collaterals from various sensory pathways. It gives outputs
to thalamus and from where finally to different areas of cerebral cortex. This circuit is for maintenance of
alertness or consciousness.
2. Descending reticular system: It is influenced by cerebral cortex, cerebellum, basal ganglia, substantia
nigra, red nucleus. It projects to autonomic centers of brainstem and spinal cord, motor and sensory neurons of
spinal cord, some cranial nerve nuclei, hypothalamus and limbic system.
It will be now easy to understand the connections of two systems of reticular formation.
􏱧o􏱧􏱧e􏱧􏱧io􏱧s o􏱧 􏱧s􏱧e􏱧􏱧i􏱧􏱧 􏱧e􏱧i􏱧ul􏱧r 􏱧􏱧􏱧i􏱧􏱧􏱧i􏱧􏱧 􏱧􏱧s􏱧e􏱧 􏱧􏱧􏱧􏱧􏱧
{
Efferents Afferents
{
Afferents:
1. Impulse from all ascending sensory tracts (e.g. spinal lemniscus, trigeminal lemniscus, lateral lemniscus) is
carried to ascending reticular activating system via collaterals.
250
All areas of cerebral cortex

Intralaminar and reticular nuclei of thalamus
Ascending reticular activating system
Inputs from pathway of vision, smell, taste, hearing
Collaterals from all ascending sensory tracts

2. Impulse from other sensory pathways, namely olfactory, visual, gustatory (taste), auditory.
Efferents:Initiallygotointralaminarandreticular nuclei of thalamus, and finally from thalamus go to

stimulate all areas of cerebral cortex which will help to develop alterness by an individual.
Reticular Formation
Connections of Descending Reticular System
Cerebral cortex
{ {
Afferents Efferents
Afferents from: 1. Cerebral cortex 2. Cerebellum

5. Red nucleus.
3. Basal ganglia
􏲠. Substantia nigra and
Efferentsto:
1. Autonomic centers of brainstem and spinal cord
to regulate respiration, heart rate, blood pressure and some other visceral function.
Basal ganglia
Descending reticular system
Cerebellum
Substantia nigra
Red nucleus
Autonomic centers of brainstem and spinal cord
Hypothalamus
Limbic system
Motor neurons of anterior horn of spinal cord
Sensory neurons of posterior horn of spinal cord
251
advantage, to relieve excrutiating pain in some
diseases by stimulating these reticular nuclei.
2. Impulse carried from various sensory pathways to ascending reticular activating system makes various
areas of cerebral cortex alert. Thus, it helps in alertness or consciousness and also arousal from sleep. Like
other sensory pathway, impulse from visual and auditory pathways are also carried to this part of reticular
system via tectoreticular tract. So, a powerful light or sound stimulating visual or auditory pathway causes
transmission of impulse via tectoreticular fibers to ascending reticular activating system, thus drawing
attention or alertness, and even helps in
arousal when a person is sleeping.
3. When we are awake, nuclei of reticular activating
system send continuous discharge to different areas of brain. Sleep is induced when activity of reticular
activating system is diminished. Some drugs, e.g. general anesthetics, sedatives, tranquilizers also reduce
activity of reticular system.
In some diseases, patient suffers from coma when
activity of reticular system gets further diminished.
CLINICAL ANATOMY
1. Midline (median) column nuclei of brainstem reticular formation produces serotonin, which act as
neurotransmitter. Dorsal raphe nucleus of midbrain sends reticulospinal fibers which project on sensory neurons of
dorsal gray horn of spinal cord which carries pain sensation via lateral spinothalamic tract. Serotonin released at
the synapse between descending axon of dorsal raphe nucleus and posterior horn cells of spinal cord exerts
inhibitory effect on pain pathway via lateral spinothalamic tract. So pain is felt less. Raphe nucleus magnus of
medulla oblongata produces similar effect on spinal nucleus of trigeminal nerve carrying pain sensation from face.
This pain inhibiting function of reticular nucleus is taken as
252
2. Motorneuronsofanteriorhorncellsofspinalcord to regulate voluntary movements.

3. Sensory neurons of posterior horn cells of spinal cord to exert inhibitory effect on sensory pathway.
􏲠. 􏲠ypothalamus and limbic system to regulate
emotional and endocrine functions.

The word ‘limbic’ means border or margin. The term limbic system is used to include a group of structures which lie
in a ring-shaped manner in the demarcating zone between cerebral cortex and thalamus.
But recent studies showed that limbic system also includes some other structures beyond demarcating zone which
are concerned with following function— Emotion
Behavior Drive
Memory.
Anatomical Components of Limbic System
A. Gray matter:
1. 􏲄uperficial cortical structures:
Hippocampal formation
A ring of cortical areas which is called limbic
lobe. It includes –
Cingulate gyrus, isthmus, parahippocampal gyrus terminating anteriorly as uncus.
2. 􏲄ubcortical structures: These are present in the form of some nuclei as follow—
Amygdaloid nuclear complex (also known as
amygdaloid body)
Septal area (septal nuclei)
Part of hypothalamus – namely mammillary
bodies
Anterior nucleus of thalamus
Olfactory areas are also included.
B. White matter: Some important named band of white matter needs special mention. These are–
1. Alveus
2. Fimbria
3. Fornix
4. Mammillothalamic tract 5. Stria terminalis.
HIPPOCAMPAL FORMATION (FIG. 17.1)
Hippocampal formation is a composite structure which is composed of –

1. Hippocampus
2. Dentate gyrus
3. Parahippocampal gyrus.
So, at the beginning, it should be very clear to the
readers that hippocampal formation, hippocampus and parahippocampal gyrus are three different terminologies.
Hippocampus and parahippocampal gyrus are two components of hippocampal formation.
Another important point is also to be noted carefully. Parahippocampal gyrus is exposed area of limbic cortex
which is visible on medial surface of cerebral hemisphere. But hippocampus and dentate gyrus are the hidden parts
which form floor of inferior horn of lateral ventricle.
Hippocampus
Hippocampus is a smooth, curved, elongated elevation of gray matter which is lying along the floor of inferior horn of
lateral ventricle and it is only clearly observed when cavity of inferior horn of lateral ventricle is dissected out (Fig.
17.2).
Limbic System
17
254
Choroid fissure Cavity of lateral ventricle
Alveus Hippocampus
Fimbria Dentate gyrus
Hippocampal fissure
Stria terminalis
Tapetum Collateral eminence
Anterior expanded end presents a few shallow cleft giving the appearance of animal’s foot. That is why it is
called pes hippocampus. Hippocampus itself is so named because in coronal section, it looks like a ‘sea-horse’.
Convex ventricular surface lined with ependyma, when viewed on coronal section, presents in subependymal
plane a thin layer of white matter called alveus.
Uncus Pes hippocampus
Hippocampus
Alveus is formed by the fibers which converge medially after originating from the nerve cells of hippocampus.
All the fibers of alveus turns further posteromedially to form a bundle called fimbria (Fig. 17.3).
The fimbria runs posteriorly to become continuous with posterior column of fornix (Fig. 17.3). So, it is clear that
axonal processes of neurons of hippocampus
Floor of inferior horn of lateral ventricle
Fig. 17.1 Hippocampal formation
Collateral sulcus
Fig. 17.2 Hippocampus seen on floor of inferior horn of lateral ventricle
255
which first extend medially but finally posteriorly as alveus, fimbria and ultimately as posterior column of
fornix. Posterior column of fornix curves round posterior end of thalamus.
Hippocampus ends posteriorly below splenium of corpus callosum.
Dentate Gyrus
It is so called because margin of this gyrus is serrated on denticulated. This narrow and notched gray matter
also extends anteroposteriorly between fimbria of hippocampus and parahippocampal gyrus. Parahippocampal
gyrus is positioned inferomedially.
Dentate gyrus extends posteriorly parallel to fimbria. Turning round splenium of corpus callosum, dentate
gyrus becomes continuous with a thin vestigial lamina of gray matter over superior surface of corpus callosum.
This thin sheet of gray matter covering superior surface of corpus callosum is called indusium griseum. On the
surface of this thin gray matter lamina on either side of middle there run a pair of thin thread-like band of
white matter called medial and lateral longitudinal stria.
Posterior end of dentate gyrus, below splenium, is known as splenial gyrus or gyrus fasciolaris, which in turn, is
continuous as indusium griseum.
Parahippocampal Gyrus
Hippocampus comes directly in formations of floor of inferior horn of lateral ventricle, but parahippocampal
Pes hippocampus Hippocampus
Alveus
Fimbria
Limbic System
gyrus is more superficial in position and positioned inferolateral to hippocampus (Fig. 17.1). Two are separated
by hippocampal fissure. On the lateral side, parahippocampal gyrus is separated from medial temporooccipital
gyrus by collateral sulcus which produces an impression on inferior horn of lateral ventricle called collateral
eminence. Collateral eminence forms a bulge on lateral part of floor of inferior horn lateral ventricle.
Structural Characteristic of Hippocampal Formation
Earlier, limbic system used to be termed as rhinencephalon because it was thought that it is only related to
function of olfaction. But actually in human brain olfaction is related to only a small portion of limbic system.
Major part of cerebral cortex is highly developed in man and characterized by six layers of neurons. This is
called neocortex. But limbic area of cortex is phylogenetically older component of cortex which is called
allocortex. It is made up of neurons of three layers occupying central part of cerebrum. Transitional zone
between allocortex and neocortex is called juxta-allocortex where neuronal layer vary from three to six.
Parahippocampal gyrus is considered to be part of neocortex and made up of six layers of neurons. As the cortex
of hippocampus is traced, gradual transition of six layers to three layers is observed. Three layers of
hippocampus (allocortex) are as follows.
Body of fornix
Fig. 17.3 Alveus arising from hippocampus continued as fimbria and finally as posterior column of fornix
 􏱧􏱧 􏱧u􏱧erfi􏱧i􏱧l 􏱧ole􏱧ul􏱧r l􏱧􏱧er: It is made up of scattered nerve cells and nerve fibers. The
neurons are smaller in size.
 􏱧􏱧 􏱧􏱧􏱧er􏱧e􏱧i􏱧􏱧e􏱧􏱧r􏱧􏱧i􏱧􏱧ll􏱧􏱧er:Itismadeupof many large sized pyramidal cells.
 􏱧􏱧 􏱧􏱧􏱧er􏱧ol􏱧􏱧or􏱧􏱧i􏱧l􏱧􏱧er:Itisstructurallysim- ilar to the polymorphic layer of neocortex.
Dentate gyrus is also three layered. But it differs
from structure of hippocampus by the fact that, intermediate layer is made up of granule cells instead
of pyramidal cells. Neurons of the granular layer of dentate gyrus are small in size and round or oval in
shape. Their axons terminate in neurons of pyramidal cell layer of hippocampus. Some of the fibers of
granular layer may be directly continued as fibers of fimbria.
Subiculum is the site of transition between six layered cortex of parahippocampal gyrus to three layered
cortex of dentate gyrus and hippocampus.
Fibrous Component of Hippocampal Formation
256 Afferent fibers from various sources reach hippocampus which are discussed below. But fibers which
leave as axons of neurons of hippocampus curved on the subependymal surface of hippocampus to form
alveus which converge and continues backwards as shining band known as fimbria. The fimbria is
continued backward towards posterior end of thalamus as posterior column of fornix (Fig. 17.3).
Connections of Hippocampal Formation
Afferent connections
It is the hippocampus which receive afferent connections from following sources.
Cingulate gyrus
Anterior commissure
Septal nuclei
Hippocampus
Fig. 17.4B Afferent from septal nuclei
􏱧􏱧 􏱧ro􏱧 􏱧i􏱧􏱧ul􏱧􏱧e 􏱧􏱧rus: Afferent fibers from cingulate gyrus curve round downwards and backward,
and finally forward to reach hippocampus (Fig. 17.4A).
􏱧􏱧 􏱧ro􏱧se􏱧􏱧􏱧l􏱧u􏱧lei:Thesearenucleilyinginthe midline close to anterior commissure. Fibers pass via fornix

to reach hippocampus (Fig. 17.4B).
􏱧􏱧 􏱧ibers 􏱧ro􏱧 o􏱧􏱧osi􏱧e 􏱧i􏱧􏱧o􏱧􏱧􏱧􏱧us: Fibers from one hippocampus reach another hippocampus. These
fibers pass through posterior column of fornix backwards. Reaching the junction between posterior column and
body, instead of continuing forwards to the body, the fibers cross the midline through posterior column of fornix
of opposite side to reach contralateral hippocampus. These fibers are called
Hippocampus
Hippocampus
Hippocampus
Hippocampal commissure
Fig. 17.4A Afferents from cingulate gyrus
Fig. 17.4C Afferents from opposite hippocampus
Indusium griseum
Olfactory bulb
Limbic System
257
Olfactory area (entorhinal area)
Hippocampus
Fig. 17.4D Afferents from indusium griseum
commissure of fornix or hippocampal commissure (Fig. 17.4C).

4. 􏱧ibers 􏱧ro􏱧 i􏱧􏱧usiu􏱧 􏱧riseu􏱧: These fibers form lateral and medial longitudinal striae. Hipp- ocampus
receive these fibers as axonal process of neurons of indusium griseum which is considered as vestigial part of
limbic cortex (Fig. 17.4D).
5. 􏱧ibers 􏱧ro􏱧 ol􏱧􏱧􏱧􏱧or􏱧 􏱧sso􏱧i􏱧􏱧e􏱧 􏱧or􏱧e􏱧: These afferent fibers are received by hippocampus from
anterior part of parahippocampal gyrus which is also called entorhinal area (Fig. 17.4E).
6. 􏱧ibers 􏱧ro􏱧 􏱧e􏱧􏱧􏱧􏱧e 􏱧􏱧rus 􏱧􏱧􏱧 􏱧􏱧r􏱧􏱧i􏱧􏱧􏱧 o􏱧􏱧􏱧􏱧􏱧l: Gyrus pass to the adjacent hippocampus (Fig.
17.4F).
Efferent connections
Efferent connections from hippocampus are axons of pyramidal cells lying in intermediate layer. The
Fig. 17.4E Afferents from olfactory associated cortex

efferent fibers first lies in subependymal plane as alveus. The fibers of alveus converge to form a white band
known as fimbria. Fimbria continues posteriorly as posterior column of fornix. Posterior column from both sides
curve upwards and forwards around posterior end of thalamus and join together to form body of fornix. Body of
fornix divides into two anterior columns which pass downwards and forwards in front of interventricular
foramen of Monro. Next at the level of anterior commissure it divides into two limbs called postcommissural
and precommissural roots running posterior and anterior to anterior commissure respectively. Fibers of these
two roots end as efferent fibers of hippocampus in following destinations (Fig. 17.5).
􏱧􏱧 􏱧os􏱧􏱧o􏱧􏱧issur􏱧l roo􏱧s:
a) To anterior nucleus of thalamus
Dentate gyrus Hippocampus
Hippocampus
Fig. 17.4F Afferents from dentate gyrus and parahippocampal gyrus
258
Anterior nucleus of thalamus
􏱺recommissural fibers
Septal nuclei
Hypothalamic nuclei Anterior commissure
􏱺ostcommissural fibers Nucleus of mammillary body
Body of fornix
Hippocampus Tegmentum of midbrain
To nucleus of mammillary body To tegmentum of midbrain.
b)
c)
Efferent from mammillary body further proceeds
this small mass of gray matter is situated at the depth of temporal lobe. It is connected to anterior end of tail of
caudate nucleus on anterior end of roof of inferior horn of lateral ventricle.
Connections (Fig. 17.6)
􏱧􏱧􏱧ere􏱧􏱧: Afferent connections are mostly from primary olfactory area.

􏱧􏱧􏱧ere􏱧􏱧: Efferent fibers come out of amygdaloid body in the form of stria terminalis. Stria terminalis is a
curved band of fibers which follow the similar curve of caudate nucleus, being adjacent to it, but follow its tail
end and pass along the direction of tail, body and finally head. Obviously it curves round thalamus and along
the walls of lateral ventricle until it reaches anteriorly to the level of anterior commissure. The fibers finally
reach following destinations (Fig. 17.6). 1. Septal area
2. Amygdaloid nucleus of opposite side via anterior commissure
3. Anterior portion of hypothalamus

4. Fibers from posterior end of stria terminalis pass
to Habenular nucleus.
Functions of Amygdaloid Body
1. Amygdaloid body exerts an effect on internal needs, drives and instincts of an individual.
2. Amygdaloid body, if active, generates anger, rage, excitability and fear.
to anterior thalamic nuclei via mammillothalamic tract.

􏱧􏱧 􏱧re􏱧o􏱧􏱧issur􏱧lroo􏱧s:
a) To septal nuclei
b) Lateral preoptic nucleus
c) Anterior part of hypothalamus.
Functions of Hippocampus
Hippocampus is the prime central component of limbic system.
But through the outlet of hypothalamus, hippocampus acts as a center for integration for autonomic (visceral),
endocrine and emotional activities of an individual.
Hippocampus plays an important role for recent memory.
Earlier it was regarded as part of olfactory system, but it does not possess direct relationship with this function.
AMYGDALOID BODY
It is also known as amygdaloid nuclear complex or amygdala. It is so called because it is an almond- shaped
mass of gray matter which is situated subja- cent to anterior part of parahippocampal gyrus. So
Fig. 17.5 Efferent fibers of hippocampus
Septal area
Limbic System
259
Olfactory bulb
Olfactory tract
Anterior hypothalamic region
Some efferents go to opposite amygdaloid nucleus through anterior commissure
Habenular nucleus Stria terminalis
Amygdaloid body Prepyriform area

Fig. 17.6 Connections of amygdaloid body
3. Amygdaloidbodypossessesaninhibitoryeffecton sexual activity.
CLINICAL ANATOMY
Anatomical connections of limbic system are truly extremely complex. Their significance are also not clearly
understood as on date. So, a reader must not go for too much taxation of brain.
Limbic system, through the outlet of hypothalamus, mainly acts as a center for integration of visceral
(autonomic), endocrine and emotional activities. For example, some visceral activities appear in reference to
change in emotional status of an individual.
Limbic system controls excitability, rage, anger, fear of an individual.
Hippocampus functions for collection and recapit- ulation of recent memory.
Amygdaloid body exerts inhibitory effect on sexual activity.
􏱧􏱧􏱧i􏱧o􏱧􏱧re􏱧i􏱧: It is a psychotic condition characterized by disordered thinking, hallucinations, blu-

nted affect and withdrawal of emotional activity. These are the manifestations because of hyperactivity of
limbic system receptors to dopamine. That is why for management of this disease, limbic receptors are blocked
for dopamine by using some phenothiazine group of drugs. But these pharmacological agents may lead to
extrapyramidal system disorders, for which drugs controlling extrapyramidal disorders are very often
coprescribed.
Autonomic Nervous System
A COMPONENT – PARALLEL TO SOMATIC NERV- OUS SYSTEM
Nervous system is functionally divided into following two components –

1. Somatic nervous system
2. Autonomic nervous system.
Somatic nervous system is the part of nervous system that controls voluntary functions of body. It means that,
functions which are controlled or governed as per one’s own desire. It may be movements of joint or voluntary
movements of any organ, like movements of eyeball or tongue, which are results of contraction of voluntary muscles.
Autonomic nervous system is the component of nervous system which controls or regulates involuntary
functions of body, i.e. those which cannot be governed as per one’s own desire. Units of these functions are
fundamentally following two.
1. Increase rate and force of contraction of involuntary muscles (smooth as well as cardiac muscles):
Which results in, e.g.
a) Contraction (systole) and relaxation (diastole)
of cardiac muscles resulting in increase of rate
of heartbeat.
b) Contraction of smooth muscles of viscera, blood
vesicles, skin (Arrectores pili).

2. Secretion of exocrine glands: Which may be,
larger and solitary (salivary glands, lacrimal gland) or minute and multiple like mucous glands of alimentary and
respiratory tracts, sweat glands of skin.
AUTONOMIC NERVOUS SYSTEM AND ENDOCRINE SYSTEM – JOINTLY MAINTAIN INTERNAL ENVIRONMENT
OF BODY
Both these systems jointly maintain together normal internal environment of body (homeostasis). Autonomic
nervous system regulates activities of different organs and tissues through its action on cardiac muscle, smooth
muscles and exocrine gland. Endocrine system through its hormones circulated in bloodstream controls functions of
different organs and tissue of body. But the difference is with the fact that, when autonomic nervous system exerts
fine and fast action, endocrine system produces slower and more diffuse action.
COMPOSITION OF AUTONOMIC NERVOUS SYSTEM (FIG. 18.1)

Same as somatic nervous system, autonomic nervous system is made up of following components.
1. Receptors: These are baroreceptors, chemorec-
eptors, osmoreceptors present in the wall of viscera. Stretch and pain receptors are also present. Pain receptors
present in the wall of viscera are stimulated in its ischemic change causing lack of oxygen.
2. Afferent pathway: This are peripheral sensory fibers whose cell bodies are situated outside central nervous
system forming peripheral sensory nerve root ganglia.
18
3. Interneurons or connecting neurons: These are present inside central nervous system and interconnect
afferent autonomic neuron with efferent autonomic neuron.
4. Efferent neurons: There are connector neurons situated in brainstem and spinal cord. In the brainstem
they are present in the form of cell group forming motor nuclei of some cranial nerves (3rd, 7th, 9th and 10th).
In the spinal cord these are motor neurons of intermediate area of T 1 to L2 and S2, S3 and S4 segments of spinal
cord.
These efferent neurons are preganglionic (presynaptic) neurons which form synaptic connections outside the
central nervous system.
5. Autonomic ganglia: This is the special feature
of efferent pathway of autonomic nervous system, by which it differs from somatic nervous system. These are
the synapses or relay station where preganglionic neuron ends and postganglionic neurons start with its cell
bodies. These are called ganglia being relay stations or synapses with cell bodies of postsynaptic neurons which 261
differ from posterior root ganglia of spinal nerve and peripheral ganglia of sensory root of cranial nerve which
are made up of cell bodies of 1st order of sensory neuron.
6. Postganglionic efferent neurons: These are situated outside central nervous system. Cell bodies of these
neurons form autonomic ganglia.
Advantage of Autonomic Ganglia (Fig. 18.2)
In case of somatic nervous system, axon of one efferent neuron reaches straightway to effector organ (skeletal
muscle fiber). But in case of autonomic nervous system, one pregangalionic neuron, reaching the autonomic
ganglia, outside central nervous system, forms synaptic connections with multiple postganglionic neurons for
widespread action.
SUBDIVISION OF AUTONOMIC NERVOUS SYSTEM – SYMPATHETIC AND PARASYMPATHETIC
Autonomic nervous system is divided into two parts— sympathetic and parasympathetic. It is very
fundamental matter to note at this stage that, both the parts possess their respective centers inside central
nervous system and their peripheral outflow. Again peripheral outflow in both the case is made up of afferent
and efferent pathways.
Interrelationship: There are many effector organs where one system acts, other does not. For
Brainstem and spinal
cord
56
1. 2. 3. 4. 5. 6. 7.
Receptor—In visceral wall

Input—Afferent neuron
Connecting neuron
Preganglionic (presynaptic) efferent neuron Autonomic ganglion (synapse) outside CNS Postganglionic (postsynaptic) efferent neuron Effector
organ—
* Smooth muscle * Cardiac muscle * Exocrine gland.
Fig. 18.1 Composition of autonomic nervous system
Central nervous system

262
Somatic efferent neuron
Effector organ (voluntary muscle)
Effector organs (involuntary muscle)
1
B
Multiple postganglionic autonomic efferent neurons
Preganglionic autonomic efferent neuron
Fig. 18.2 Advantage of autonomic ganglia. A. One somatic neuron ends in one voluntary muscle fiber, B. Autonomic efferent neurons– 1.
One preganglionic neurons from synapses with, 2. Multiple postganglionic neurons to supply, 3. Many effector organs (involuntary muscle
fibers)
example, arrectores pili muscles and sweat glands of skin are controlled by sympathetic whereas secretomotor
fibers of parasympathetic supplies exocrine glands, e.g. salivary glands or mucous glands. Again, there are
some organs where both the system produce physiologically antagonistic effects. Force of contraction of heart
muscles is increased by sympathetic, diminished by parasympathetic. But circular muscle fibers of
tracheobronchial tree are stimulated by parasympathetic causing bronchoconstriction, whereas sympathetic
causes relaxation (bronchodilatation) of tracheobronchial musculature. However, it is the balance between the
activities of two components of autonomic nervous system which maintain the stability of internal environment
of body, as both operate in conjunction with each other.
Sympathetic and Parasympathetic – How One Differs from the Other?
For maintenance of internal environment (homeostasis), though one reciprocates other, sympathetic and
parasympathetic parts of autonomic nervous
system differ from each other as per following criteria–
1. 2.
Structural — Anatomical Functional — i) Physiological
ii) Pharmacological.
Structural (anatomical) differences
1. Center: Center for sympathetic system is formed by antonomic neurons present in intermediolateral cell
column of spinal cord extending from T1 to L2 segments.
Center for parasympathetic system is located partly in brainstem and partly in spinal cord. In brainstem the
center is present in the form of general visceral efferent nuclei of following cranial nerves.
3rd — Edinger–Westphal nucleus – in upper half of midbrain.
7th — Superior salivatory nucleus – in lower half of pons.
9th — Inferior salivatory nucleus – in upper half of medulla oblongata.
10th — Dorsal nucleus of vagus – in lower half of medulla oblongata.
Fig. 18.3A Sympathetic outflow

1. Short preganglionic neuron originating from CNS
2. Long postganglionic neuron ending in target organ autonomic ganglion is close to CNS
263
In spinal cord, parasympathetic center is present in the intermediate area of 2nd, 3rd and 4th sacral segments
of spinal cord.
2. Supraspinal control: Parasympathetic and
sympathetic centers, as mentioned above, are controlled by nuclei posterior and anterior halves of
hypothalamus respectively by hypothalamospinal tract.
3. Autonomic ganglia (Figs 18.3A and B): Auto- nomic ganglia of both the systems are situated outside the
central nervous system and formed by synaptic connection between 1st and 2nd order of efferent neuron along
with the cell bodies of postsynaptic neurons.
Sympathetic ganglia interconnected by vertically oriented chain of fibers called sympathetic chain (sympathetic
trunk) are situated close to central nervous system (spinal cord) being paravertebral in position. The
sympathetic chain is formed because fibers from each ganglia ascend or descend for one or two segments up and
down before proceeding toward destination. As sympathetic ganglia are close to central neuraxis, postganglionic
fibers are longer to produce more generalized activities on effector organ. Parasympathetic ganglia are very
close to the target
organ, in the wall of viscera. So postganglionic fibers are shorter to produce more localized action.
Physiological difference
Both sympathetic and parasympathetic systems work in subconscious level, but they come into action in
different environment.
Sympathetic system gets activated during emer- gency, stress or anger. This can be explained with a classical
example. A man walks around a park in a pleasant afternoon. Suddenly, he is chased by a rabied street dog.
The man runs away very fast to save himself from the attack of the dog when his sympathetic system becomes
more active with the following changes in body.
1. Heartbeat increases.
2. Pulse rate becomes rapid with rise of blood
pressure.
3. Pupils get dilated.
4. Vasodilatation of skeletal muscles due to muscular
exercise.
5. Extremities become cold due to peripheral vasoc-
onstriction.
6. Sweating due to hypersecretion of sweat glands.

1
Fig. 18.3B Parasympathetic outflow

1. Long preganglionic neuron originating from CNS
2. Short postganglionic neuron present in wall of target organ (viscera) autonomic ganglion is close to or within the wall of viscera
264
7. Erection of hairs due to contraction of arrectores pili.
8. Tightening of anal and urinary sphincters. Parasympathetic system is concerned with conser-
vation and storage of energy. For example, in a comfortable holiday, when there is no stress or anxiety for
classes or examinations, a student takes a full meal and goes for sleep in bed, his parasympathetic part of
autonomic nervous system gets activated with
following changes in the body.

1. Heart rate settles down.
2. Pulse rate gets slower with blood pressure settles
down to normal level.

3. Rate of respiration becomes slower with ‘snoring’
due to constriction of muscles of respiratory tree. 4. Digestion of food gets promoted as a result of
secretion of glands causing liberation of enzymes. 5. Peristaltic movement of intestine is increased
with
6. Splanchnic vasodilatation due to ‘redistribution
of blood’ from skeletal muscles and brain to gastrointestinal tract.
Pharmacological difference (Fig. 18.4)
First, it is to be noted that in both sympathetic as well as parasympathetic system, neurotransmitter released
from the preganglionic neurons at the side of synaptic junction of autonomic ganglion is acetylcholine.
Following excitation of preganglionic neuron, acetylcholine is liberated, which crosses through synaptic cleft to
bind with the receptor at the postganglionic neuron. Following quick action, acetylcholine is hydrolyzed by the
enzyme acetylcholinesterase.
Pharmacological difference between sympathetic and parasympathetic system are as follows in nerve ending of
postganglionic neurons. Axons of postganglionic neurons terminate in the form of specialized nerve ending in
the optimum spaces between the gland cells, smooth or cardiac muscle fibers. Neurotransmitter of different
kind in two different system pass from postganglionic nerve ending through the gap to many effector cells. In
case of parasympathetic system, neurotransmitter is acetylcholine as in synaptic junction between pre- and
postganglionic neurons. But sympathetic postganglionic neurotransmitter are of different types in different
sites as follows.
1. In most of the cases sympathetic postganglionic
neurotransmitter are norepinephrine (noradrenaline) which act on effector cells like smooth muscles of heart,
involuntary sphincters, wall of blood vessels.
2. Cells of suprarenal medulla are structurally and functionally same as postganglionic sympathetic
neuron. These cells liberate epinephrine (adrenaline) which exerts action on sympathetic effector cells through
bloodstream.
3. Nerve ending of sympathetic postganglionic neurons which terminate in sweat glands and blood vessels of
skeletal muscles, liberate acetylcholine.
SYMPATHETIC PART OF AUTONOMIC NERVOUS SYSTEM
Sympathetic system is the greater components of autonomic nervous system and is more widely distributed in
the body.
Fundamentally sympathetic nervous system regulates following unitary functions –

1. Smooth muscles: Which may be in wall of blood
vessels, root of hair follicles (arrectores pili) and
wall of viscera.
2. Cardiac muscles
3. Exocrine glands: Which are only sweat glands.
It is also important to note that sympathetic system produces opposite action on same kind of effector organs in
different sites. For example, it causes constriction of muscular wall of blood vessels of skin and gastrointestinal
tract, whereas same system causes vasodilatation of skeletal muscles, heart and brain. Sympathetic system
produces excitatory effect on smooth muscles of involuntary sphincters of body and inhibitory effect in smooth
muscles of intestine, bronchial tree and wall of urinary bladder.
Actions of sympathetic component of autonomic nervous system on different effector organs as follows— 1.
Itincreaseforceandrateofcontractionofcardiac
muscles, resulting increase of heart rate, pulse
rate and blood pressure.

2. It causes vasoconstriction of skin and alimentary
tract, but vasodilatation of skeletal muscle, heart
and brain.
3. It causes erection of hair due to contraction of
arrectores pili muscles at the root of hair follicle. 4. It increases secretion of sweat gland.
5. It causes dilatation of pupil due to stimulation of
dilator pupillae.
6. It causes excitation of smooth muscles of invol-
untary sphincters of body.

7. It causes inhibitions of smooth muscles of intestinal
and bladder walls, and bronchial tree.
Efferent Component of Sympathetic System
Sympathetic part of autonomic nervous system is made up of following efferent components—

1. Spinal center: This is the collection of nerve
cells in the intermediolateral column if spinal
265
Parasympathetic
Sympathetic
Acetylcholine_
Acetylcholine_
• 􏱺iscera
• Smooth muscle • 􏱺􏱺ocrine gland
Noradrenaline_
• Cardiac muscle • 􏱺lood vessels of skeletal muscle Heart and brain
Capillary
Cardiac muscle Smooth muscle of sphincters
Acetylcholine
• 􏱺eripheral
Blood vessels
• Sweat glands
• Arrector muscle
Acetylcholine
Acetylcholine_
Adrenal medulla_
Adrenaline_
– Acetylcholine
Fig. 18.4 Pharmacological difference between sympathetic and parasympathetic system
cord extending from T1–L2 (may be L3) segments.
These cells are called connector neurons.

2. Effector neuron: These neurons are situated outside central nervous system (spinal cord) which receive
synaptic connection from axons of connector neuron. The synaptic connection with cell bodies of effector neurons
from knob- like structures, paravertebral in position, called sympathetic ganglia, situated in vertical row. The
ganglia are connected by chain of nerve fibers
called sympathetic trunk (sympathetic chain).
3. Effector organs: Effector organs which receive axon terminal of effector neuron, are—
i. Cardiac muscle fibers.
ii. Smooth muscle fiber of – a) Different viscera,
b) Wall of blood vessels, and c) Root of hair
follicles – Arrectores pili. iii. Sweat glands.
4. Supraspinal center: Nuclei of posterior half of hypothalamus which influence spinal center through
hypothalamospinal tract.
266
Epidermis of skin
Connector neuron of sympathetic system
Branch to sweat gland Spinal nerve
Branch to arrectores pili
􏱺ascular
(vasoconstrictor) branch
Sympathetic ganglion
White rami communicantis
Gray rami communicantis arise from postganglionic effector neurons

􏱽􏱽􏱽􏱽at􏱽etic efferent out􏱽o􏱽
Fundamental points:
1. Sympathetic efferent outflow going to end in
target organs anywhere in the body possess the center which is limited in intermediolateral cell column
of spinal gray matter from T1–L2 (may be L3) segment of spinal cord.
2. All sympathetic efferent outflow finally to end in target organs come out as branches of sympathetic
ganglia.
3. Branchesofsympatheticgangliaareoftwotypes– Lateral branches
Medial branches.
Lateral branches (Fig. 18.5)
Axons of sympathetic connector neurons come out through spinal nerve. The fibers are myelinated. Close to
midline, and adjacent to vertebral column, these fibers leave spinal nerve and join the sympathetic ganglia as
preganglionic fibers. As these fibers are myelinated, they are white in color for lipid content of myelin sheath.
That is why they are called white rami communicantis. As white rami, the preganglionic fibers relay in
sympathetic ganglia. Postganglionic fibers, which are nonmyelinated leave the sympathetic ganglia to rejoin
spinal nerve, are called gray rami communicantis. The gray rami communicantis, rejoining spinal nerve are the
lateral branches of sympathetic ganglia.
It is important to notice at this stage that, white rami communicantis are myelinated, preganglionic and
topographically distal in position. Gray rami communicantis are nonmyelinated, postganglionic and
topographically proximal in position. Pre- and postganglionic status of white and gray rami respectively may be
remembered by a simple formula— ‘Ganglion Gives Gray’ (GGG).
Lateral branches of sympathetic ganglia, through the spinal nerve supply –
Arrectores pili muscles of skin

Sweat glands
Peripheral blood vessels (smooth muscles of
tunica media).
Medial branches (Fig. 18.6)
Some of the axons of connector neurons from sympathetic center, passing through white rami communicantis to
sympathetic ganglia, do not relay. So these fibers do not rejoin spinal nerve through gray rami. These fibers
come out as medial branches of sympathetic ganglia, still as preganglionic fibers. They are known as splanchnic
branches. These medial branches of sympathetic ganglia take a long course to reach the central or proximal
arteries of trunk where they relay in second order of (excitor) neurons. The ganglia formed here are homologous
to sympathetic ganglia and are named according to the name of the arteries to which they are related, e.g.
celiac ganglia, aorticorenal ganglia. These ganglia,
Fig. 18.5 Lateral branches of sympathetic ganglion
267
Sympathetic trunk
Sympathetic effector neurons in ganglia (and plexus) related to blood vessels
Medial splanchnic branch
Sympathetic connector neuron
Postganglionic sympathetic
fibers accompanying blood
vessel to reach target organ
along with network of nerves form autonomic plexus from where postganglionic sympathetic nerves follow the
branch arteries to reach wall of viscera.
At this stage, it is important to note that, some of the medial branches of sympathetic ganglia come out as
postganglionic fibers to reach the target organ.
􏱪􏱪􏱪􏱪s of 􏱪􏱪t􏱪o􏱪 f􏱪o􏱪 􏱪􏱪􏱪􏱪at􏱪􏱪tic 􏱪an􏱪lia
1. Sympathetic ganglia numbered from 1st thoracic (T1) to 2nd lumbar (L2), may be L3, are connected to
the corresponding spinal nerve with the help of white rami (preganglionic) and gray rami
(postganglionic). It is not difficult to understand that as white rami enter the ganglia, they are
considered as roots of sympathetic ganglia. Wher- eas, gray rami, as come out of the ganglia are known
as branches of ganglia. As discussed earlier, these are lateral branches of sympathetic ganglia, which
are distributed through spinal nerve to,
Sweat glands
Arrectores pili muscles of skin
Smooth muscles of wall of blood vessels (Fig.
18.5).
2. Ithasalreadybeenclarifiedthat,medialbranches
of sympathetic ganglia are preganglionic. They reach to the centrally situated, more proximal arteries of
body, where they form autonomic ganglia named as per the name of the arteries. Postganglionic fibers
are distributed to,
Smooth muscles of the wall of viscera including heart.
Smooth muscles of wall of visceral blood vessels. These medial branches are known as splanchnic branches
(Fig. 18.6).
3. Someofthepreganglionicfibers,afterreachingthe corresponding sympathetic ganglia, may not come out either

as lateral branches or medial branches. These fibers, either ascend or descend, to reach one or two ganglia
above or below, where they relay to pass as postganglionic branches of that ganglia (Fig. 18.7). These fibers of
sympathetic ganglia, ascending or descending for one or two ganglia level up or down, explain the formation of
sympathetic chain or sympathetic trunk.
􏱧u􏱧􏱧o􏱧 􏱧bo􏱧e 􏱧1 􏱧􏱧􏱧 belo􏱧 􏱧2 ganglia: As the center for sympathetic system extends from T1 to L2
segments of spinal cord, outflow from T1 to L2 ganglia corresponds to the sympathetic connector neurons of
respective segments of spinal cord.
4. AboveT1segment,thereare8cervicalsegmentsof spinal cord which give out 8 pair of cervical spinal nerve.
These segments do not possess intermediolateral gray column, so also sympathetic centers. But 8 cervical
sympathetic ganglia are represented as 3, namely superior, middle and inferior, which correspond to upper four
(C1 to C4), middle two (C5, C6) and lower two (C7, C8) ganglia respectively. These cervical sympathetic ganglia
receive preganglionic fibers from intermediolateral cell group of T1 segment. Postganglionic fibers are
distributed
Fig. 18.6 Medial branches of sympathetic ganglion
268
􏱺ostganglionic fiber 􏱺oining
spinal nerve of upper level
􏱺reganglionic fiber ascending
for one or two segments
􏱺reganglionic fiber descending for
one or two segments
􏱺ostganglionic fiber 􏱺oining spinal
nerve of lower level
Sympathetic trunk (chain)
Sympathetic ganglion
Fig. 18.7 Preganglionic sympathetic fibers from one segment may ascend or descend for one or two segments up or down to relay in higher
or lower sympathetic ganglia
Note: This explains formation of sympathetic chain or sympathetic trunk
C1 C2
C3
C4 C5
C6 C7
C8
C1 to C8 nerves
1st thoracic spinal nerve 1st thoracic sympathetic ganglion
Medial (splanchnic) branches from superior cervical ganglion
Medial (splanchnic) branch from middle cervical ganglion
Medial (splanchnic) branch from inferior cervical ganglion
1st thoracic segment of spinal cord
Sympathetic connector neurons at T1 segment of spinal cord which send out preganglionic fibers for cervical sympathetic ganglia
Fig. 18.8 Many of preganglionic fibers from T1 segment of spinal cord ascend to relay in all the three cervical sympathetic ganglia.
Postganglionic fibers leave ganglia as
Lateral branches (gray rami) to join spinal nerves and Medial (splanchnic) branches to viscera and their blood vessels. Note: Cervical
spinal nerves are connected to sympathetic ganglia only by gray ramia communicantis
sponding to lower lumbar (L –L ) sacral (S –S ) 35 15
􏱧􏱧􏱧er􏱧l br􏱧􏱧􏱧􏱧es: As gray rami to corresponding spinal nerve.

􏱧e􏱧i􏱧l br􏱧􏱧􏱧􏱧es: These branches are mostly postganglionic and called splanchnic branches. They form
different autonomic plexus in lower part of posterior abdominal wall and posterior wall of pelvis. Branches from
autonomic plexus supply smooth muscles of viscera and wall of blood vessels.
Spinal nerve
Sometimes, they may be 11 in number, when 1st ganglion fuses with inferior cervical ganglion to form
cervicothoracic ganglion. It is called stellate ganglion, as its radiating branches give it a star- shaped
appearance.
Branches (Fig. 18.10)
􏱧􏱧􏱧er􏱧l: Conventionally, lateral branches of all the 12 thoracic ganglia are gray rami which join the
respective thoracic spinal nerve. These branches
T11 to L2 segments L2 ganglion
􏱺escending fibers of white rami
for sympathetic ganglia below L1/L2
Medial splanchnic branches

269
􏱪􏱪tail􏱪􏱪 􏱪ff􏱪􏱪􏱪nt 􏱪􏱪t􏱪o􏱪 f􏱪o􏱪 􏱪􏱪􏱪􏱪at􏱪􏱪tic Trunk
Distribution of branches from whole sympathetic trunk needs to be studied in following three components.
Branches from thoracic sympathetic ganglia.
Branches from cervical sympathetic ganglia.

Branches from lumbosacral sympathetic ganglia.
Branches from Thoracic Sympathetic Ganglia
Thoracic part of sympathetic chain is continuous above with its cervical part and below with its lumbosacral
part.
The thoracic part of sympathetic chain descends
vertically one on each side of thoracic part of
vertebral column.
At its upper end it crosses the neck of 1st rib, and
then crosses in front of head of the successive ribs. At its lower end it crosses over anterolateral aspect of bodies
of 11th and 12th thoracic vertebrae.
The thoracic part of the trunk contains 12 ganglia numbered as 1st (T1)–12th (T12) thoracic ganglia.
as lateral and medial branches as follows – (Fig. 18.8).

Lateral branches from—
1. Superior cervical ganglion: As gray rami to
upper four, i.e. C1–C4 nerves.

2. Middle cervical ganglion: As gray rami to C5
and C6 nerve.
3. Inferior cervical ganglion: As gray rami to C7
and C8 nerves.
Medial branches from all the three ganglia are
postganglionic to pass to the viscera of neck
and thorax.
5. Below L2 segment, there is no sympathetic center.
But there are still sympathetic ganglia corre-
and one coccygeal nerve. These ganglia receive preganglionic fiber from connector neurons of lower thoracic (T11
and T12) and upper lumbar
(L1 and L2) sympathetic centers of spinal cord. Postganglionic fibers pass from each of these ganglion to come
out as following branches, (Fig. 18.9).
L3
Only gray rami

communicantis L4
Fig. 18.9 Branches of sympathetic trunk below L1/L2 segments of spinal cord
270
11
2
3
45
78
5 66
78
99
10 11 12
10 11
12
are distributed segmentally through corresponding spinal nerve to sweat glands and arrectores pili muscles of
skin and, to peripheral blood vessels for vasoconstriction effect.
Medial: It is already understood that medial branches are splanchnic branches. It is important to note at
this stage that, medial splanchnic branches of 12 pair of thoracic ganglia have the duty to supply branches not
only to thoracic viscera, but also to upper abdominal viscera.
That is why medial branches of thoracic sympathetic ganglia are classified into following two groups.
1. Medial branches from T –T ganglia to thoracic
viscera.
2. Medial branches from T5–T12 ganglia to upper
abdominal viscera.
Medial branches from T1–T5 ganglia
It is important to note at this stage that, these are postganglionic fibers. So these are axons of excitor neurons
situated in these sympathetic ganglia which from synaptic connection with processes of connector neurons.
Before reaching the target organs these branches of sympathetic ganglia form plexuses with parasympathetic
fibers of vagus (10th cranial) nerve close to the viscera. The plexuses are following—
1. Cardiac plexus: It is divided into superficial and deep cardiac plexuses. Sympathetic fibers for cardiac
plexus are not only derived from medial branches of T1–T5 ganglia, but also from medial branches of 3 cervical
sympathetic ganglia. Fibers for cardiac plexus is also derived from vagus nerve. Thoracic sympathetic fibers
join deep cardiac plexus.
15
CBA ABC
Fig. 18.10 Medial splanchnic branches of thoracic sympathetic ganglia

T1–T5 ganglia = Postganglionic branches for cardiac, pulmonary, esophageal and aortic plexuses T5 – T12 ganglia = Preganglionic fibers
forming thoracic splanchnic nerves
A. Greater splanchnic, B. Lesser splanchnic, C. Least splanchnic nerves
2. Pulmonary plexus: Sympathetic fibers for pulmonary plexus are derived from T 2–T5 ganglia.
The plexus formed with parasympathetic fibers from vagus nerve is related to root of lung.
For the whole tracheobronchial tree with parenchyma of lung sympathetic fibers cause
bronchodilatation, vasoconstriction and decreased secretion of mucous glands.
Parasympathetic fibers cause bronchoconstriction, vasodilatation and increased secretion
of mucous glands.
3. Esophageal plexus: Sympathetic fibers arising from T1–T4 ganglia possess minor role in
formation of esophageal plexus. These fibers are vasomotor in nature. Parasympathetic
fibers from vagus are motor, secretomotor and sensory in function. Thoracic sympathetic
fibers supply lower half of esophagus.
4. Aortic plexus: It is formed by medial branches of T1–T5 sympathetic ganglia. Nerve fibers 271
from the plexus run along the wall of arteries which are vasodilator in nature.
Medial branches from T5–T12 ganglia (Fig. 18.10)
Following three fundamental points are to be noted in connection with these branches.
1. These are preganglionic fibers coming out from
medial side of sympathetic ganglia. They relay in ganglia which are in relation to the arteries close to midline of
body.
2. These branches leave posterior thoracic wall to reach posterior abdominal wall from where
postganglionic fibers are distributed to the upper abdominal viscera and the blood vessels along which
they are carried to viscera.
3. Nerves formed by medial branches from T 5–T12 ganglia are following –
Greater splanchnic nerve: T5 – T9 ganglia
Lesser splanchnic nerve: T10 and T11 ganglia
Least (Lowest) splanchnic nerve: T12 ganglia These three nerves are commonly termed as
thoracic splanchnic nerve.

Greater splanchnic nerve (Fig. 18.11):
Formation: It is formed by union of medial branches of T5–T9 sympathetic ganglia.
􏱧􏱧􏱧r􏱧 i􏱧􏱧o 􏱧b􏱧o􏱧e􏱧: By piercing crus of diaphragm of respective side.
􏱧is􏱧ribu􏱧io􏱧: Preganglionic fibers carried through greater splanchnic nerve terminate in following three
ways.
1. Celiacganglia:Itisbilateralandplacedoneither
side of celiac trunk. Celiac ganglia receive fibers of greater splanchnic nerve. Postganglionic fibers from the
ganglia are distributed to the viscera along the direction of blood vessels arising from celiac trunk.
Celiac ganglia of both sides are connected by network of nerve fibers which form celiac plexus.
2. Aorticorenal ganglia: It is also bilaterally sym-
metrical, situated near origin of renal artery. Postganglionic fibers run along branches of renal artery.
Network of nerves around these ganglia forms
aorticorenal plexus.
3. Some fibers of greater splanchnic nerve pass
along the direction of suprarenal arteries to reach cells of suprarenal medulla with which they form synaptic
connection. This is because, cells of suprarenal medulla are considered as 􏱧o􏱧ifie􏱧 form of postganglionic
sympathetic neurons.
Lesser splanchnic nerve:

Formation: It is formed by union of medial branches of T10 and T11 ganglia.
􏱧􏱧􏱧r􏱧 􏱧o 􏱧b􏱧o􏱧e􏱧: From posterior thoracic wall, like greater splanchnic nerve, it enters posterior
abdominal wall by piercing crus of diaphragm of respective side.
􏱧is􏱧ribu􏱧io􏱧: Preganglionic fibers coming from connector neurons of sympathetic center of T 10 and T11
segments of spinal cord, come out from medial side of two corresponding ganglia. These fibers relay in celiac
ganglia. Postganglionic fibers from celiac ganglia are carried to the target organs along the course of branches
of celiac trunk.
Least (Lowest) splanchnic nerve:
Formation: It is formed by preganglionic medial branches of T12 ganglia. Sometimes, it may be absent.
􏱧􏱧􏱧r􏱧 􏱧o 􏱧b􏱧o􏱧e􏱧: From posterior thoracic wall, it enters posterior abdominal wall passing deep to
medial arcuate ligament along with sympathetic trunk.
􏱧is􏱧ribu􏱧io􏱧: Preganglionic fibers of least splanchnic nerve relay in aorticorenal ganglia. Postganglionic
fibers arising from the ganglia follow the course of branches of renal artery to produce vasomotor effect.
Cervical Part of Sympathetic Trunk
Cervical part of sympathetic trunks are situated on either side of cervical part of vertebral column, behind the
carolid sheath and in front of prevertebral layer of cervical fascia. The trunk presents three cervical ganglia —
Superior, middle and inferior. At the upper end of trunk, superior ganglion is situated close to base of skull.
Middle and inferior ganglia, close to each other, are situated at the lower end of cervical part of chain, near root
of neck.
Connection of three cervical ganglia with eighth cervical spinal nerves through gray rami (lateral branch of
ganglia) are as follows–
272
5. T5– –T5
6. T6– –T
6
T7 –
– T7 T8– –T8
T9 –
– T9
Celiac trunk
Celiac plexus
Left suprarenal gland
Renal artery
11
Fig. 18.11 Distributions of greater splanchnic nerve preganglionic fibers arise from T5–T9 ganglia postganglionic neurons with their
synaptic connections are found in 1. Celiac ganglion 2. Aorticorenal ganglion and 3. Suprarenal medulla
Right suprarenal gland
Superior cervical ganglia: Homologous to upper four ganglia is connected to C1–C4 nerves.
Middle cervical ganglia: Homologous to next two ganglia is connected to C5 and C6 nerves.
Inferior cervical ganglia: Homologous to last two ganglia is connected to C7 and C8 nerves.
At the upper end, superior cervical ganglia is tied
by its branches which radiate in different direction. It is large and elongated ganglion, may be as long as 2.5 cm
in size.
Inferior cervical part of sympathetic trunk is continuous with thoracic part in front of neck of 1st rib.
Branches from cervical sympathetic ganglia (Fig. 18.12)
Cervical sympathetic ganglia receive preganglionic fibers from T1–T4 segments of spinal cord. The fibers, while
ascending from upper thoracic ganglia
upwards, relay one after another to the three cervical sympathetic ganglia, form each of the three ganglia,
postganglionic fibers emerge in following two forms – 􏱧􏱧 􏱧􏱧􏱧er􏱧l: These are nothing but gray rami
communicantis which join cervical spinal nerves. 2. Medial: Like lateral branches, medial branches of cervical
sympathetic ganglia are also postga-
nglionic which are of following two kinds –
a) Vascular: Run along the walls of different
arteries of head and neck.

b) Splanchnic: To supply some viscera.
Superior cervical ganglion
􏱧􏱧􏱧er􏱧l br􏱧􏱧􏱧􏱧es: These are four gray rami communicantes to join C 1–C4 nerves.
Medial Branches:
1. Internal carotid nerve: It is a very prominent
branch which arises from the upper end of fusiform
273
Short ciliary nerve

Nerve of pterygoid canal
Lateral branches (gray rami)
Middle cervical ganglion
􏱺ertebral nerve 􏱺ertebral artery
Ansa subclavia
Cardiac branches
Deep petrosal nerve
Branch to sweat gland of face
Facial artery
Internal carotid nerve
Pharyngeal branch
Cardiac branch
Thyroid, tracheal and esophageal branches
T1– T4 segments of spinal cord
T1 ganglion
superior cervical ganglion. It catches internal carotid artery at the base of skull and possesses widespread
distribution along its different branches. Network of nerves along the wall of artery form internal carotid
plexus. Some of the important distribution of this plexus are following –
a) Nerves running along ophthalmic branches of the artery supply dilator pupillae muscle.
b) Deep petrosal nerve: Arising from internal carotid plexus, this nerve, joining with greater petrosal nerve
(parasympathetic fibers from facial nerve) forms nerve of pterygoid canal, which joins sphenopalatine ganglion.
c) 􏲄􏲄mpat􏲄etic fibers to communicate 􏲄it􏲄 ciliary ganglion: These fibers run initially along ophthalmic branch
of internal carotid
Fig. 18.12 Branches of cervical part of sympathetic trunk
274
artery, then join with long ciliary nerve to
communicate with ciliary ganglion.

2. Branches along external carotid artery: These fibers from superior cervical ganglion run along external
carotid artery and its branches which are mainly vasomotor. Important branches
from external carotid plexus are following.

a) Sympathetic branches along facial artery supply vasoconstrictor fibers and also fibers to
the sweat glands of one half of face.

b) Sympathetic fibers communicating otic and
submandibular ganglion.
 􏱧􏱧 􏱧􏱧􏱧r􏱧􏱧􏱧e􏱧lbr􏱧􏱧􏱧􏱧:Itformspharyngealplexus
along with pharyngeal branches of glossophar-
yngeal and vagus nerve.
 􏱧􏱧 􏱧􏱧r􏱧i􏱧􏱧 br􏱧􏱧􏱧􏱧: Cardiac branch from left sup-
erior cervical ganglion form superficial cardiac plexus whereas right joins deep cardiac plexus.
Middle cervical ganglion
􏱧􏱧􏱧er􏱧l br􏱧􏱧􏱧􏱧es: These are two rami communicantes to join C5 and C6 nerves.
Medial Branches:
 􏱧􏱧 􏱧r􏱧􏱧􏱧e􏱧l 􏱧􏱧􏱧 eso􏱧􏱧􏱧􏱧e􏱧l br􏱧􏱧􏱧􏱧es: These
branches accompany the arteries supplying the
organ and are vasomotor in nature.

 􏱧􏱧 􏱧􏱧􏱧roi􏱧 br􏱧􏱧􏱧􏱧: This branch runs along inferior
thyroid artery.
 􏱧􏱧 􏱧􏱧r􏱧i􏱧􏱧 br􏱧􏱧􏱧􏱧: Cardiac branch of both middle
cervical ganglia takes part in formation of deep cardiac plexus.
Inferior cervical ganglion
􏱧􏱧􏱧er􏱧l br􏱧􏱧􏱧􏱧es: Two lateral branches from inferior cervical ganglion are gray rami comm-
unicantes to join C7 and C8 nerves.
􏱧e􏱧i􏱧l br􏱧􏱧􏱧􏱧es:
 􏱧􏱧 􏱧􏱧s􏱧 sub􏱧l􏱧􏱧i􏱧: This branch from inferior cervical ganglion forms a loop around subclavian
artery to join middle cervical ganglion. Branches from the ansa form plexus around subclavian artery.
 􏱧􏱧 􏱧er􏱧ebr􏱧l 􏱧er􏱧e: It is so called because it forms plexus around vertebral artery. Along with 2nd
part of the artery nerve ascends through foramen transversarium of upper six (C 1–C6) cervical
vertebrae.
 􏱧􏱧 􏱧􏱧r􏱧i􏱧􏱧 br􏱧􏱧􏱧􏱧: Cardiac branch from inferior ganglion of both sides join deep cardiac plexus.
PARASYMPATHETIC PART OF AUTONOMIC NERV- OUS SYSTEM
General Considerations
1. Parasympatheticsystemisthesmallercomponent of autonomic nervous system in comparison to its

sympathetic counterpart.
2.
3. 4.
5.
This system gets activated for conservation or restoration of energy, thereby keeps the body in restful condition.
Like sympathetic system, it is also made up of afferent as well as efferent components.
Afferent component of parasympathetic system carries mainly the physiological sensations from the receptors
present in the wall of viscera. For example, sense of awareness of distension of urinary bladder is carried
through parasympathetic afferent pathway, whereas pathological pain from wall of urinary bladder is carried
by sympathetic afferent pathway.
Efferent pathway (parasympathetic outflow) of parasympathetic nervous system is composed of following

components.
i. Centers: cranial (in brainstem) and spinal (in
spinal cord).
Cranial centers: These are nothing but general visceral efferent nuclei of four cranial nerves present in
brainstem, 3rd (oculomotor), 7th (facial), 9th (glossopharyngeal) and 10th (vagus) nerves.
Spinal centers: These are neuronal group present in intermediomedial area of spinal cord gray matter of S , S
and S segments.
6.
like those of sympathetic are preganglionic
neurons or connector neurons.

ii. 􏲄reganglionic fibers: These are longer in com-
parison to those of sympathetic and pass in the form of visceral efferent fibers of 3rd, 7th, 9th and 10th cranial
nerves, and pelvic splanchnic nerves formed by union of visceral efferent fibers carried through S 2, S3 and S4
spinal nerve.
iii. Autonomic ganglia: They are close to the target organ (viscera), so postganglionic fibers are very short.
Gross manifestations of parasympathetic activity
i.
ii.
􏲄􏲄eball: Constriction of pupil due to contraction of sphincter pupillae.

Increase in curvature of lens helping
accommodation due to contraction of ciliary
muscle.
Cardiovascular channel:
Slowering of heart rate (bradycardia) with
234
Neurons of centers of parasympathetic system,
diminished force of contraction. iii. Respiratory tract:
Constriction of smooth muscles of tracheobronchial tree and secretion of mucous glands.
iv. Gastrointestinal tract:

Increase of peristalsis
mucous glands.
and secretion of
v. Urinary tract:
Contraction of detrusor muscle.
Parasympathetic efferent pathways originate fundamentally from the following sites—
1. Cranial: From 4 parasympathetic cranial nerve
nuclei which are –
1. a) Edinger–Westphal nucleus of oculomotor

275
nerve (III): Present in midbrain at the level of
superior colliculus.
2. b) Superior salivatory nucleus of facial nerve
(VII): Present in lower half of pons.
3. c) Inferior salivatory nucleus of glossopharyngeal nerve (IX): Present in upper part of medulla
oblongata.
4. d) Dorsal nucleus of vagus nerve (X): Present in
lower part of medulla oblongata.
2. Spinal:Itistheintermediateareaofgraymatter
of S2, S3 and S4 segments of spinal cord which is considered to be spinal center for parasympathetic system.
􏱽fferent out􏱽o􏱽 fro􏱽 􏱽􏱽in􏱽er􏱽􏱽est􏱽􏱽al nucleus (Fig. 18.13)
Edinger-Westphal nucleus is the parasympathetic efferent nucleus of oculomotor nerve. It is situated closely
apposed and ventrolateral to main (somatic motor) nucleus of the nerve in the periaqueductal gray matter of
midbrain at the level of superior colliculus.
Axons of the cells of this nucleus, traverse the tegmentum of midbrain from behind forwards along
Somatic efferent nucleus Oculomotor nerve nuclei

{
with somatic motor fibers to pass through red nucleus, substantia nigra and crus cerebri.
Emerging out of midbrain through lateral wall of sulcus in between two halves of cerebral peduncle, the fibers
follow the course of main trunk of nerve, its inferior division and finally branch to inferior oblique. Finally from
branch to inferior oblique it leaves to relay in a tiny ganglion. It is called ciliary ganglion which is situated near
the apex of orbit in the space between optic nerve and lateral rectus muscle. Postganglionic parasympathetic
fibers emerge from ciliary ganglion in the form of 8–10 short branches which are called short ciliary nerves
which finally divide into 15–20 divisions which pierce sclera around optic nerve and pass over the surface of
choroid to supply sphincter pupillae and ciliary muscles.
Communications of ciliary ganglion (Fig. 18.14)
Communications are the nerve fibers which join the ciliary ganglion from its posterior side which are known as
roots of the ganglion as follows.
1. Parasympathetic root: As mentioned above,
this is made up of preganglionic parasympathetic fibers which emerge from Edinger-Westphal nucleus and
pass through oculomotor nerve to relay in ciliary ganglion (Fig. 18.14A).
2. Sympathetic root: Fibers of this root originate as postganglionic fibers from superior cervical ganglion and
enter cranial cavity through internal carotid plexus. Sympathetic fibers for the orbit
Ciliary ganglion
Short ciliary nerves

Sphincter pupillae
Ciliary muscle
Edinger-Westphal nucleus
􏱺reganglionic parasympathetic fiber 􏱺visceral efferent fiber􏱺
LPS SR
IO
IR
Oculomotor nerve
Somatic efferent fiber
MR
Fig. 18.13 Parasympathetic efferent pathway from Edinger-Westphal nucleus of oculomotor nerve
276
A
Short ciliary nerves to blood vessels of eyeball and orbit
Ophthalmic artery Internal carotid artery
Internal carotid nerve
Short ciliary nerve to sphincter pupillae Short ciliary nerve to ciliary muscle
Ciliary ganglion
Parasympathetic root of ciliary ganglion
Short ciliary nerve to dilator pupillae
Ciliary ganglion Sympathetic root

B
Nasociliary nerve
Short ciliary nerve to cornea
Short ciliary nerve to sclera, cornea and uveal tract
Ciliary ganglion Sensory root
Fig. 18.14 Communication roots of ciliary ganglion. A. Parasympathetic root, B. Sympathetic root, C. Sensory root
travel via ophthalmic artery. From this fibers, a root joins the ciliary ganglion. As this sympathetic root of
fibers is already postganglionic sympathetic fibers, it traverses ciliary ganglion uninterrupted, finally to pass
through short ciliary nerve to
supply dilator pupillae and wall of blood vessels

(Fig. 18.14B).
3. Sensory root: This is the branch from nasociliary
nerve which joins posterior end of ciliary ganglion. While traversing the ganglion without relay it
divides into multiple branches which pass through short ciliary nerves for sensory innervations of eyeball (Fig.
18.14C).
Branches of ciliary ganglion
These are nothing but bunch of short ciliary nerves which contain parasympathetic, sympathetic and sensory
fibers for following distribution.
1. Parasympathetic: To sphincteral pupillae and
277
ciliary muscle.
2. Sympathetic: To dilator pupillae and blood ves-
sels of eyeball.
3. Sensory: To sclera, cornea and uveal tract. 􏱽fferent out􏱽o􏱽 fro􏱽 su􏱽erior sali􏱽ator􏱽 nucleus
Superior salivatory nucleus is the parasympathetic or general visceral efferent nucleus of facial (VII) nerve
which is situated in lower half of pons. Preganglionic efferent outflow from the nucleus comes out in the form of
two branches of facial nerve which relay respectively in two different ganglia from where postganglionic fibers
are distributed to two different groups of target organs which are summarized as follows.
Branch of facial nerve 􏱧􏱧rr􏱧i􏱧􏱧 􏱧re􏱧􏱧􏱧􏱧lio􏱧i􏱧 􏱧􏱧􏱧􏱧lio􏱧 􏱧􏱧ere 􏱧re􏱧􏱧􏱧􏱧lio􏱧i􏱧

􏱧􏱧r􏱧e􏱧 or􏱧􏱧􏱧s
􏱧􏱧r􏱧s􏱧􏱧􏱧􏱧􏱧􏱧e􏱧i􏱧 fibers fibers rel􏱧􏱧
1. Mucous glands of pharynx, nasal
cavity and palate
Greater superficial petrosal nerve Sphenopalatine ganglion
2. Lacrimal glands
Submandibular and sublingual
Chorda tympani nerve Submandibular ganglion
salivary glands
However, it is important to note that, through both of the above two different distributions, target organs
supplied are all exocrine glands.
􏱧􏱧r􏱧s􏱧􏱧􏱧􏱧􏱧􏱧e􏱧i􏱧 􏱧is􏱧ribu􏱧io􏱧 􏱧􏱧rou􏱧􏱧 􏱧re􏱧 􏱧􏱧er su􏱧erfi􏱧i􏱧l 􏱧e􏱧ros􏱧l 􏱧er􏱧e 􏱧􏱧i􏱧􏱧

􏱧􏱧􏱧􏱧􏱧􏱧: Greater superficial petrosal branch of facial nerve
Lacrimal gland
Lacrimal nerve carrying postganglionic
secretomotor fibers
Motor root of facial nerve
Facial colliculus
Nucleus of abducent nerve
Section of pons
Superior salivatory nucleus of facial nerve
􏱺reater superficial petrosal nerve
Deep petrosal nerve

Zygomatic nerve Maxillary nerve
Sphenopalatine ganglion
Nasal branch
Palatal branches Pharyngeal branch
Fig. 18.15 Parasympathetic efferent pathway from superior salivatory nucleus of facial nerve (via sphenopalatine ganglion)
278
carrying preganglionic parasympathetic fibers arises from geniculate ganglion. It joins with deep petrosal nerve
to form nerve of pterygoid canal. Deep petrosal nerve carries sympathetic fibers from superior cervical ganglion
along internal carotid artery. Parasympathetic fibers along greater superficial petrosal nerve relay via nerve of
pterygoid canal in sphenopalatine ganglion. Postganglionic fibers from the ganglion pass through following
branches to supply target organs which are different exocrine glands.
􏱧􏱧 􏱧􏱧􏱧r􏱧􏱧􏱧e􏱧l br􏱧􏱧􏱧􏱧es: To the mucous glands of pharynx.
 􏱧􏱧 􏱧􏱧l􏱧􏱧i􏱧e br􏱧􏱧􏱧􏱧es: To mucous glands of palate.

 􏱧􏱧 N􏱧s􏱧l br􏱧􏱧􏱧􏱧: To mucous glands of nasal cavity.
4. Branch for lacrimal gland: It passes to the
gland via following route.
Sphenopalatine ganglion – anterior root of communication to maxillary nerve–maxillary nerve – Zygo- matic
branch – Zygomaticotemporal branch–communication to lacrimal nerve – lacrimal nerve – to lacrimal gland.
􏱧􏱧r􏱧s􏱧􏱧􏱧􏱧􏱧􏱧e􏱧i􏱧 􏱧is􏱧ribu􏱧io􏱧 􏱧􏱧rou􏱧􏱧 chorda tympani nerve (Fig. 18.16): Chorda tympani
branch of facial nerve carrying preganglionic parasympathetic fibers arises 6 mm above stylomastoid foramen.
Coming out of tympanic cavity and finally outside cranium, it joins lingual nerve in infratemporal fossa.
Carried through lingual nerve fibers relay in the submandibular ganglion
Geniculate ganglion
Lingual nerve
Sublingual gland
Postganglionic secretomotor
fibers supplying sublingual gland
Submandibular duct
placed on hyoglossus muscle in submandibular region. Postganglionic parasympathetic fibers are secretomotor
in nature to supply submandibular and sublingual salivary glands.
􏱽fferent out􏱽o􏱽 fro􏱽 inferior sali􏱽ator􏱽 nucleus (Fig. 18.17)
Inferior salivatory nucleus is the parasympathetic or general visceral efferent nucleus of glossopharyngeal
nerve which is situated in upper part of medulla oblongata. Preganglionic efferent outflow from the nucleus
comes out from the glossopharyngeal nerve as its tympanic branch at base of skull. From the tympanic branch
parasympathetic fibers reach parotid gland through following route.
Inferior salivatory nucleus – glossopharyngeal nerve – tympanic branch – tympanic plexus in middle ear cavity
– lesser superficial petrosal nerve – otic ganglion – trunk of mandibular nerve – its posterior division –
auriculotemporal nerve – auricular branch to parotid gland.
􏱽fferent out􏱽o􏱽 fro􏱽 􏱽orsal nucleus of 􏱽a􏱽us (Fig. 18.18)
Dorsal nucleus of vagus is a composite nucleus, being mixed in nature with a motor and a sensory component.
Sensory part of the nucleus receives inputs from different viscera (of thorax and abdomen) which receive
efferent fibers from its motor component. Dorsal nucleus of vagus is situated in
Abducent nerve nucleus Facial colliculus
Section of pons Superior salivatory nucleus
Facial nerve
Chorda tympani nerve
􏱺oining lingual nerve

Submandibular ganglion
Submandibular gland
Fig. 18.16 Parasympathetic efferent pathway from superior salivatory nucleus of facial nerve (via submandibular ganglion)
279
Inferior salivatory nucleus
Tympanic plexus
Tympanic branch of glossopharyngeal nerve
􏱺esser superficial petrosal
nerve
Foramen ovale transmitting two roots of mandibular nerve
Otic ganglion
Anterior division and
Posterior division of mandibular nerve
Autonomic Nervous System Section of medulla oblongata
Jugular foramen
Glossopharyngeal nerve Superior ganglion
Inferior ganglion Postganglionic parasympathetic
secretomotor fibers to parotid gland
Auriculotemporal nerve
Fig. 18.17 Parasympathetic efferent pathway from inferior salivatory nucleus of glossopharyngeal nerve Dorsal nucleus of
vagus nerve
􏱺agus nerve
Cardiac branches for cardiac plexus
Pulmonary branches for ant and postpulmonary plexuses

Esophageal branches Gastric nerves
Branches for biliary tree
Enteric branches for small intestine
Large intestinal branches upto right two- thirds of transverse colon
Fig. 18.18 Distribution of parasympathetic fiber through vagus nerve in abdomen
280 medulla oblongata beneath the ependyma of floor of 4th ventricle opposite the vagal triangle.
As the vagus nerve is characterized by its long course like a vagabond, parasympathetic efferent distribution
through this nerve is widespread to many organs in neck, thorax and abdomen.
Before the distribution of parasympathetic fibers of vagus is further studied, following fundamental points are
to be noted.
1. Preganglionic fibers carried through vagus nerve
are very long.
2. These fibers may straightway pass upto wall or
surface of the viscera.
3. In some cases these fibers form a plexus along

with sympathetic fibers, in relation to the arteries
supplying the organ.
4. However, long preganglionic fibers of both the
above mentioned varieties, relay in small localized parasympathetic ganglia on the surface or wall of
the viscera.
5. Small postganglionic fibers are short for localized and discrete actions to the target organs of following
kinds.
i. Smooth muscles, action on which may be exci-
tatory, e.g. bronchial musculature, smooth muscles of wall of gut, or inhibitory, e.g. cardiac muscle.
ii. Exocrine gland – These are to increase secretion of mucous glands of tracheobronchial tree foregut and
midgut.
iii. Visceral blood vessels – Vasoconstrictor fibers for coronary arteries but vasodilator fibers for viscera.
􏱧􏱧r􏱧s􏱧􏱧􏱧􏱧􏱧􏱧e􏱧i􏱧 􏱧is􏱧ribu􏱧io􏱧 􏱧􏱧rou􏱧􏱧 􏱧􏱧􏱧us nerve (Fig. 18.18):

􏱧􏱧 􏱧􏱧r􏱧i􏱧􏱧 br􏱧􏱧􏱧􏱧es: Parasympathetic fibers to
heart, like sympathetic, are for myocardium, conducting system and coronary vessels. Cardiac branches are
cervical (superior and inferior) and thoracic. These branches form cardiac plexuses (smaller superficial and
larger deep) along with sympathetic (T 2 – T5). Cardiac plexuses are situated in relation to pulmonary trunk and
bifurcation of trachea. Postganglionic parasympathetic fibers from cardiac plexus, on activation, result—
i. 􏲄ardioin􏲄ibition: Reduction of rate and force of contraction of cardiac muscle.

ii. Constriction of coronary arteries.
Activation of sympathetic fibers of cardiac plexus cause cardioacceleration and coronary vasodilatation. 􏱧􏱧
􏱧ul􏱧o􏱧􏱧r􏱧 br􏱧􏱧􏱧􏱧es: Parasympathetic fibers
to the lungs (bronchial tree), like sympathetic, are for bronchial musculature, mucous glands and blood vessels.
Pulmonary branches of vagus,
unlike cardiac branches are only thoracic in origin. These branches, along with sympathetic fibers (T2 – T5),
form anterior and posterior pulmonary plexuses which are situated in front and behind root of lung
respectively.
Postganglionic parasympathetic fibers from pulmonary plexus on activation, result in –
i. Bronchoconstriction: Constriction smooth muscles of tracheobronchial tree.
ii. Enhanced mucus secretion: Secretion of mucous glands of respiratory tree is increased.
iii. Slight vasodilatation.
Stimulation of sympathetic fibers of pulmonary plexus causes bronchodilatation and diminished glandular
secretion.
􏱧􏱧 􏱧so􏱧􏱧􏱧􏱧e􏱧l br􏱧􏱧􏱧􏱧es: Parasympathetic fibers
for esophagus are derived from both vagi which form esophageal plexus with sympathetic fibers from T 1 – T4
segments. Parasympathetic fibers are visceromotor for musculature and secretomotor for mucous glands.
Sensory fibers from esophagus are also carried by vagus. Sympathetic fibers of esophageal plexus are vasomotor
in nature.
􏱧􏱧 􏱧􏱧s􏱧roi􏱧􏱧es􏱧i􏱧􏱧l br􏱧􏱧􏱧􏱧es: In embryonic life, initially whole gastrointestinal tract used to be placed
along midline and embryological surfaces of the gut used to be right and left which remain demarcated by
ventral and dorsal border. Upto right two-thirds of transverse colon, where ends the midgut, parasympathetic
nerve fibers are derived from both vagi.
􏱧􏱧s􏱧ri􏱧 br􏱧􏱧􏱧􏱧es: Left and right vagal fibers form anterior and posterior gastric nerves respectively to
be in relation to anterior and posterior surfaces of stomach.
􏱧􏱧􏱧eri􏱧 br􏱧􏱧􏱧􏱧es: Beyond supply of stomach, fibers of both the vagus nerve are continued along the
blood vessels to supply the small gut, midgut portion of large gut and also associated organs. Along with the
sympathetic fibers from splanchnic nerves they form plexuses, e.g. celiac plexus and superior mesenteric
plexus. Parasympathetic fibers which are still preganglionic, proceed beyond these plexuses to relay in short
postganglionic neurons in two different planes of wall of the gut to form following two plexuses (Fig. 18.19).
i. Auerbac􏲄 􏲄􏲄􏲄enteric􏲄 ple􏲄us: This is placed in the plane between longitudinal and circular muscle coats of
intestine. Postganglionic neurons from this plexus (relay station) supply motor branches to the musculature of
the gut. Stimulation of this parasympathetic pathway increases peristaltic movement of gut with inhibition of
sphincters.
Auerbach (myenteric) plexus
􏱺reganglionic fibers of vagus
nerve
Meissner (submucous) plexus
Sympathetic fibers for the gut upto right two- thirds of transverse colon pass via celiac and superior mesenteric
plexuses carrying fibers from greater and lesser splanchnic nerve. Stim- ulation of these nerve fibers causes
sphincteric contraction and splanchnic vasoconstriction.
ii. 􏲄eissner 􏲄submucousal􏲄 ple􏲄us: These plexuses are the sites of relay station with short postganglionic
parasympathetic neurons beneath the mucous membrane in the submucous layer of intestine. From these
plexuses postganglionic secretomotor fibers supply intestinal mucous glands.
Enteric nervous system: The above mentioned two plexuses extend continuously along the length of
almost whole gastrointestinal tract starting from esophagus to anal canal. Out of the two, activity of Auerbach
or myenteric plexus leads to coordinated purposeful contraction of smooth muscles of gut resulting its 281
peristalsis and segmental movements. At the site of reflex, sympathetic postganglionic neurons are found to
terminate on postganglionic parasympathetic neurons. These exert an inhibitory effect on parasympathetic
activity. Parasympathetic sensory neurons are also found to relay in myenteric plexus to form a local reflex arc.
As it has been found that the gut-wall plexus through formation of local reflex arc may act for segmental
movement of intestine, even when isolated from central nervous system and it extends throughout the entire
gut-wall. It is referred as ‘Enteric nervous system’.
5. 􏱧r􏱧􏱧􏱧􏱧es 􏱧o 􏱧􏱧llbl􏱧􏱧􏱧er 􏱧􏱧􏱧 bili􏱧r􏱧 􏱧ree: Parasympathetic fibers for gallbladder and biliary tree
are derived via hepatic plexus from celiac
Mucous glands
Submucous coat
Circular muscle Longitudinal muscle
plexus. But the fibers are from vagus nerve. These motor fibers of vagus arc for contraction of smooth muscles
of gallbladder and bile duct. But it is inhibitory to ampullary sphincter of Oddi.
􏱽fferent out􏱽o􏱽 fro􏱽 s􏱽inal 􏱽aras􏱽􏱽􏱽at􏱽etic center
Spinal parasympathetic center is made up of general visceral efferent neuronal group present in the
intermediate (intermediomedial) area of gray matter of S , S and S segments of spinal cord.
Fig. 18.19 Parasympathetic plexuses in the wall of intestine
234
Principles of distribution
Exit from spinal center: Parasympathetic pre– ganglionic efferent fibers come out of spinal cord via
ventral (motor) root of S2, S3 and S4 nerves, and finally through ventral rami of the same nerves. But ultimately
parasympathetic fibers, leaving these spinal nerves join together to form pelvic splanchnic nerve (Fig. 18.20).
􏱧􏱧r􏱧e􏱧 or􏱧􏱧􏱧s:
1. As the name suggests, pelvic splanchnic nerve
supplies all pelvic viscera in both male and female. 2. In addition, it provides both motor as well as
secretomotor fibers for the wall of hindgut.

􏱧ou􏱧es o􏱧 􏱧is􏱧ribu􏱧io􏱧: Primarily, preganglionic parasympathetic efferent fibers carried via pelvic
splanchnic nerve, along with sympathetic contribution, form a plexus in the pelvic cavity which called pelvic
plexus or inferior hypogastric plexus. The plexus is situated in extraperitoneal fat, lateral to rectum and
posterolateral to urinary bladder as well as reproductive organs of pelvis. From inferior
282
Inferior mesenteric plexus
Left one-third of transverse colon
Superior hypogastric plexus
Pelvic splanchnic {S 3 nerve S4
Urinary bladder
}
S3 Pelvic splanchnic
S 2 S2
S4
nerve
Inferior hypogastric plexus
Fig. 18.20 Distribution of parasympathetic fibers from pelvic splanchnic nerve
hypogastric plexus fibers are distributed along two directions as follows.

1. For the pelvic viscera, fibers pass either directly
or in reverse direction of the course of branches of
internal iliac artery.

2. Branches run upwards to join superior hypogastric
plexus which is situated below bifurcation of abdominal aorta and between two common iliac arteries. Finally
the fibers ascend further to inferior mesenteric plexus. Through this plexus parasympathetic fibers are
distributed along the reverse direction of branches of inferior mesenteric artery to the wall of hindgut starting
from left one- third of transverse colon.
Like foregut and midgut, as supplied by vagus, in the wall of hindgut, preganglionic relay with postganglionic
neurons, parasympathetic distribution forms myenteric (Auerbach) and submucousal (Mei- ssner) plexuses.
Purpose of distribution
1. Hindgut (upto rectum):

a) Visceromotor fibers: For coordinated peristaltic
movement via myenteric plexus.

b) 􏲄ecretomotor fibers: For secretion of mucous
glands via submucous plexus.

􏱧􏱧 􏱧ri􏱧􏱧r􏱧 bl􏱧􏱧􏱧er: Contraction of detrusor mus-
3. Uterus: Parasympathetic fibers of pelvic splanchnic nerve antagonises contractile effect of sympathetic
fibers on uterine musculature.
4. Erectile tissue of genital organs: Parasym- pathetic fibers of pelvic splanchnic nerve increases vascular
congestion through vasodilatation of erectile tissue.
CLINICAL ANATOMY OF AUTONOMIC NERVOUS SYSTEM
It is already understood that autonomic nervous system is not isolated, rather it is a part of nervous system.
That is why, in some clinical conditions affecting nervous system in general, autonomic nervous system is also
affected. Again, there are some situations where autonomic nervous system (sympathetic or parasympathetic or
both) is selectively lesioned.
Following are the two fundamental causes of lesion of autonomic nervous system,
1. Injury
2. Diseases.
cles and relaxation of involuntary sphincters.
INJURIES TO AUTONOMIC NERVOUS SYSTEM
Parasympathetic
It may be cranial or spinal. Causes of damage to the cranial component of parasympathetic system is

i. 􏲄ateral branc􏲄es: Gray rami to join cervical spinal nerve to arterial wall and sweat gland.
ii. Medial splanchnic branches.

iii. 􏲄nternal carotid branc􏲄: It runs along internal
carotid artery to enter inside the cranium. Apart from vascular branches, fibers along ophthalmic artery,
entering the orbit supply dilator pupillae and part of levator palpebrae superioris.
A patient may suffer from Horner syndrome due to lesion of anyone of following three level of sympathetic
pathway for head and neck.
1. First neuron lesion – Affecting

reticulospinal tract. Due to degeneration
}
diseases like
2. Second neuron lesion – Affecting * Multiple sclerosis 1st thoracic segment of spinal * Syringomyelia gray matter.
3. Third neuron lesion – Affecting Due to – cervicothoracic ganglion (stellate * Penetrating injury at ganglion). root of neck
}
* Traction by cervical rib * Metastatic lesion at root
of neck
1. Horner syndrome: Important clinical manifestations: 283
i. Miosis: Constriction of pupil due to unopposed action of sphincter pupillae for nonfunctioning dilator
pupillae.
ii. Ptosis: Partial dropping of upper eyelid due to paralysis of levator palpebrae superioris.
iii. Anhidrosis: Dryness of one half of the face with head and neck due to impaired secretion of sweat gland.
iv. Flushing or blanching of same half of face due to loss of vasoconstrictor effect on skin.
2. Raynauddisease:Itisavasospasticdiseasedue to hyperactivity of vasoconstrictor sympathetic fibers affecting

digital arteries of fingers. It is a bilateral disorder which is precipitated by exposure to cold and smoking. In
case of smokers nicotine aggravates vasospasm. Clinical manifestations are pain, pallor and cyanosis due to
impaired vascular supply. Fingertips show black discoloration with formation of dry gangrene.
3. Buerger disease: It is arterial occlusive disease of lower limb. Ischemia of muscles of leg causes pain due to
muscular cramps intermittently. That is why the disorder is named as intermittent clau- dication.
Parasympathetic System
Argyll Robertson pupil
It is a disorder in a patient of neurosyphilis due to lesion of pretectal nucleus of midbrain which is one of
head injury. Head injury may cause impairment of function of following components of parasympathetic
system.
Oculomotor nerve: It is affected when head injury is associated with herniation of uncus of temporal lobe.
Visceral efferent fibers of the nerve supply sphincter pupillae and ciliary muscles. So damage of the nerve cau-
ses loss of light reflex with dilation of pupil due to nonfunctioning of sphincter pupillae. Accommodation reflex
is also affected due to nonfunctioning of ciliary muscle along with medial rectus and sphincter pupillae.
Facial nerve containing visceral efferent fibers with other functional components may be affected in fracture
of base of skull affecting internal auditory meatus of petrous part of temporal bone. Lesion of preganglionic
secretomotor fibers to the lacrimal gland causes impaired lacrimation. Salivary secretion is not fully impaired,
as parotid gland remains functioning, because it is supplied by visceral efferent fibers through
glossopharyngeal nerve.
Spinal injury affecting the parasympathetic system along with sympathetic system leads to disorders of
bladder, bowel and sexual function.
Sympathetic
It is the sympathetic trunk which in injured opposite the level of cervicothoracic (stellate) ganglion at the root
of neck. This injury may occur due to stab or gunshot wound. It may also occur due to traction by cervical rib.
Beside injury, metastatic lesion at the root of neck may affect stellate ganglion. Clinical condition arising from
this lesion is known as Horner syndrome which is described below.
DISEASES INVOLVING AUTONOMIC NERVOUS SYSTEM

Sympathetic System
1. Horner syndrome: Clinical manifestations of this syndrome occur due to interruption of sympathetic
nerve supply to the head and neck. Center (connector neurons) for the sympathetic outflow to head and neck
lies in lateral horn cells of first thoracic segment of spinal gray matter. Proximally it gets supraspinal control
through reticulospinal tract descending from brainstem reticular formation. Preganglionic sympathetic fibers
for head and neck arising from 1st thoracic segment ascend through cervical part of sympathetic chain. After
relay in cervical sympathetic ganglia, postganglionic fibers are distributed to head and neck through following
branches –
the cell stations in light reflex pathway. The disease is characterized by narrow pupil with no reaction to light due
to interruption of light reflex pathway which is as follows.
Retina – optic nerve – optic chiasma – optic tract –lateral geniculate body – superior brachium – pretectal nucleus –
Edinger – Westphal nucleus– oculomotor nerve – ciliary ganglion–short ciliary nerve – sphincter pupillae.
In case of Argyll – Robertson pupil, accommodation reflex is not disrupted as it is not passing through pretectal
nucleus and its pathway is as follows.
Retina–optic nerve–optic chiasma–optic tract– lateral geniculate body–optic radiation–primary visual cortex (Area
17) – superior longitudinal fasciculus– Frontal eye field–corticonuclear tract–oculomotor nucleus (somatic efferent
as well as visceral efferent) –oculomotor nerve to supply medial rectus, sphincter pupillae and ciliaris for
accommodation.
A simple formula mentioned below may be helpful to remember manifestation of Argyll–Robertson pupil.
ARP (Accommodation Reflex
Present)
ARP (Argyll–Robertson Pupil)
{
PRA (Pupillary Reflex Absent)
Adie tonic pupil
This is a syndrome characterized by following clinical presentations.

1. Diminished or absent light reflex due to disorder
of function sphincter pupillae.
2. Slow or delayed dilatation of pupil in the dark.

3. Slow or delayed accommodation to near vision because of suppressed function of ciliary muscle which is
concerned for increase of curvature of lens. All the above features are supposed to be due to suppression of
parasympathetic ocular function.
Frey syndrome
It is a clinical condition that is found to occur following healing of a penetrating wound of face over parotid gland.
During healing process, injured nerves of this area of face communicate with one another, as done by
auriculotemporal nerve supplying parasympathetic postganglionic secretomotor fibers to parotid gland with great
auricular nerve supplying sweat glands of this area of face. So stimulation of salivary secretion during mastication
of food causes sweating of area of face supplied by great auricular nerve.
Hirschsprung disease
This disease is also called megacolon. It is a congenital disease characterized by failure of development Auerbach
(myenteric) plexus with absence of
postganglionic parasympathetic neurons in the wall of distal part of colon. So this part of colon does not show
peristaltic activity, for which part of the colon proximal to it presents huge dilatation with stagnant faecal matter.
COMBINED SYMPATHETIC AND PARASYMPA- THETIC LESION CAUSING URINARY BLADDER DYSFUNCTION
IN SPINAL CORD INJURY
Detrusor muscle of urinary bladder is supplied by parasympathetic fibers from S 2, S3 and S4 segments through
pelvic splanchnic nerve which is called nerve of evacuation. Sympathetic fibers for urinary bladder arising from L1
and L2 segments of spinal cord is called nerve of filling which supplies sphincter vesicae or internal urethral
sphincter.
Sensory impulse from the urinary bladder is carried through both parasympathetic as well as sympathetic
pathways. When urinary bladder is distended, stretch receptors in the wall of bladder are stimulated and impulse
for sense of fullness of bladder is carried through sensory fibers of pelvic splanchnic nerve to the spinal cord. Dorsal
column (fasciculus gracilis) is the tract for awareness of distension of bladder. But pain sensation, e.g. in case of
carcinoma or calculus, traveling through sympathetic fibers ascend through lateral spinothalamic tract which
carries somatic pain sensation. That is why patient with symptom of intractable pain due to carcinoma of urinary
bladder is managed by lateral cordotomy without any disturbance to awareness for fullness of bladder which passes
through dorsal column.
DISRUPTED MOTOR FUNCTIONS OF BLADDER

Atonic Bladder
It is the dysfunction of urinary bladder during the initial phase of spinal shock following spinal injury. Spinal shock
phase lasts from a few days to a few weeks. If the level of spinal injury is above S 2, S3, S4 segmental level of spinal
cord, during the period of spinal shock, the bladder losses its normal tonic affect due to temporary withdrawal of all
cord function. In normal condition, an individual can temporarily suspend the act of micturition by voluntary
contraction of external urethral sphincter with maintenance of detrusor muscle tone even with awareness of
fullness of bladder. In case of spinal shock, awareness for fullness is lost with loss of voluntary contraction of
external sphincter which becomes relaxed and atonia of detrusor which becomes relaxed, but internal sphincter is
tightly
closed. So atonic bladder with overdistension, tightly closed internal sphincter and relaxed external sphincter causes
overflow of urine.
When period of spinal shock is over, dysfunction of urinary bladder may be one of the following two types depending
upon the level of lesion.
Automatic Bladder
This type of bladder disfunction is observed if the lesion is above the level of S 2, S3 and S4 segments of spinal cord.
These sacral segment are called spinal micturition center which possesses excitatory effect on detrusor muscle and
inhibitory effect on sphincter vesicae (internal urethral sphincter). Paracentral lobule is called cortical micturition
center which possesses inhibitory control on sphincter urethrae (external urethral sphincter). If the spinal cord
lesion is above S2, S3 and S4 segments, it means that control of cortical micturition center by descending tract is lost
and spinal center (S2, S3 and S4) remains functioning. So following changes are observed.
1. External urethral sphincter is relaxed.

2. When the bladder is distended, impulse from stretch receptor is carried to S 2, S3 and S4 segments by afferent
fibers of pelvic splanchnic nerves. Stimulation of motor neuronal roots of same segments through
interneurons completes the activity of local segmental reflex arc to lead to contraction of detrusor with
relaxation of internal sphincter which results emptying of bladder.
So through activity of local reflex pathway, bladder once distended, becomes empty automatically. That is why it is
called automatic bladder.
Autonomous Bladder
This type of dysfunction of urinary bladder occurs when spinal injury causes lesion in sacral segments (namely S2,
S3 and S4) of spinal cord. In this case bladder is deprived of both supraspinal voluntary control as well as local reflex
control. Voluntary control is lost because influence of descending tract is cut off. Again local reflex pathway circuit is
cut off due to lesion of local sacral center. Urinary bladder is, therefore, released from its nervous control and enjoys
its autonomy for which it is called autonomous bladder. The bladder wall becomes flaccid and urine is getting
accumulated more and more with overdistension of the organ. As the sphincters are ineffective, overdistension of
bladder is characterized by continuous dribbling.
VISCERAL PAIN
Before this topic is discussed, following general points are to be taken into consideration in connection with afferent
autonomic pathway.
Different kinds of sensations carried from the viscera are sense of compression, distension (stretch) and pain.
Pain sensation carried from the viscera is due to lack of oxygen as a result of ischemia, or due to accumulation of
metabolites.
Different kinds of sensations are carried from viscera through afferent fibers of both sympathetic as well as
parasympathetic components of autonomic nervous system.
Afferent fibers of sympathetic system are carried from the viscera which travel through the sympathetic ganglion to
join the spinal nerve via gray rami communicantes.
Cell bodies of first order of neuron of both sympathetic as well as parasympathetic system are also situated in
posterior root ganglia like somatic sensory pathway.
Impulse, entering the spinal cord, stimulates afferent tract neurons in the base (lamina VII) of posterior horn of T 1 –
L2 and S2, S3 and S4 segments of spinal cord. These neurons are visceral afferent cell group. Visceral afferent tract
fibers ascend as axons of the cells. But these fiber tracts ascend in common, intermingling with somatic afferent
tracts for example lateral and anterior spinothalamic tracts.
Before passing through the ascending tracts, pain sensation is mostly carried through peripheral sympathetic
pathway. But in case of viscera like urinary bladder, pain sensation are of two different kinds, physiological and
pathological. Physiological pain, due to stimulation of stretch receptors in detrusor muscle wall of bladder is carried
through parasympathetic afferent fibers entering S2, S3 and S4 segments of spinal cord. Then, it ascends through
dorsal column. Impulse reaching the sensory cortex through this pathway leads to awareness for fullness of bladder.
Pathological pain due to irritation of bladder wall nerve endings by vesical calculus or due to carcinoma of urinary
bladder is carried through T11–L2 sympathetic ganglia to corresponding segments of spinal cord via lateral
spinothalamic tract. Advantage of this dual sensory pathway is utilized by neurosurgeons by performing selective
lateral cordotomy for relief of intractable bladder pain in a patient of bladder carcinoma, in which case sense of
fullness of bladder passing through dorsal column is not disturbed.
Explanation of Referred Visceral Pain
Visceral pain is diffuse and poorly localized. But somatic pain is comparatively more intense and localized more
accurately. But in general, when pain fibers (sympathetic as well as parasympathetic) from viscera are stimulated,
instead of being felt at the site of viscera, it is felt over the belt of skin (dermatome) supplied by somatic nerve of
same segment of spinal cord supplying viscera. It is called referred pain. Explanation of referred pain is not
absolutely clear. But it is based on the following two theories.
1. Pain fibers from viscera and corresponding dermatome ascend through same ascending tract in central
nervous system. Sensory area of cerebral cortex is unable to locate exactly site of origin of pain, viscera or
dermatome. As already mentioned that pain from dermatome is more sharply and accurately felt than
viscera, sensory cortex locates that pain is arising from the dermatome.
2. Innormalcondition,nociceptorsofdermatomeare constantly charged by noxious stimuli, which is not so in
case of viscera. So when pain fibers from viscera are stimulated, sensory cortex interprets that impulse is
coming from the respective dermatome.
Important Visceral Pain
Cardiac pain: Nature of cardiac pain varies from mild discomfort in the chest to severe crushing pain.
Sympathetic pain fibers are stimulated in the myocardium due to ischemia which results in oxygen deficiency and
accumulation of metabolites in the myocardial wall. Impulse is carried via cardiac branches of sympathetic trunk to
the lateral horn cells of upper four thoracic segments (T 1–T4) of spinal cord.
It is very important to note at this stage that cardiac pain is not felt in heart. Pain is felt over the skin area supplied
by T1–T4 nerves, which is corresponding dermatome areas of chest wall. Intercostobrachial nerve is the lateral
cutaneous branches of T2 nerve which supplies the area of skin of medial side of arm. That is why cardiac pain felt
also along medial side of arm of left side which is the dominant side in respect of inclination of cardiac position to
the left.
Ischemia (infarction) of inferior wall (diaphragmatic surface) of heart leads to epigastric pain.It is because of
irritation of diaphragmatic surface of fibrous pericardium supplied by T 7, T8 and T9 nerves which also supply skin
area of epigastrium.
􏱧􏱧llbl􏱧􏱧􏱧er 􏱧􏱧i􏱧: Diseases of gallbladder those commonly give rise to pain are inflammation (chol- ecystitis)
and calculus (cholelithiasis).
Sympathetic pain fibers travel through celiac plexus and then along greater splanchnic nerve (T 5– T9). So pain is
felt over T5–T9 dermatome which is the area over lower chest wall and upper abdomen.
When inflammation spreads over parietal peritoneum over peripheral part of diaphragm of right side, pain is felt
over right upper quadrant of abdominal wall and area over inferior angle of scapula of right side.
Pain over tip of right shoulder: Spread of inflammation from gallbladder finally to the parietal peritoneum
over central part of diaphragm irritates phrenic nerve (C 3, C4 and C5). That is why referred pain is felt over tip of
right shoulder which is supplied by supraclavicular nerve having root value of C3 and C4.
STOMACH PAIN
Most commonly, referred pain from stomach is felt in epigatrium. Sympathetic pain fibers from stomach travel
through celiac ganglion and finally along greater splanchnic nerve (T 5–T9). So severe gastric pain is felt over lower
chest and upper abdominal wall which is supplied by T5–T9 spinal nerves.
APPENDICULAR PAIN
In case of appendicitis, pain is felt due to distension of wall and spasm of muscle fibers of the wall following
inflammation. Sympathetic pain fibers travel through superior mesenteric plexus and finally along lesser
splanchnic nerve (T10 segment only). So referred pain is felt in the region of umbilicus which area is supplied by Xth
intercostal nerve.
With the advancement of inflammatory process, parietal peritoneum opposite right iliac fossa over the appendix is
involved. This area of parietal peritoneum is supplied by right T 12 and L1 nerve. Because of inflammation of parietal
peritoneum, severe localized somatic pain is felt over right iliac fossa from where impulse is carried by T12 and L1
somatic nerves.
RENAL PAIN
If the pain is of renal origin, due to infection, calculus or any other pathology, it is felt over loin. Sympathetic fiber
carrying pain sensation from kidney passing through aorticorenal ganglion and finally via least (lowest) splanchnic
nerve (T12) enter T12 segment of spinal cord. That is why pain is felt in loin over the skin belt supplied by subcostal
nerve (T12).
the ureter receives its sympathetic innervation from T11–L2 segments, manifestations of ureteric colic will be
following:
1. Severeagonizingpainradiatingfromlointogroin.
2. Pain in scrotum or labium majus.
3. Painoveruppermostpartoffrontofthighwhichis supplied by femoral branch of genitofemoral nerve (L 1 and L2).
4. Retraction of testis due to reflex spasm of crem- aster muscle which is supplied by genital branch of
genitofemoral nerve (L1 and L2).
URETERIC PAIN
A calculus in the lumen of ureter is characterized by severe agonizing pain. By mistake, it is commonly termed as
renal colic. Pain is felt due to distension or spasm of muscular wall of ureter. Pain fibers from ureter traverse via
T11 – L2 sympathetic ganglia to the corresponding spinal cord segments. Due to impaction of stone, obstruction in
the ureter is gradually forced down as a result of muscular spasm. That is why pain is felt radiating from loin to
groin, the area which is supplied by T11 – L2 nerves. As
Fundamental points:
As 31 pairs of spinal nerves are peripheral outflow
from spinal cord, 12 pairs of cranial nerves are
peripheral outflow from brain.

Unlike spinal nerve, cranial nerves are not seg-
mental in origin.
All spinal nerves are mixed in nature composed
of both motor and sensory roots. But in case of cranial nerve, some are mixed, again some are either purely motor or
purely sensory.
Spinal nerves have separate site of attachment of motor and sensory roots. But in case of mixed cranial nerves
motor and sensory fibers may come out of brain commonly, e.g. glossopharyngeal (􏲠th) and vagus (􏲠th) nerves. In
some cases, motor and sensory roots come out separately, but close to each other, e.g. trigeminal (Vth) and facial
(VIIth) nerves.
Like spinal nerves, mixed cranial nerves are:
1. Trigeminal (Vth cranial) nerve

2. Facial (VIIth cranial) nerve
3. Glossopharyngeal (I􏲠th cranial) nerve
􏲠. Vagus (􏲠th cranial) nerve.

Motor cranial nerves are:
1. Oculomotor (IIIrd cranial) nerve

2. Trochlear (IVth cranial) nerve
3. Abducent (VIth cranial) nerve
􏲠. Accessory (􏲠Ith cranial) nerve

5. 􏲠ypoglossal (􏲠IIth cranial) nerve. Sensory nerves are:
1. Olfactory (Ist cranial) nerve

2. Optic (IInd cranial) nerve
3. Vestibulocochlear (VIIIth cranial) nerve.
Out of 12 pairs of cranial nerves, Ist cranial (olfactory) nerve and IInd cranial (optic) nerve differs from IIIrd to
􏲠IIth cranial nerves as follows. Olfactory nerve carrying impulse for olfaction
(smell) and optic nerve carrying impulse for vision (sight) protrude from basal aspect of forebrain (cerebrum). So
their centers are situated in forebrain. Other cranial nerves (IIIrd–􏲠IIth) come out of the surface of brainstem.
Their centers are situated inside the three components (midbrain, pons and medulla) of brainstem in the form of
cranial nerve nuclei.
OLFACTORY NERVE AND OLFACTORY PATHWAY
Fundamental Points
1. Olfactory nerve, the Ist cranial nerve, is a special somatic afferent nerve carrying sense of olfaction or smell.
2. Olfactorynerveformsthepartofolfactorypathway which starts from olfactory receptor cell, through chain of
two orders of neurons to the olfactory cortex.
3. Function of olfactory pathway is more sharp in some animals like dogs which are considered as
Macrosmatic. In contrast human being are considered as Microsmatic.
􏲠. Olfactoryreceptorcellslocatedinnasalmucosaare the nerve cells which act as end organs stimulated by air
molecules carrying odors. These neurons are the only examples which are exposed to the body surface (nasal mucous
membrane) (Fig. 1􏲠.1).
Cranial Nerves
19
289
Frontal air sinus
Superior nasal concha
Lateral wall of nose
Cranial Nerves
Olfactory bulb Olfactory tract
Sphenoidal air sinus
Olfactory nerves Olfactory area of nasal
cavity
Soft palate
Fig. 19.1 Olfactory epithelium area which lodges bipolar olfactory neurons acting as olfactory end organ (receptors), from where originate
bunch of olfactory nerves
5. Olfactory receptor neurons undergo a degenerative process through continuous cycle, and these are replaced
or renewed by fresh cells developed by basal cells of nasal mucous membrane.
􏲠. Leaving the olfactory receptor neurons, olfactory pathway is made up of only two orders of neurons before it
reaches the olfactory cortex.
7. Olfactory pathway is the only sensory pathway which does not pass through any component of nucleus of
thalamus.
Components of Olfactory Pathway
1. Olfactory receptors (neuroreceptors) present in specialized area of nasal mucosa and olfactory nerves.
2. Two orders of neurons.
3. Olfactory area of cerebral cortex present in
temporal lobe.
Olfactory receptors and olfactory nerve (Fig. 19.2)
􏲠nd organs or receptors for olfactory pathway are specialized neurons present in specialized area of mucous
membrane of nasal cavity called olfactory epithelium.
Olfactory epithelium
This epithelium lines uppermost part mucous membrane of nasal cavity which is—
i. 􏲠ppermost part of lateral wall of nose along with sphenoethmoidal recess above the level of superior
nasal concha.
ii. 􏲠ppermost part of nasal septum (medial wall of nose), which is formed by perpendicular plate of
ethmoid bone.
iii. Roof of the nose between above mentioned lateral and medial walls.
Cells of olfactory epithelium (Fig. 19.2):

1. Receptor cells: Which are specialized bipolar neu-
rons.
2. Supporting cells: These are tall columnar inter-
stitial cells which intervenes between receptor
cells having supportive function.

3. Basal cells: These are shorter cells resting on
basement membrane intermingled with other cells. Basal cells are progenitor cells concerned with replacement
(renewal) of receptor cells. Olfactory receptor cells are specialized bipolar
neurons scattered among supporting cells. Perip- heral processes of these bipolar cells are wider and extend to
the surface of nasal mucous membrane. Form the end of peripheral process, a number of short cilia arise which
project into the mucus covering olfactory mucous membrane. These are called olfactory hairs. These projecting
olfactory hairs react to odors of inhaled air and stimulates olfactory receptor cells.
Central processes of olfactory receptors are finer which form olfactory nerve fibers. These finer fibers aggregate
to form 2􏲠 bunches. These are nonmyelinated. These 2􏲠 bunches of finer nonmyelinated fibers form olfactory
nerves. It is clear therefore, unlike other cranial nerve, in each side, olfactory nerve is multiple in number.
First order of neurons (Fig. 19.2)
Bunch of olfactory nerve, the central processes of olfactory receptor cells, pass upwards from roof nose through
foramina in cribriform plate of ethmoid bone to reach anterior cranial fossa. Reaching anterior cranial fossa,
olfactory nerves terminate in first
290
Olfactory bulb
Cribriform plate of ethmoid bone
Granula cell
Tufted cell Olfactory tract
Mitral cell
Basal cells
Supporting cells Olfactory cells
Olfactory epithelium
Mucus in contact with olfactory hairs
Fig. 19.2 Bipolar olfactory receptor cells present in olfactory epithelium of nasal mucosa form contact with first order of neurons of olfactory
pathway in olfactory bulb
order of neurons of olfactory pathway which are present inside an ovoid flattened structure lodged on orbital
surface of frontal lobe of cerebrum. It is called olfactory bulb. Neurons present inside olfactory bulb are of
following types.
Mitral cells
Tufted cells
Granule (Stellate) cells.
Mitral cells are largest cells in olfactory bulb.
Incoming fibers of olfactory nerve form synaptic connections with mitral cells. These synaptic junctions also
receive connection from tufted cells and granule cells. 􏲠unctional areas of these cells with olfactory nerve
ending are known as glomeruli. Axons of these cells, within olfactory bulb, which are 1st order of neurons, pass
backward to be continued as olfactory tract.
Olfactory tract: It is a narrow and flat band of white matter extending from olfactory bulb to run
backwards along olfactory sulcus on orbital surface of frontal lobe of cerebrum. Olfactory tract passes backward
upto anterior perforated substance of base of the brain where it divides in an angular fashion into lateral and
medial olfactory striae. Anterior perforated substance is embrassed anterolaterally and anteromedially by
lateral and medial olfactory striae. The two straie form olfactory trigone (Fig. 1􏲠.3).
Medial olfactory stria carries axons from cells of olfactory bulb which cross the midline as a component of
anterior commissure to pass to olfactory bulb of
opposite side. Lateral olfactory stria carries axons of 1st order of neurons present in olfactory bulb to the
primary olfactory area beyond anterior perforated substance.
Intermediate olfactory stria is a short band of fibers, being occasionally present, passes from the angle of
olfactory trigone to a small elevation on anterior perforated substance which is called olfactory tubercle (Fig.
1􏲠.3).
Second order of neurons (Fig. 19.3)

Lateral olfactory stria, as continuation of olfactory tract relays in second order of neurons which are present in
periamygdaloid and prepyriform areas of temporal lobe of cerebrum. These areas, placed beyond anterior
perforated substance and close to amygdaloid body are known as primary olfactory cortex.
Primary olfactory cortex sends nerve fibers to other centers of brain. These connections are concerned with
integration of olfactory function with emotional and autonomic activities.
Olfactory cortex
It is called entorhinal area (area 28). This area is made up of uncus and anterior part of parahippocampal
gyrus. It receives fibers from second order of neurons situated in primary olfactory areas. That is why is called
secondary olfactory cortex.
Olfactory bulb
Olfactory tract Medial olfactory stria
Anterior perforated substance
Secondary olfactory cortex
Lateral olfactory stria Olfactory tubercle

291
Neurons of primary olfactory cortex
Cranial Nerves
Fig. 19.3 Parts of olfactory pathway related to inferior surface of brain Components of Visual Pathway
CLINICAL ANATOMY
Loss of sense of smell is known as anosmia. It may be due to variable causes of peripheral to central origin.
Pathology of the disorder may be in different level of olfactory pathway starting from olfactory epithelium of
nasal mucosa. Cause may be minor as nasal obstruction following attack of common cold. Again, it may be due
to meningioma of anterior cranial fossa pressing olfactory bulb and tract or it may be effect of lesion of olfactory
cortex.
Sense of smell is tested clinically separately for both the nostril.
Sense of smell and sense of taste are clinically interrelated. Smelling of aroma of delicious food helps in
appreciation of taste.
1. Retina
2. Optic nerve
3. Optic chiasma
􏲠. Optic tract
5. Lateral geniculate body (metathalamus)
􏲠. Optic radiations - (Geniculocalcarine tract)
7. Visual center of cerebral cortex
— Rods and cones cells – Receptor Bipolar cell – First order of neurons multipolar ganglionic cells – Sencond order of neurons
}
— Third order of neurons
— Axons of ganglionic cells (second order of neurons)
(in thalamic level)
— Axons of neurons of lateral geniculate body
— Area 17 of Broadmann in medial surface of occipital lobe of cerebrum

OPTIC NERVE AND VISUAL PATHWAY
Optic nerve is the second cranial nerve. It is special sensory nerve. It forms a part of visual pathway.
Visual pathway is the special somatic afferent pathway concerned with reception and transmission of visual
impulse and perception of vision or sight. Like other sensory pathway visual pathway is also composed of
receptor, orders of neurons and sensory cortex.
Extent of pathway: From retina of eyeball to sensory cortex in occipital lobe of cerebrum.
Receptors – layer of rods and cones (Fig. 19.4)
These cells are arranged in a single row of retina. Both the type of cells are elongated having a peripheral part
and a central part. Structurally outer part of two types of cells differs. Outer part is cylindrical in rod cells and
conical in cone cells. These outer components of the cells contain pigments. Both these type of cells are called
photoreceptors, as they are stimulated by light. It is the pigment component of the cells that converts light
energy into nerve impulse (action potential).
292
Pigmented epithelium
Rod cell Cone cell
Bipolar neuron
Multipolar ganglionic neuron
Axons of ganglionic neurons forming optic nerve
Fig. 19.4 Receptors (rods and cones) and first two orders of neurons of visual pathway present in retina Comparison of rods and
cones
Rod cells Cone cells

Pigment content — Rhodopsin Iodopsin
Most abundant in peripheral part of retina, absent in central Thickly populated in central part of retina
Disposition —
part of retina only cell in macula lutea (central part of retina)
Stimulating factor Stimulated by light of lower intensity (dim light) Stimulated by light of higher intensity (bright light)
Function — (concerned Sharp vision or acuity of vision and color vision
Twilight vision (scotopic vision)
for) (photopic vision)
Number in one retina 1􏲠􏲠 millions or more 7 millions
First and second order of neurons (Fig. 19.4) (placed in retina)
First order of neurons are bipolar cells, so its cell body is fusiform in appearance. Its peripheral process makes
contact with inner or central end of rods and cones in an end to end fashion. So ratio of receptor cells and
bipolar cells is almost 1:1. Central process (axons) of bipolar cells form synaptic connection with dendrites of
second order of neurons called ganglionic cells.
Second order of neurons are called ganglionic cells which are multipolar with multiple dendrites. These cells are
larger in size with bigger nuclei, as compared
to bipolar cells. Secondary multiple dendrites of one ganglionic cells form synaptic junction with axons of more
than one bipolar cells. So number of ganglionic cells are far less than bipolar cells. It is histologically evident by
larged size and lesser number of nuclei of ganglionic cells in comparison to small sized, more number of nuclei
of bipolar cells.
Some important points on retina (in connection with visual pathway):
1. Outermost layer of retina is a layer of pigmented
epithelium. Melanin pigment of this epithelial layer absorbs light and thereby prevent reflection of light from
outer coats of eyeball.
2. Next to pigmented epithelium, from outside inwards, cellular layer are rods and cones, bipolar cells
and ganglionic cells.
3. Layer of pigmented epithelium (choroid side) is separated from layer of rods and cones (inner or
vitreous side) by a loose membrane called Bruch􏲠s membrane.
􏲠. Posterior pole retina (center of posterior equator) contains only cone cells with a yellowish color, called
macula lutea which is the area of retina concerned for sharpest vision. Center of macula presents a small
depression (pit) called fovea centralis.
5. Axons of ganglion cells are long and convergent which form optic nerve. These fibers are innermost layer of
retina, separated from vitreous body by hyaloid membrane.
􏲠. Fibers of optic nerve converge and pierce through the retina, choroid and sclera at a point which is a small
circular area called optic disk. It is 3–􏲠 mm medial (nasal) to posterior pole (macula lutea) of retina. As optic
disk contains of nerve fibers, but no photoreceptor cells, it is called blind spot. 293
Axons of second order of neurons: These fibers come out of eyeball as optic nerve which is continued
further backwards as optic chiasma and optic tract. 􏱧el􏱧􏱧io􏱧s be􏱧􏱧ee􏱧 re􏱧i􏱧􏱧 􏱧􏱧􏱧 fiel􏱧 o􏱧 􏱧isio􏱧:
Retina of each eyeball is divided into inner (nasal) and outer (temporal) half. Field of vision of each eye is also
similarly subdivided. Now, it is important to note that temporal half of retina receives visual impulse from
nasal half of visual field and vice versa. Again each half of retina is divided into upper and lower quadrants
which receive visual impulse from opposite quadrants of field of vision.
OPTIC NERVE
It is already understood that optic nerve is made up of axons of ganglionic cells (2nd order of neurons) placed in
retina. The fibers of optic nerve converge on optic disk of retina. Optic nerve comes out of eyeball finally
piercing sclera 3–􏲠 mm medial to posterior pole.
Optic nerve fibers are myelinated. But the fibers, though belong to a peripheral nerve, are myelinated by
oligodendrocytes (not Schwann cell). For this reason, optic nerve is compared to fiber-tract of central nervous
system.
Optic nerve leaves orbital cavity to enter cranial cavity through optic canal. It runs backwards and medially to
unite with the nerve of other side to form optic chiasma.
OPTIC CHIASMA
Optic chiasma is attached to the base of the brain forming anterior most component of interpeduncular fossa. At
its anterolateral angle joins the optic nerve in both sides. Posterolateral angle continues as optic tract. It means
that fibers of optic nerve continues backwards as optic tract through optic chiasma. But the optic chiasma is
formed because of decussation of half of the fibers of optic nerve of both side.
Decussation of Fibers
Fibers of optic nerve continued from medial (nasal) half of retina, which receive visual impulse (light energy)
from lateral (temporal) field of vision decussate in the optic chiasma to be carried through optic tract of other
side. Obviously, the fibers from lateral (temporal) half retina concerned with medial (nasal) half of field of
vision, run along the optic tract of same side.
OPTIC TRACT
First it is to be followed that optic tract is made up of fibers which are continuation of optic nerve and these are
still nothing but axons of ganglionic cells (second order neuron) placed in retina. Next, it is to be very clear that
optic tract of any side carries fibers from lateral (temporal) half of same retina and medial (nasal) half of
opposite retina concerned with opposite field of vision. From this, it is the time to understand that right optic
tract carries fibers from temporal (right) half of right retina and nasal (also right) half of opposite retina.
Similarly left optic tract carries fibers from temporal (left) half of left retina and nasal (also left) half of opposite
retina.
Quadrantic representation of retina: Each half of retina, right or left, is divided into upper and lower
quadrants. 􏲠ach quadrant of retina is related to opposite quadrant of field of vision. It means upper quadrant of
one-half retina receives visual impulse from lower quadrant of opposite half of field of vision and vice versa.
Course and Termination of Optic Tract
Optic tract, starting from posterolateral angle of optic chiasma, runs posterolaterally around cerebral peduncle
to relay in neurons of lateral geniculate body, a component of metathalamus projecting from posterior end of
thalamus.
Cranial Nerves
294
LATERAL GENICULATE BODY (THIRD OF NEURONS)
It is a component of metathalamus, other one being medial geniculate body. Lateral geniculate body is a small
oval projection from posterior pole (pulvinar) of thalamus. It is made up of six concentric layers of neurons
where relay fibers of optic tract which are terminal part of axons of second order of neurons, the multipolar
ganglion cells placed in retina.
Axons of lateral geniculate body, the third order of neurons, have following destinations.
1. Continuation of visual pathway: These fibers
pass backward as component of retrolenticular part of internal capsule to end in visual cortex (area 17). This
area is on upper as well as lower lips of calcarine sulcus on medial surface of occipital lobe of cerebral
hemisphere. This bundle of fibers are known as optic radiation or geniculocalcarine tract.
2. As superior brachium to midbrain: Superior brachium is band of fibers which extend from lateral
geniculate body to superior colliculus of midbrain. Fibers of this band relay in following two groups of cells in
midbrain for two different purposes.
a) To tectum (at the level of superior colliculus): These fibers form the afferent component of spinovisual reflex
pathway or visual body reflex pathway.
b) To pretectal nucleus: These fibers form afferent component of pupillary light reflex pathway.
Cells of lateral geniculate body is subdivided into lateral and medial halves which possess somatotopic
relationship with other components of visual pathway. Somatotopic relationship of visual pathway:
􏲠pper quadrant of field of vision
and color vision. Optic nerve fibers from macular area of retina, through relay in lateral geniculate body, end in
posterior end of both the lips of calcaline sulcus continued on superolateral surface of occipital lobe of cerebral
hemisphere. Visual cortex (area 17) on medial surface of occipital lobe is supplied by branches of posterior
cerebral artery, but macular visual area on superolateral surface is supplied by branches of middle cerebral
artery.
Visual Association Area
Both the upper and lower lips of visual cortex (area 17) are superimposed by visual association cortex area, area
18 and area 1􏲠, one over other. This area is concerned with recognition of an object and perception of its color.
Visual Reflexes
These are some reflex path, afferent components of which are formed by visual pathway.
􏱽irect an􏱽 consensual li􏱽􏱽t re􏱽e􏱽es
When light is projected on one eye (retina), normally, pupil of both eyes, which is a small circular aperture in
iris, constricts.
Constriction of pupil of the eye, on which light is projected, is the effect of direct light reflex. Constriction of the
pupil of the eye, on which light is not projected, even if it is passively closed, is the effect of consensual light
reflex, when light projects on another eye.
Components of light reflex pathway (Fig. 1􏲠.5)
1. Receptors: Rods and cones of retina.

2. Afferent pathway: The fibers formed by chain of bipolar cells, ganglionic cells and their
axons as optic nerve, optic chiasma and optic tract. Some fibers from optic tract, passing
through superior brachium to pretectal nucleus of midbrain. Axons from prectectal nucleus,
which is close to and at the level of superior colliculus, relay in 􏱧dinger- Westphal nucleus of
oculomotor nerve of same
side as well as opposite side.
3. Center: It is 􏱧dinger-Westphal nucleus of oculo-
motor (IIIrd cranial) nerve. This nucleus is the parasympathetic efferent nucleus. Situated
close to somatic afferent nucleus of the same cranial nerve at the level of superior colliculus
of midbrain. Axons from this parasympathetic efferent preganglionic neurons travel via
oculomotor nerve to supply two muscles, i.e. constrictor pupillae and ciliary muscles.
Lower quadrant of retina (L)
So,
Lower quadrant of field of vision
Lateral half
of lateral geniculate body
Lower lip of visual cortex (L)
Medial half
of lateral
geniculate body cortex (􏲠)
(L)
􏲠pper quadrant of retina (􏲠)
MACULAR VISION
Upper lip of visual
Visual impulse from central field of vision project on macula lutea (yellow spot) which is the small central area
of retina, on the posterior pole. This area contains only cone cells of photoreceptors. That is why the macular
area is concerned with sharpest vision
Field of vision
Cranial Nerves
295
Temporal Nasal
Nasal Temporal
Retina of left eyeball
Retina of right eyeball Right half Left half
Short ciliary nerve
Ciliary ganglion
Oculomotor nerve Optic nerve
Optic chiasma
Optic tract
Pretectal nucleus
Optic radiation (geniculocalcarine tract)
Visual area
Left half
Frontal eye
field
Right half
Corticonuclear
fibers
Oculomotor nucleus
Occipitofrontal fasiculus
Fig. 19.5 Visual pathway with routes for light reflex and accommodation reflex
4. Efferent pathway: Oculomotor nerve of same side as well as opposite side. Via nerve to inferior oblique,
which is a branch from inferior division, preganglionic fibers relay in ciliary ganglion. Post- ganglionic fibers
enter eyeball via short ciliary nerve.
5. Effector organ: Constrictor pupillae muscle of same side as well as opposite side.
Accommodation Reflex (Fig. 19.5)
It is the reflex pathway through function of which eyeball is adjusted from vision of a distant object
296
to the vision of a near object. For this reflex action following three changes occur in eyeball.
1. Constriction of pupil: It is caused by constrictor
pupillae.
2. Medial convergence of both eyeball: It is
caused by contraction of medial rectus of both side.
3. Increase of curvature of lens: It is caused by relaxation of suspensory ligament of lens which

is
due to contraction of ciliary muscles.
Co􏱽􏱽onents of acco􏱽􏱽o􏱽ation re􏱽e􏱽 􏱽at􏱽􏱽a􏱽
1. Receptors: Rods and cones of retina.

2. Afferent pathway: It is composed of following
three components –
1. a) Total visual pathway: Retina – optic nerve –
optic chiasma – optic tract – lateral geniculate body – optic radiation – visual cortex
(area 17) of occipital lobe.
2. b) Superior longitudinal fasciculus: These are long association fibers extending from
area 17 of occipital lobe to frontal eye field of frontal lobe.
3. c) 􏱴orticonuclear or corticobulbar fibers: These fibers extend from frontal eye field to
somatic efferent nucleus and 􏱧dinger–Westphal nucleus of oculomotor nerve.
3. Center:
1. a) Somatic efferent nucleus of oculomotor nerve
which supplies medial rectus muscle.

2. b) 􏱧dinger–Westphal (parasympathetic efferent) nucleus of oculomotor nerve which
supplies ciliary muscle as well as constrictor pupillae
muscle.
4. Efferent pathway: Oculomotor nerve fibers.

5. Effector organ: Following three muscles.
1. a) Medial rectus
2. b) Ciliaris
3. c) Constrictor pupillae.
Spinovisual Reflex (Visual Body Reflex)
Due to projection of visual impulse on eye (retina) following types of automatic (reflex) movements occur in our
body.
1. Reflex movement of eye, head and neck, and even
trunk toward the source of light.
2. On projection of light of higher intensity there
may occur automatic protective closure of eyelids.
3. Automatic scanning movement of eyes and head
side to side occur while reading line by line.
For these types of reflex activities, neural pathway
is as follows.
1. Receptor: Rods and cones of retina.
2. Afferent component: Retina neurons – optic nerve – optic chiasma – optic tract – lateral geniculate body –
superior brachium.
3. Center: Neurons of tectum of midbrain at the level of superior colliculus.
4. Efferent component:
a) Tectobulbar tract which end on motor nuclei of
some cranial nerves which are concerned with
movement of eyeball, eyelid, head.

b) Tectospinal tract which is concerned with
movement of neck and trunk.

5. Effector organ: These are voluntary muscles of
eyeball, eyelid, head, neck and trunk.
Corneal Reflex
Light touching of cornea or conjunctiva with a small piece of cottonwool causes reflex blinking of eyelids of both
eyes. This is the effect of functioning of a reflex called corneal reflex.
Corneal reflex differs from above mentioned reflexes by the point that visual pathway does not have only
contribution to afferent component of this reflex path.
Co􏱽􏱽onents of t􏱽e re􏱽e􏱽 􏱽at􏱽􏱽a􏱽
1. Receptors: Touch receptors in conjunctiva and cornea.

2. Afferent pathway:
1. a) Nasociliary branch of ophthalmic division of
trigeminal nerve through which touch fibers end in superior sensory nucleus of the
nerve situated at the level of pons.
2. b) Fibers of medial longitudinal fasciculus connecting superior sensory nucleus of

trigeminal nerve with motor nucleus of facial nerve.
3. Center:Motornucleusoffacialnerveofbothside.
4. Efferent pathway: Temporal and zygomatic
divisions of the terminal branches of facial nerve.
5. Effector organ: Orbicularis oculi muscle of
eyelids of both eyes.
CLINICAL ANATOMY
CLINICAL EXAMINATION OF RETINA
It is known as fundal examination. Fundus or posterior part of retina is examined with the help of
ophthalmoscope. While carrying out the examination, physician should systematically examine different
structures as per following sequence.
Optic disk: Optic disk looks creamy pink in color. Its central part is found hollowed with prominent lateral
margin.
Cranial Nerves
1
22
3 44
5 55
2
1 34 3
6
6
Fig. 19.6 Lesions of visual pathway at different levels causing various types of visual field defects
1. Right sided circumferential blindness due to retrobulbar neuritis
2. Total blindness of right eye due to damage of right optic nerve
3. Right nasal hemianopia due to partial lesion of right marginal part of optic chiasma
􏲠. Bitemporal hemianopia due to lesion of central part of optic chiasma
5,􏲠,7. Right sided homonymous hemianopia due to lesion of optic tract, optic radiation and visual cortex of right side
Retina: Retina is found to be reddish pink in color. Its normal clear appearance signifies that it is free from
hemorrhage and exudates.
Blood vessels: Blood vessels include four radiating arteries with accompanying veins. Sites of arteriovenous
crossing are to be carefully examined, as because veins normally should not be indented by arteries.
Macula: Macula looks comparatively darker than the surrounding retina. It is visualized by asking the patient to
look toward the source of light of ophthalmoscope.
DETACHMENT OF RETINA
inner neural layer of retina, because these two layers are developed from outer and inner layers of optic cup
respectively. But outer surface of pigmented epithelium is firmly attached to layer of choroid (uveal tract). A blow on
the eye may lead to separation of neural layer from pigmented layer of retina, leading to a condition called
detachment of retina. Fundal examination reveals irregular wavy appearance of neural layer of retina. Clinically
detachment of retina causes progressive impairment of vision.
Detachment of retina is a condition which may be potentially congenital in origin.
VARIOUS KINDS OF LOSS OF VISUAL FIELD (FIG. 19.6)
Normally, there remains a plane of cleavage or potential space between outer pigmented layer and
Visual defects may result when surrounding area is affected by following pathology.
297
1. Expandingtumor:Likepituitarytumorormeni- ngioma.
2. Cerebrovascularaccidents:􏱧ffectwillbewide- spread when lesion occurs in the pathway
where the nerve fibers are more tightly packed, e.g. in optic nerve and optic tract.
298
Circumferential Blindness
This clinical condition is characterized by loss of circumferential field of vision of one eye affected. It occurs
due to optic neuritis, as a complication of infection of sphenoidal or ethmoidal sinus. Optic neuritis causes
infection of peripheral fibers of optic nerve while it is passing through optic canal.
Total Blindness
Complete lesion of one optic nerve will result total blindness which is characterized by loss of complete (both
right and left) field of vision of one eye.
Hemianopia
The term anopia means loss of vision. 􏲠emianopia is characterized by loss of half of field of vision. First, it is to
be very clear that clinically when the manifestation of hemianopia is studied, it is considered to be in relation to
loss of right or left of field of vision, but not the temporal and nasal half. If the same half, e.g. right or left (not
temporal or nasal half) of field of vision is lost in both eyes, it is called homonymous hemianopia. But if right
half of field of one eye and left half of field of another eye (e.g. both temporal field) are affected, it is called
heteronymous hemianopia.
In this connection, it is also to be remembered that light from one half of field of vision projected to opposite half
of retina, loss of one half of field of vision is the effect of lesion of opposite half of retina (right or left).
Beyond optic nerve, nasal fibers of both retina decussate to go the opposite side to form optic chiasma. Beyond
optic chiasma, optic tract carries fibers from temporal half of same retina and nasal half of opposite retina.
Lesion beyond optic nerve may occur in any of the following sites.
1. Optic chiasma
2. Optic tract
3. Lateral geniculate body
􏲠. Optic radiation
5. Visual cortex of occipital lobe.
Lesion of optic chiasma
This may be of following two types. These are:

Lesionofperipheralpart:Itisusuallyunilateral and may occur in any side. It causes damage to the
temporal fibers so there will be loss of nasal field of vision of one eye. The defect is called unilateral nasal
hemianopia.
Lesion of central part of optic chiasma may occur due to pressure effect by pituitary tumor. It will cause lesion
of central decussating nasal fibers resulting loss of temporal half of field of vision of both eyes. It means loss of
right half of field of vision of right eye and left half of field of vision of left eye. That is why the visual defect is
called heteronymous hemianopia.
Lesion beyond optic chiasma
Lesion in optic tract, optic radiation (geniculocalcarine tract) or visual cortex will cause homonymous
hemianopia. Lesion anywhere in right side will lead to loss of left half of field of vision of both eyes. A special
point to note that, if lesion occurs in both the lips of calcarine sulcus (area 17), which is primary visual area,
homonymous hemianopia will be the effect with sparing of macular vision because area for macular vision
extends on superolateral surface of occipital pole where extends posterior end of visual area. 􏲠pper and lower
lips corresponds with lower and upper quadrant of field of vision of opposite side. So, lesion of one lip upper or
lower only will cause inferior or superior quadrantic hemianopia respectively.
ARGYLL ROBERTSON PUPIL

It is the clinical condition observed in a patient suffering from neurosyphilis, which is characterized by
selective lesion of pretectal nucleus of midbrain which is in the route of pupillary light reflex, but not connected
with pathway of accommodation reflex.
Pathway for papillary light reflex is retina – optic nerve – optic chiasma – optic tract – lateral geniculate body –
superior brachium – pretectal nucleus – 􏲠dinger–Westphal nucleus – oculomotor nerve – ciliary ganglion –
short ciliary nerve – sphincter pupillae.
Pathway for accommodation reflex is, retina – optic nerve – optic chiasma – optic tract – lateral geniculate body
– optic radiation – visual cortex of occipital lobe – occipitofrontal fasciculus – frontal eye field – corticonuclear
tract – oculomotornucleus (motor nucleus as well as 􏲠dinger–Westphal nucleus) – oculomotor nerve – medial
rectus, ciliary muscle and sphincter pupillae.
So, in Argyll Robertson􏲠s pupil (ARP), due to lesion in pretectal nucleus, accommodation reflex present (ARP),
but pupillary reflex absent (PRA).
299
CRANIAL NERVES — ARISING FROM BRAINSTEM
These are IIIrd–􏲠IIth cranial nerves. Their nuclei are located in different levels of three components of
brainstem — Midbrain, pons and medulla oblongata. Out of these 1􏲠 pairs of cranial nerves, some are either
purely motor or purely sensory, whereas some are mixed. Roots of the nerves come out through the ventral
surface of brainstem except the IVth (trochlear) nerve which emerges from dorsal surface of midbrain. Some of
the cranial nerves emerge from brainstem surface in the form of multiple roots, e.g. 􏲠th (vagus), 􏲠Ith
(accessory) and 􏲠IIth (hypoglossal) nerves. In case of the mixed nerves, e.g. Vth (trigeminal) and VIIth (facial)
nerves, motor and sensory roots comes out of brainstem separately and join afterwards.
Motor nuclei of these (IIIrd to 􏲠IIth) cranial nerves develop from cell columns of basal plate (Fig. 1􏲠.7) which
are of 3 functional types as follows—
1. Somatic efferent
2. Special visceral efferent (branchial efferent) 3. General visceral efferent (visceral efferent).
A cranial nerve may have one or more than one functional types of motor nuclei. Again sensory fibers of one
cranial nerve may be one or more than one functional varieties of following sensory nuclei,
1. Somatic afferent General somatic afferent
{
Special somatic afferent
2. Special visceral afferent (branchial afferent)

3. General visceral afferent (visceral afferent).
A cranial nerve, while going to be studied, is to be
considered under following headings.

1. Numbers, significance of the name, if any
2. Type
3. Purpose of distribution
􏲠. Functional components
5. Nuclei
􏲠. Supranuclear connections of motor nuclei
7. Intraneural course (course inside brainstem) 8. Surface attachments in brainstem
􏲠. Intracranial course, and distribution, if any 1􏲠. 􏲠xit from cranium
11. 􏲠xtracranial course and distribution
12. Clinical anatomy.
OCULOMOTOR NERVE
Introduction
Oculomotor nerve is the third cranial nerve. It is so- called because it is the main motor nerve for oculus or
eyeball. Though it does not supply all the muscles, but supplies majority of extrinsic as well as intrinsic muscles
of eyeball which are as follows—
1. Extrinsic:Outofsevenmusclesfivearesupplied, which are—
Cranial Nerves
i. Superior rectus
ii. Inferior rectus
iii. Medial rectus (not lateral rectus)
iv. Inferior oblique (not superior oblique), and
v. Levator palpebrae superioris.
Superior oblique is supplied by IVth cranial (tro-
chlear) nerve and lateral rectus is supplied by VIth cranial (abducent) nerve.
2. Intrinsic: Out of three, two muscles are supplied
by oculomotor nerve, which are—
i. Sphincter pupillae (not dilator pupillae) ii. Ciliary muscle or ciliaris.
Type
Oculomotor nerve is a purely motor nerve which is very clear from areas of distribution as described above.
Functional Components
1. Somatic efferent: This component of fibers of oculomotor nerve supplies 5 out of 7 extrinsic
muscles of eyeball (except superior oblique and lateral rectus). All these 7 muscles of eyeball
are developed from preoccipital somites of paraaxial mesoderm.
2. General visceral efferent: These fiber component of the nerve is to supply two out of three
intrinsic muscles, which are smooth muscles. So the general visceral efferent fibers are
parasympathetic efferent fibers.
The above two components of fibers of oculomotor
nerve come out from their respective nucleus.

3. General somatic afferent: These fiber compo-
nent which are sensory, carry proprioceptive sensation from extrinsic muscles of eyeball. It is an interesting
point to note here that a nerve, even which is purely motor, may contain at best 􏲠􏲠 percent sensory fibers to
carry proprioceptive sensation from the muscle. In case of oculomotor nerve, these proprioceptive general
somatic afferent fibers, entering brainstem end in mesencephalic nucleus of trigeminal nerve.
Nucleus
Following are the two motor nuclei of oculomotor nerve.

1. Somatic efferent nucleus: Main motor nucleus
to supply extrinsic (voluntary) muscles. This nucleus of both sides merge together ventral to cerebral aqueduct.
2. General visceral efferent: It is named as 􏲠dinger–Westphal nucleus which is the parasympathetic
efferent nucleus.
Both the nuclei are closely apposed to each
other in the periaqueductal gray matter and placed

300
Special somatic afferent General somatic afferent
General visceral efferent Special visceral efferent
Alar lamina
Basal lamina
Gen som. aff. Ex Prop
Floor plate
Somatic efferent
Sulcus limitans
Som eff.
6
9 I9
S
Sp som. aff. Ex Prop
Sp. visc. eff.
Gen. visc. eff.
Gen. visc. aff.
Sp. visc. aff.
3 nucleus
Midbrain
Pons
Medulla oblongata
Upper end of spinal cord

Edinges–Westphal
12
C5 Nucleus ambiguous
Basal lamina
Alar lamina
77
L 8MI
10 N
11
10 10
Ventral coch ncl.
Vest. nuclei
11 Dorsal nucleus
Dorsal nucleus
Mesenceph nucleus
Dorsal
Superior sensory nucleus
79
10
Nucleus tractus solitarius
5
Nucleus of
sp. tract
C2
8
8
Fig. 19.7 Nuclei of cranial nerves (IIIrd–􏲠Ith) in different level of brainstem
ventrolateral to aqueduct of Sylvius at the level of 2. superior colliculus of midbrain.
The visceral efferent nucleus (􏲠WN) receives connection from pretectal nucleus of both sides, thus completing
the pathway for pupillary light reflex.
The oculomotor nucleus is connected through central tegmental chain of nerve fibers to nuclei of Trochlear (IV),
Abducent (VI) and Vestibul- ocochlear (VIII) nerves. This connection is
Connections of nucleus
1. The somatic efferent nucleus receives connection from motor area of cerebral cortex of both sides by
corticobulbar or corticonuclear tract.
3.
Cranial Nerves
301
called medial longitudinal fasciculus which is for coordination of reflex eye movements during alteration of
equilibrium (balance) of the body.
Intraneural course (inside midbrain)
The nerve, arising from the nucleus which is more dorsally placed, passes ventrally through central tegmental
core and finally traverses the following structures from behind forwards (Fig. 1􏲠.8).
1. Red nucleus
2. Substantia nigra
3. Cruscerebrithroughwhichpasscorticospinaland corticobulbar (corticonuclear) tract.
Exit from brainstem
On either side of midline, the nerve comes out through the lateral wall of a midline sulcus between two halves
of cerebral peduncle (Fig. 1􏲠.8).
Intracranial course
Inside the cranium, oculomotor nerve proceeds forwards step by step as follows—
It passes forwards through the window bounded by posterior cerebral artery above and superior cerebellar
artery below, lateral to basilar artery (Fig. 1􏲠.􏲠).
􏲠ere the nerve may be compressed by an aneurysm developed at the junction of basilar artery and posterior
cerebral artery.
Oculomotor nerve
Basilar artery
Vertebral artery
Exit of oculomotor nerve Crus cerebri
Substantia nigra
Red nucleus
Tegmentum
Anterior clinoid process
Posterior clinoid process
Oculomotor nerve piercing dura mater
Anterior free margin of tentorium cerebelli
Posterior
fi􏱺ed margin
of tentorium cerebelli
Fig. 19.9 Oculomotor nerve proceeds forward between posterior cerebral artery and superior cerebellar artery
The nerve pierces dura mater at the angle between anterior ends of attachments of anterior free and posterior
fixed margins of tentorium cerebelli which are attached to anterior and posterior clinoid processes of sphenoid
bone respectively (Fig. 1􏲠.1􏲠).
In the lateral wall of cavernous sinus – Oculomotor nerve along with trochlear (IV), and ophthalmic (V 1) and
maxillary (V2) divisions of trigeminal nerve,
Somatic efferent nucleus
Section of midbrain
Edinger–Westphal nucleus
Fig. 19.8 Nuclei of oculomotor nerve with its intraneural course and exit from brainstem
Fig. 19.10 Oculomotor nerve pierces dura mater at angle between anterior attachments of free and fixed margins of tentorium cerebelli
Base of brain Hypophysis cerebri

302
Endothelial lining Cavernous sinus
Oculomotor nerve (sup. div)
Oculomotor nerve (inf. div)
Trochlear nerve
Ophthalmic nerve
Maxillary nerve
Meningeal dura
Endosteal dura Abducent nerve
Optic nerve Superior division

Hypophyseal fossa (of sphenoid)
Internal carotid artery
Oculomotor nerve
SR
IR
MR
Ciliary ganglion
LR
IO
Short ciliary nerves
Fig. 19.11 Superior and inferior division of oculomotor nerve in relation to lateral wall of cavernous sinus
from above downwards, passes forwards along the lateral wall of cavernous sinus. In the anterior part the nerve
divides into superior and inferior branches (Fig. 1􏲠.11).
Exit from cranium (to enter the orbit)
Oculomotor nerve leaves the cranium to reach the orbit lodging eyeball. It passes out through middle
Superior ophthalmic vein
Fig. 19.13 􏲠xtracranial course and distribution of oculomotor nerve
compartment of superior orbital fissure. Superior and inferior divisions of the nerve are separated by
nasociliary nerve (Fig. 1􏲠.12). Abducent nerve is inferolateral to these nerves.
Extracranial course and distribution (in the orbit) (Fig. 19.13)
Oculomotor nerve may enter undivided in the orbit where division may occur. Superior division passes upwards
lateral to optic nerve to supply.
1. Superior rectus first and a branch pierces this
muscle to supply
2. Levator palpebrae superioris from its inferior
surface.
Inferior division supplies following muscles—
1. Medial rectus
2. Inferior rectus
3. Inferior oblique.
General visceral (parasympathetic) efferent fibers
are carried so far through nerve to inferior oblique from where the fibers leave finally to relay in ciliary
ganglion. This very tiny ganglion with a size like that of a pin􏲠s head, is situated behind eyeball and lateral to
optic nerve but medial to lateral rectus muscle.
POSTGANGLIONIC BRANCHES OF CILIARY GAN- GLION (FIG. 19.14)
The ganglion send out 8–1􏲠 short branches which are called short ciliary nerves which in turn divide into
Inferior division
Rec. meningeal br. of lac. artery
Trochlear nerve Superior division
and Inferior division of oculomotor nerve

Nasociliary nerve
Abducent nerve
Frontal nerve
Inferior ophthalmic vein
Lacrimal nerve
Fig. 19.12 􏲠xit of two divisions of oculomotor nerve through middle compartment of superior orbital fissure (right superior orbital fissure
seen from behind)
Sensory root Nasociliary nerve
Ciliary ganglion
Cranial Nerves
303
Eyeball
Sympathetic root from int. carotid plexus
Nerve to inferior oblique
Fig. 19.14 Communication and branches of ciliary ganglion
15–2􏲠 branches. These branches pierces sclera and runs over the surface of choroid to reach forwards to
supply—
1. Ciliary muscle (ciliaris)
2. Sphincter pupillae.
ROOTS OF COMMUNICATION TO CILIARY GAN- GLION (FIG. 19.14)
1. Motorroot:Thisisnothingbutparasympathetic preganglionic fiber leaving the nerve to

inferior oblique muscle and relaying in ciliary ganglion.
2. Sensory root: This fiber comes from nasociliary nerve and traversing ciliary ganglion
uninterrupted, supplies sensory branches to eyeball via short ciliary nerves.
3. Sympatheticroot:Thisrootalsojoinstheciliary ganglion from behind and without relaying
comes out of ciliary ganglion to pass through short ciliary nerves to the eyeball.
Origin of Sympathetic Root
These are postganglionic fibers arising from superior cervical ganglion. The fibers form internal carotid plexus
along internal carotid artery and enter cranial cavity. From internal carotid plexus fibers reach orbit along
ophthalmic artery and in the form of sympathetic root join the ciliary ganglion. Through ciliary ganglion
passing without interruption fibers of sympathetic root of communication are finally distributed through same
short ciliary nerves to–
1. Dilator pupillae
2. Blood vessels of eyeball.
Components of a short ciliary nerve
1. a) 􏲠ead injury leading to herniation of uncus of temporal lobe of brain.

2. b) Aneurysm of junction between basilar artery and posterior cerebral artery.
Effect of Lesion
1. Ptosis: Drooping of upper eyelid due to paralysis of levator palpebrae superioris.

2. Lateral strabismus (Lateral squint): It is due to unopposed action of lateral rectus because of
paralysis of medial rectus.
3. Midriasis (Dilatation of pupil): Due to paralysis of sphincter pupillae. It leads to loss of
light reflex.
4. 􏱧osso􏱧􏱧􏱧􏱧o􏱧􏱧o􏱧􏱧􏱧io􏱧re􏱧e􏱧:Accommodation is a process by which vision is adjusted from
distant object to near object. For this three changes occur in the eyeball which are as
follows.
1. a) Medial convergence of both eyeballs: Caused by medial rectus
2. b) Constriction of pupil by sphincter pupillae
3. c) Increase in curvature of lens: Due to relaxation of suspensory ligament of lens
which is the
result of contraction of ciliary muscle.
5. As all these three muscles are supplied by oculomotor nerve, its lesion will lead therefore
to loss of accommodation.
6. Proptosis:Itisforwardbulgingofeyeballbecause of laxity of paralyzed five out of seven
extrinsic muscles of eyeball.
7. Diplopia (Double vision): Due to paralysis of extrinsic muscles, eyeball of paralyzed side will
no more be in same axis of normal side. This change is the cause for double vision or
diplopia.
CLINICAL ANATOMY
Lesion of oculomotor nerve may be of following types— Intercranial lesion: Causes of this type of lesion
may be–
304
Weber’s syndrome: It is a clinical condition occurring due to damage of intraneural part of oculomotor
nerve. It is vascular lesion caused by occlusion of branch of posterior cerebral artery supplying ventral part of
midbrain. It is manifested by contralateral hemiplegion due to damage of crus cerebri with ipsilateral
oculomotor nerve palsy presenting above mentioned ocular disorders.
TROCHLEAR NERVE
Introduction
Trochlear nerve is IVth cranial nerve which supplies one out of seven extrinsic (extraocular) muscles of eyeball
which is superior oblique. This nerve is so called because it runs in relation to the fibrocartilaginous pulley
(trochlea) around which, the tendon of superior oblique muscle hooks. The only muscle supplied by it, superior
oblique, hooks round a fibrocartilaginous pulley or trochlea (Fig. 1􏲠.15).
Type
Trochlear nerve is a purely motor nerve.
1. Somatic efferent: It is the component which supplies superior oblique muscle which, along with other
extraocular muscles develops from preoccipital myotome of paraaxial mesoderm.
2. General somatic afferent: Though trochlear nerve is a purely motor nerve, it contains some proprioceptive
sensory nerve fibers which carry the proprioceptive sensation from the muscle.
Cerebral peduncle
Superior cerebellar peduncle Superior medullary velum
􏲠ntering the brainstem these fibers end in mesencephalic nucleus of trigeminal nerve.
Nucleus (Fig. 19.15)
Somatic efferent nucleus is the only nucleus of trochlear nerve which is situated –
i. In ventromedial part of periaqueductal gray matter

ii. In front of cerebral aqueduct
iii. At the level of inferior colliculus of midbrain.
1. Corticobulbar or corticonuclear tract: These are the descending fibers projecting from motor areas of
cerebral cortex to nuclei of both sides.
2. Mediallongitudinalfasciculus:Thisfiberbun- dle passing through central tegmental core of brainstem

connects vestibular nuclei at pontomedullary junction with nuclei of oculomotor (III), trochlear (IV) and
abducent (VI) nerves which supply extraocular muscles. This fasciculus helps in reflex movement of eyeball in
case of change in equilibrium or balance of body.
Intraneural course (Fig. 19.15)
The nerve emerging from the nucleus, passes backwards winding round the lateral aspect of aqueduct of
Sylvius to reach the dorsal tectal part of midbrain, while doing this, the fibers of the nerve decussate to join
nerve of opposite side.
Exit from brainstem
Trochlear nerve is the only cranial nerve that emerges from dorsal aspect of brainstem (Fig. 1􏲠.15).
Trochlear nerve nucleus Intraneural course of trochlear nerve
Trochlear nerve emerges from brainstem piercing superior medullary velum

Fig. 19.15 Nucleus and intraneural course of trochlear nerve with its exit from posterior aspect of brainstem (midbrain), after which it
winds round superior cerebellar peduncle and then cerebral peduncle
Cerebral peduncle
Cranial Nerves
Same as oculomotor nerve, trochlear nerve also passes forwards through the arterial window bounded – (Fig.
1􏲠.17).
Above – by posterior cerebral artery Below – by superior cerebellar artery Medially – by basilar artery.
In the lateral wall of cavernous sinus: Trochlear nerve comes in relation to lateral wall of cavernous sinus
piercing dura mater on the posterosuperior aspect of roof of the venous sinus. It then passes forwards between
oculomotor nerve and ophthalmic division of trigeminal nerve. In the anterior part of lateral wall of the sinus if
crosses oculomotor nerve to approach superolateral compartment of superior orbital fissure (Fig. 1􏲠.18).
Exit from cranium (to reach orbital cavity) (Fig. 19.12)

The nerve leaves the cranium to reach orbit passing through lateral (superolateral) compartment of superior
orbital fissure, medial to exit of frontal and lacrimal divisions of ophthalmic nerve.
Extracranial course (in the orbit) (Fig. 19.19)
In the orbit, trochlear nerve runs forwards and medially over the eyeball to supply superior oblique piercing its
superior (orbital) surface.
CLINICAL ANATOMY
TRIGEMINAL NERVE
Introduction
Trigeminal nerve is so called because it presents three primary divisions— Ophthalmic, maxillary and mandibular.
It is Vth cranial nerve and mixed in nature.
Motor:Itisthespecialvisceralefferentcomponent of fibers which is concerned with innervation of muscles

developed from 1st branchial arch mesoderm.
Sensory: It is the general somatic afferent component of following two types—
Exteroceptive: This component receives sensation from—
i. Skin: Touch, pressure, pain and temperature sensation from skin of face which is divided into three areas
overlying three parts of
Trochlear nerve
Fig. 19.16 􏲠merging from back of brainstem (midbrain), trochlear nerve winds round superior cerebellar peduncle and then
cerebral peduncle to run forward
The nerve comes out from back of midbrain below inferior colliculus, piercing superior medullary velum on either
side of frenulum veli.
Intracranial course
Finally to pass from behind forwards, the intracranial course of the nerve is as follows—
The nerve runs forwards curving round the supe-
rior cerebellar peduncle and then lateral aspect of cerebral peduncle (Fig. 1􏲠.1􏲠).
Trochlear nerve
Basilar artery
Vertebral artery
Fig. 19.17 Trochlear nerve passes forward between posterior cere- bralandsuperiorcerebellararteries,lateraltobasilarartery
Isolated lesion of trochlear nerve, though rare, will cause diplopia, if head is moved downwards. Because in this
position of head, both superior oblique muscles, by intorsion bring both eyeballs in same axis in normal individual.
305
306
Anterior margin of foramen magnum Section of midbrain
Tentorium cerebelli
Trochlear nerve leaves cranium through lateral
compartment of superior orbital fissure
Trochlear nerve runs forward along lateral wall of cavernous sinus
Trochlear nerve pierces dura mater posterosuperior to cavernous sinus

Trochlear nerve comes out of brainstem on its posterior aspect and curves round forward
Fig. 19.18 Intracranial course of trochlear nerve
face developed from frontonasal process, maxillary process and mandibular process supplied respectively by
ophthalmic, maxillary and mandibular division of trigeminal nerve.
ii. Mucous membrane of oral cavity and nasal cavity.

iii. Sensitive areas of eyeball, e.g. conjunctiva, cornea, ciliary body and iris.
iv. Mucous lining of paranasal air sinuses.

Proprioceptive: This component carries sensations from muscles of mastication, temporomandibular joint
and fibrous joints (gomphosis) at the roots of
teeth of both upper and lower jaw.
Nuclei (Fig. 19.20)
Motor nucleus: It is the special visceral efferent nucleus axons from which finally travel through
mandibular division of trigeminal nerve to supply muscles developed from mesoderm of first branchial arch.
The motor nucleus is situated in upper half of pons.
Sensory nuclei: Trigeminal nerve has three different nuclei of general somatic afferent nature, present in
three different components of brainstem receiving three different types of sensations as follows: 1.
Nucleusofspinaltract:Itispresentthroughout
the length of medulla oblongata extending upwards in the lower end of pons and downwards upto 2nd cervical
segment of spinal cord. It receives pain and temperature sensation via all the three divisions of trigeminal
nerve.
2. Superiorsensorynuclei:Thisnucleusispresent in pons. It receives touch and pressure sensation via the

same three divisions of trigeminal nerve.
3. Mesencephalic nucleus: It is the nucleus receiving proprioceptive sensations from muscles of mastication,
temporomandibular joint and joints at the root of teeth. This nucleus is so called as it is situated in midbrain
(mesencephalon).
Fibro- cartilaginous pulley
Superior oblique muscle
Eyeball
Trochlear nerve
Optic nerve Lateral compartment of
superior orbital fissure
Fig. 19.19 􏲠xtracranial course and distribution of trochlear nerve

307
Mesencephalic nucleus
Superior sensory nucleus
Nucleus of spinal nucleus
Motor (special visceral efferent) nucleus of trigeminal nerve
Sensory root (Vth nerve)
Motor root (Vth nerve)
Cranial Nerves
and fibers from medullary nucleus ascend with horizontally directed fibers from superior sensory nucleus and
motor nucleus at the level of pons to converge. Finally all the convergent fibers come out of brainstem through a
common site at the level of pons (Fig. 1􏲠.2􏲠).
Exit from brainstem (Fig. 19.21)

It is important to note that motor and sensory roots of trigeminal nerve comes out of brainstem separately.
Both the roots come out of brainstem close to each other at the junction of basilar part of pons and middle
cerebellar peduncle. Motor root is medial to sensory root.
Intracranial course
Trigeminal nerve arises from brainstem in posterior cranial fossa. But, first it reaches middle cranial fossa
crossing over the superior border of petrous part of temporal bone close to apex of the part of the bone (Fig.
1􏲠.22).
In the middle cranial fossa, course of trigeminal nerve is divided as follows—
i. Proximal to trigeminal ganglion ii. Distal to trigeminal ganglion.
Trigeminal Nerve Proximal to Trigeminal Ganglion
Trigeminal ganglion (Fig. 1􏲠.23) is a prominent semilunar ganglion of considerable size located in a small
depression called trigeminal cave on anterosuperior surface of apex of petrous part of temporal bone. Posterior
(proximal) margin of the ganglion is concave where ends the sensory root of trigeminal
Fig. 19.20 Nuclei of trigeminal nerve Supranuclear connection
Like motor nuclei of other cranial nerve, motor nucleus of trigeminal nerve is connected by corticonuclear or
corticobulbar fibers to motor areas of cerebral cortex.
Intraneural course
First, it is to be noted that exit of trigeminal nerve is on the ventral aspect of junction between basilar part of
pons and middle cerebellar peduncle. But nuclei extend through the whole length of brainstem. Therefore,
fibers from midbrain nucleus descend
Sensory root Motor root Trigeminal ganglion

Ophthalmic nerve Maxillary nerve
Mandibular nerve
Lateral sensory root and Medial motor root of
trigeminal nerve
Fig. 19.21 􏲠xit of motor (medial) and sensory (lateral) roots of trigeminal nerve. Relation of both the roots with trigeminal ganglion is also
seen
Sensory root of trigeminal nerve
Superior border of petrous part of temporal bone

308
Motor root of trigeminal nerve
Semilunar ganglion Common tendinous ring
Superior orbital
fissure
Foramen rotundum
Foramen ovale
Petrous part of temporal bone (vertical section)
Midbrain
Pons
Medulla oblongata
nerve. From the convex anterior margin of the ganglion arise three sensory divisions of the nerve, namely
ophthalmic, maxillary and mandibular nerve. Trigeminal (semilunar) ganglion is made up of cell bodies of 1st
order pseudounipolar neurons of trigeminal pathway. So sensory trunk of trigeminal nerve represents the
central (axonal) process and three sensory divisions on convex side of ganglion represent the peripheral
dendritic process of the 1st order of sensory neurons.
Distal to trigeminal ganglion, three sensory divisions of trigeminal nerve are related to wall of cavernous sinus.
Ophthalmic and maxillary division
pass forwards in relation to lateral wall of sinus. Mandibular division approaches foramen ovale below the
sinus.
Motor root of trigeminal nerve passes forwards, not through the ganglion but deep to it to run along with
mandibular sensory divisions. The whole of motor root of trigeminal nerve therefore continues distally as motor
root of mandibular nerve.
Trigeminal Nerve Beyond Trigeminal Ganglion
Following two points are to be clearly understood at this stage.

1. Beyond trigeminal ganglion, i.e. from its distal
convex margin, the trigeminal nerve is distributed as its three primary branches, ophthalmic, maxi-
llary and mandibular.
2. Motorrootoftrigeminalnerveiscontinued,beyond trigeminal ganglion, as motor root of mandibular

branch. Sensory and motor roots of mandibular nerve run separately but closely apposed to each other
upto foramen ovale.
OPHTHALMIC NERVE
Ophthalmic nerve is purely sensory division of trigeminal nerve to enter orbital cavity. The nerve, through
some of its branches carries postganglionic sympathetic fibers.
Origin: Ophthalmic nerve arises from upper part of convex distal margin of trigeminal (semilunar) ganglion
(Fig. 1􏲠.21).
Intracranial course: It is very short to run along lateral wall of cavernous sinus below trochlear nerve.
Maxillary nerve
Ophthalmic nerve
Cell bodies of sensory neurons
Fig. 19.22 Intracranial course of trigeminal nerve
Sensory root of mandibular nerve
Sensory root of trigeminal nerve

Semilunar ganglion
Fig. 19.23 Trigeminal (semilunar) ganglion
At the anterior end of the sinus, the nerve reaches superior orbital fissure.
Division: Ophthalmic nerve divides into following three branches before it reaches superior orbital fissure.
Lacrimal
Frontal
Nasociliary.
Exit from cranium: All the three branches of ophthalmic nerve leave cranium through superior orbital
fissure to reach orbit (Fig. 1􏲠.22).
Lacrimal and frontal branches pass through lateral compartment and nasociliary branch passes through
central compartment of superior orbital fissure.
Lacrimal Nerve (Fig. 19.24A)
It runs from behind forwards in the lateral part of orbit along upper border of lateral rectus muscle.
The nerve is so called because it terminates in lacrimal gland. Through the gland, branches are also distributed
to conjunctiva and lateral part of upper eyelid.
Beside these sensory distributions, lacrimal nerve carries postganglionic parasympathetic secretomotor fibers
for lacrimal gland. These fibers are received from zygomaticotemporal nerve. These are postganglionic fibers
from pterygopalatine (sphenopalatine) ganglion. So, lacrimal nerve is composed of both sensory (own) and motor
(borrowed) components.
Frontal Nerve (Fig. 19.24B)
This nerve runs straightway forwards over the eyeball, above levator palpebrae superioris and below
309
periosteum of orbital roof. Midway between apex and base of orbit, frontal nerve divides into supraorbital and
supratrochlear nerve.
Supraorbital nerve, being in the same line, is considered to be the continuation of frontal nerve. It turns
upwards round supraorbital margin at supraorbital notch to supply skin of forehead and scalp as far backwards
upto lambdoid suture.
Other branches to –
Skin of upper eyelid
Conjunctiva
Frontal air sinus.
From the above distribution, it is clear to under-
stand that, in case of frontal sinusitis referred pain is felt in forehead and scalp.
Supratrochlear nerve is so called because it runs forwards and medially above the fibrocartilaginous pulley
(trochlea) for tendon of superior oblique muscle. It turn upwards round medial end of supraorbital margin to
reach inferomedial part of forehead to give branches to–
Skin of upper eyelid Conjunctiva.
Nasociliary Nerve (Fig. 19.24C)

Nasociliary nerve enters orbit passing through central compartment of superior orbital fissure in between two
divisions of oculomotor nerve.
After entering the orbit, nasociliary nerve initially lies between optic nerve and lateral rectus muscle. Then it
crosses above optic nerve to run forward along the medial side of eyeball. Close to anterior part of medial wall of
orbit, nasociliary nerve divides into two terminal branches – infratrochlear and anterior ethmoidal nerve.
Branches of nasociliary nerve
1. Communicating branch to ciliary ganglion:
It is attached to the back of ciliary ganglion. It traverses through ciliary ganglion and comes out from the
ganglion to divide into multiple branches to pass through 15–2􏲠 short ciliary nerves for sensory supply to
eyeball.
2. Long ciliary nerves: These are 2–3 in number. These branches arise from nasociliary nerve
on the medial side of optic nerve. They pierce sclera to run forward over choroid to give
sensory branches to choroid, ciliary body, iris and cornea. Long ciliary nerve also carry
postganglionic sympathetic fibers to supply dilator pupillae muscle.
3. Posterior ethmoidal branch: It is a small branch of nasociliary nerve arising close to
posterior part of medial wall of orbit. It leaves the orbit through posterior ethmoidal canal
to supply posterior ethmoidal and sphenoidal air sinuses.
4. Infratrochlear nerve: It is one of the terminal branches of nasociliary nerve which runs
forward as a continuation of main nerve. It is so called as it passes below the
fibrocartilaginous pulley for tendon of superior oblique muscle. It gives branches to the
following—
i. Skin of upper as well as lower eyelids ii. Skin of root of nose

iii. Conjunctiva
iv. Lacrimal sac.
Terminal ends of infratrochlear and supratrochlear
nerves are connected by a small communicating twig. 5. Anterior ethmoidal nerve: It is another
terminal branch of nasociliary nerve. It runs distally through following areas in sequence, but everywhere for a
short distance.
i. In the orbit it presents brief course with no
branch.
ii. In the nasal cavity close to ethmoidal labyrinth
Skin of inferomedial part of forehead
to supply ethmoidal air sinuses.
Cranial Nerves
310
Lacrimal gland
Zygomaticotemporal nerve gives out
secretomotor fibers for lacrimal nerve
Lateral rectus muscle A Lacrimal nerve
Supratrochlear nerve
Supraorbital nerve
Levator palpebrae superioris
B Frontal nerve
Infratrochlear nerve
Anterior ethmoidal nerve
Posterior ethmoidal nerve Long ciliary nerves

Sensory branches passing through ciliary ganglion
C Nasociliary nerve Fig. 19.24 Course and distribution of three branches of ophthalmic nerve
iii. Next it enters anterior cranial fossa for a short distance where it runs forward over the cribriform plate of
ethmoid bone. It leaves cranial fossa through a narrow slit lateral to crista galli to enter again nasal cavity.
iv. In the nasal cavity it divides into two internal nasal branches, medial and lateral. Medial branch supplies
nasal septum. Lateral branch supplies small area over upper part of lateral wall of nose and finally leaves nasal
cavity
Cranial Nerves
311
Palpebral
Terminal
{ branches
Anterior superior alveolar nerve
Middle superior alveolar nerve
Anterior palatine nerve

Posterior palatine nerve
Fig. 19.25 Distribution of maxillary nerve
Zygomatic branch divides into zygomaticofacial and zygomaticotemporal nerve
Maxillary nerve emerging through foramen rotundum
Pterygoid canal
Pharyngeal branch
Nasal branch
Posterior superior alveolar nerves
Nasal Labial
below a small notch on inferior margin of nasal
bone to reach exterior of nose.

v. On the exterior of nose it supplies skin of ala,
vestibule and tip of nose as external nasal branch.
MAXILLARY NERVE
Introduction
Like ophthalmic nerve, maxillary nerve is also purely sensory division of trigeminal nerve.
Its sensory branches are distributed to—

i. Roots of teeth of upper jaw.
ii. Mucous membrane of palate, small area of
pharyngeal wall, nasal cavity.
iii. Mucous membrane of maxillary air sinus.
iv. Skin over zygomatic area, lower eyelid, ala of
nose and upper lip.
Exit From Cranium
􏲠ust after origin from convex margin of trigeminal (semilunar) ganglion, maxillary nerve emerges from
cranium through foramen rotundum to reach pterygopalatine (sphenopalatine) fossa.
Parts of Maxillary Nerve
The nerve is divided from behind forward in its course, into following parts.
i. In sphenopalatine fossa: Where it is connected to sphenopalatine ganglion by two roots.
ii. In intraorbital groove and canal: Beyond inferior orbital fissure in floor of orbit.
iii. Beyond infraorbital foramen, in face. Distribution (Fig. 19.25)

Branches in sphenopalatine fossa
1. Direct branches from trunk
i. Posterior superior alveolar nerves: These are thin multiple branches which supply roots of molar teeth passing
through small apertures on posterior surface of body of maxilla.
ii. Zygomatic branch: It arises from maxillary nerve in sphenopalatine fossa but primarily enters the orbit
through inferior orbital fissure. It divides into zygomaticofacial and zygomaticotemporal branches which leave
the orbit through two separate canals and respectively supply areas of skin over zygomatic bone and behind
zygomatic bone.
2. Branches traversing sphenopalatine ganglion:
Some sensory nerves, as branches of maxillary nerve traverse through sphenopalatine ganglion before reaching
destination. These branches are—
i. Pharyngeal branch: Slender twig passes backward through palatovaginal canal to supply small area of
mucous membrane of pharynx.
312
Lacrimal gland
Postganglionic secretomotor fibers 􏱺oining lacrimal nerve
Nasal branch Palatine branch
Pharyngeal branch
Maxillary nerve
ZT
FR ZF
􏱺reater superficial
petrosal nerve Geniculate ganglion
Deep petrosal nerve
ii. Palatine branch: It runs downwards through a bony canal to divide into anterior (greater) and posterior
(lesser) palatine nerves which supply mucous membrane of hard and soft palate respectively.
iii. Nasal branch: It runs medially to supply mucous membrane of nasal cavity passing through
sphenopalatine foramen.
Branches from infraorbital groove and canal
Middle and anterior superior alveolar nerve: These are two separate sets of alveolar branches which
run along the body of maxilla and divide into branches to supply the roots of middle (premolar) and anterior
(canine and incisor) sets of teeth respectively.
All the three sets of superior alveolar nerves also supply mucous membrane of maxillary air sinus.
Branches in face (beyond infraorbital foramen)
These are the three terminal branches of infraorbital nerve which is continuation of maxillary nerve beyond
inferior orbital fissure.
i. Palpebral – To supply skin of lower eyelid ii. Nasal – To supply skin of ala of nose
iii. Labial – To supply skin of upper lip.
SPHENOPALATINE GANGLION (FIG. 19.26)
Sphenopalatine (pterygopalatine) ganglion is the largest of the four parasympathetic ganglion of
head and neck. It is so called because it is situated in sphenopalatine (pterygopalatine) fossa being suspended
by two roots from maxillary nerve.
This ganglion presents 3 roots of communication which joins the ganglion from behind. The communications
are–
1. Parasympathetic
2. Sympathetic 3. Sensory.
Parasympathetic Root
This is nothing but made up of preganglionic parasympathetic secretomotor fibers to relay in the ganglion.
These fibers arise from geniculate ganglion of facial nerve as greater superficial petrosal nerve which joins with
deep petrosal nerve (carrying sympathetic fibers) to form nerve of pterygoid canal. As a component of nerve of
pterygoid canal these fibers join the ganglion from behind to relay there.
Postganglionic parasympathetic distribution
Postganglionic branches are secretomotor to supply different exocrine glands as follows.
i. Pharyngeal branch: Passes from the ganglion backward traversing palatovaginal canal to supply
mucous glands of pharyngeal wall.
ii. Palatine branches: Pass downward as anterior (greater) and posterior (lesser) palatine nerves to supply
mucous glands of hard palate and soft palate respectively.
Fig. 19.26 Communication and branches of sphenopalatine ganglion

iii. Nasal branches: Passes medially through sphenopalatine foramen to supply mucous glands of nasal cavity.
iv. Lacrimal branch: This is postganglionic secretomotor fibers for lacrimal gland. From the ganglion,
secretomotor fibers for lacrimal gland pass through following routes.
Sphenopalatine ganglion–anterior root of communication of maxillary nerve – maxillary nerve–􏲠ygomatic

branch–􏲠ygomaticotempor- al branch–communication with lacrimal nerve–lacrimal nerve to supply lacrimal
gland.
Sympathetic Root 313
This is made up of postganglionic fibers from superior cervical ganglion. Initially these fibers pass through
plexus around internal carotid artery. Finally the fibers pass as deep petrosal nerve which form nerve of
pterygoid canal along with greater superficial petrosal nerve. Via nerve of pterygoid canal fibers of sympathetic
root join sphenopalatine ganglion.
Sympathetic distribution (branches)
Sympathetic fibers traversing the ganglion uninterrupted come out as pharyngeal, palatine and nasal
branches to supply respective areas which are vasomotor in nature.
Sensory Root
It is composed of fibers of maxillary nerve which join sphenopalatine ganglion through posterior root connecting
the nerve with ganglion.
Sensory distribution (branches) from the ganglion are through the same pharyngeal, palatine and nasal
branches which have already been discussed as branches of maxillary nerve indirectly arising from
sphenopalatine ganglion. It is therefore clear that pharyngeal, palatine and nasal branches from sphe-
nopalatine ganglion are composed of three functional components, parasympathetic, sympathetic and sensory.
MANDIBULAR NERVE
Mandibular division of trigeminal nerve is the only mixed part of trigeminal nerve made up of both motor as
well as sensory components. So motor component of trigeminal nerve joins as a whole in mandibular nerve.
Mandibular nerve supplies—
1. Muscles developed from mesoderm of first branchial arch which are 8 in number (􏲠􏲠2􏲠2).
1. a) 4 muscles of mastication: Masseter, temporalis,
lateral pterygoid and medial pterygoid.
2. b) 2 tensors: Tensor palati and tensor tympani.

3. c) 2 muscles coupled in digastric triangle: Ante-
rior belly of digastric and mylohyoid.
Cranial Nerves
2. Skin of face overlying the area developed from mandibular process.
3. Roots of teeth of lower jaw.

􏲠. Mucous membrane of floor of mouth and anterior
two-thirds of tongue.
5. Proprioceptive sensory fibers from muscles of
mastication, temporomandibular joints and root of teeth of lower jaw.
Intracranial Course
Sensory root of mandibular division of trigeminal nerve arises from distal convex side of trigeminal ganglion.
Motor root of trigeminal nerve is continued distally beneath trigeminal ganglion as motor root of mandibular
nerve. Both motor and sensory root of the nerve descend vertically to approach foramen ovale.
Exit from Cranium
Separate motor and sensory roots of mandibular nerve comes out of cranial cavity through foramen ovale to
reach infratemporal fossa.
Extracranial Course and Distribution (Fig. 19.27)
In infratemporal fossa, motor and sensory roots unite to form trunk of mandibular nerve below foramen ovale.
The trunk of the nerve is medially related to otic ganglion to which it is connected by small root. The trunk of
the nerve immediately divides into anterior and posterior divisions.
Before division, trunk gives following two branches–
i. Nerve to medial pterygoid: It supplies medial pterygoid muscle. This branch also sends motor branches
to tensor palati and tensor tympani muscles.
ii. Recurrent meningeal branch: It is the sensory branch to supply meninges of brain. It passes backward
to reenter cranial cavity with a recurrent course to pass through foramen spinosum which is in front of
spine of sphenoid. That is why this nerve is also called nervus spinosus.
Distribution from the Divisions
It can be compared with distributions from anterior and posterior divisions of femoral nerve. Anterior division
of mandibular nerve gives all muscular branches and one sensory branch. But from posterior division one
muscular branch arises with all sensory branches. It is just reverse of branching pattern of femoral nerve.
314 Trigeminal ganglion
Ophthalmic nerve
Maxillary nerve Foramen ovale
Otic ganglion
Nerve to medial pterygoid Nerve to masseter
Deep temporal nerve
Buccal nerve Lingual nerve
Inferior alveolar nerve
Sensory root Motor root

Rec. meningeal branch Auriculotemporal nerve
Postganglionic secretomotor
fibers to parotid gland
Middle meningeal artery Nerve to lateral pterygoid
Mylohyoid nerve
} of trigeminal nerve
Branches from Anterior Division (Fig. 19.28)
They are related to lateral pterygoid muscle.

Muscular branches:
1. Nerve to masseter: Cones round posterior part of
upper border of lateral pterygoid muscle to pass laterally and enter deep surface of masseter muscle.
2. Deep temporal nerves (anterior and posterior): 􏲠merge deep to upper border of lateral pterygoid muscle to
pass upwards and supply temporalis muscle.
3. Nerve to lateral pterygoid: It enters deep (medial) surface of the muscle.
Sensory branch
Fig. 19.27 Distribution of mandibular division of trigeminal nerve

It is known as buccal nerve. It becomes superficial emerging between two heads of lateral pterygoid. The nerve
supplies skin over the buccal region of face. It is to be noted here that buccal branch of facial nerve is motor
nerve which supplies buccinator muscle.
Branches from Posterior Division
Sensory branches
i. Lingual nerve
ii. Inferior alveolar nerve iii. Auriculotemporal nerve.
Deep temporal nerves Nerve to masseter
Buccal nerve
Lingual nerve
Mylohyoid nerve
Fig. 19.28 Some of the branches of mandibular nerve related to lateral pterygoid muscle
Motor branch
It is called mylohyoid nerve. It does not arise directly from posterior division but it is a branch of inferior
alveolar nerve. It supplies anterior belly of digastric and mylohyoid muscles.
LINGUAL NERVE (FIGS 19.29 AND 19.30)
Lingual nerve arising from posterior division of mandibular nerve carries general somatic afferent fibers for
anterior two-thirds of tongue.
315
It carries therefore general sensation from anterior two-thirds of tongue.
It passes from behind forwards on the hyoglossus muscle and presents a curved (looped) course with convexity
downwards.
It terminal part hooks round anterior end of submandibular duct.
In intratemporal fossa, lingual nerve is joined at an acute angle by chorda tympani branch of facial nerve whose
fibers are carried along lingual nerve.
It is because of chorda tympani nerve fibers carried through, lingual nerve is joined with submandibular
ganglion which is suspended by two roots.
Distribution of Chorda Tympani Nerve Through Lingual Nerve
Chorda tympani nerve is like that blind person which, to reach its destination, needs a guide which is lingual
nerve.
Lingual nerve Styloglossus muscle
Cranial Nerves
Fiber components of chorda tympani nerve distributed along the course of lingual nerve are following—
1. Special visceral afferent: These are carried

from upper part of nucleus tractus solitarius. Cell bodies of first order of neurons of this
sensory pathway are situated in geniculate ganglion. These fibers of chorda tympani nerve
carry taste sensations from anterior two-thirds of tongue.
2. General visceral efferent: These are preganglionic parasympathetic secretomotor fibers
arising from superior salivatory nucleus. Carried along with the fibers of lingual nerve,
these fibers relay in submandibular ganglion from where postganglionic fibers are
distributed to submandibular and sublingual salivary glands.
INFERIOR ALVEOLAR NERVE (FIGS 19.30 AND 19.31
It is the only mixed component of posterior division of mandibular nerve having sensory as well as motor fibers.
The only motor branch is the mylohyoid nerve.
Inferior alveolar nerve, after its origin from posterior division of mandibular nerve between lingual nerve and
auriculotemporal nerve, lies deep to lateral pterygoid muscle initially.
But finally to reach mandibular foramen, it emerges from lower border of muscle.
Special visceral afferent component
and
component of
Submandibular ganglion
Submandibular gland
Hyoglossus muscle
Submandibular duct
Fig. 19.29 Lingual nerve joined by chorda tympani branch of facial (VII) nerve with distribution of fiber components
316
Posterior division of mandibular nerve
Lingual nerve Inferior alveolar nerve
Mylohyoid nerve
Lingual nerve
Sphenomandibular ligament
Alveolar branches
Fig. 19.30 Branches of posterior division of mandibular nerve seen from medial side of mandible
Before the nerve enters mandibular foramen, it lies between the sphenomandibular ligament attached to
lingula and the ramus of mandible (Fig. 1􏲠.3􏲠).
􏲠ntering the mandibular foramen, inferior alveolar nerve runs through a curved canal within the lower part
of ramus and the body of mandible called mandibular canal which extends from mandibular foramen to mental
foramen.
Branches
1. Muscular branch (Fig. 19.30)
Fig. 19.31 Distribution of inferior alveolar nerve seen from lateral side of ramus and body of mandible
It arises in the infratemporal fossa.

It runs initially horizontally backward.
It splits and reunites to enclose middle meningeal artery which passes upward to pass through foramen
spinosum.
After passing medial to neck of mandible horizontally backward, it changes its directions, first laterally then
upwards behind temporomandibular joint and in front of auricle to reach the temple.
Branches
􏱽. 􏱽e􏱽􏱽oral 􏱽ranc􏱽 􏱽su􏱽erficial te􏱽􏱽oral􏱽
It is terminal part of the nerve which runs upwards in front of auricle to supply skin of temple.
2. Auricular branch
This branch is for distribution to following areas—
i. Anterosuperior part of skin of lateral surface
of auricle.
ii. Anterior half of wall of external auditory

meatus.
iii. Anterior half of outer surface of tympanic
membrane.
3. Articular branch
To the temporomandibular joint.
4. 􏱽ecreto􏱽otor fi􏱽ers for 􏱽aroti􏱽 􏱽lan􏱽 carrie􏱽 through auriculotemporal nerve
These are postganglionic fibers arising from otic ganglion. Preganglionic fibers arising from inferior
It is the mylohyoid nerve which arises from inferior alveolar nerve proximal to mandibular foramen and pierces
sphenomandibular ligament to reach digastric triangle and to supply mylohyoid and anterior belly of digastric
muscles.
2. Sensory branch (Fig. (19.30 and 19.31)
i. Articular branches: Short multiple branches sprout from inferior alveolar nerve while it passes through canal.
These are alveolar branches to supply roots of teeth of lower jaw.
ii. Cutaneous branch: After giving incisive branches for incisor teeth, terminal part of inferior alveolar nerve
emerges out through mental foramen as mental nerve to supply skin over mental region of face.
AURICULOTEMPORAL NERVE (FIG. 19.32)
Auriculotemporal nerve, a branch of posterior division of mandibular nerve, is a purely sensory nerve.
Mental branch
Temporal branch
Cranial Nerves
317
Articular branch
Auricular branch
Glandular branch carrying
secretomotor fibers to
parotid gland
Parotid gland
salivatory nucleus at medulla oblongata, pass initially through tympanic branch of glossopharyngeal nerve to
tympanic plexus on the promontory of medial wall of tympanic cavity. Then fibers pass through lesser
superficial petrosal nerve to the otic ganglion. Postganglionic fibers from the ganglion joining the trunk of
mandibular nerve travel via auriculotemporal nerve to reach parotid gland.
CLINICAL ANATOMY OF TRIGEMINAL NERVE
Trigeminal nerve, though mixed nerve, is the only cranial nerve whose sensory distribution through three
primary divisions are widespread. It supplies somatic sensory branches not only to the skin of face, forehead,
part of scalp with temple and external ear, but also it gives branches to the roots of teeth of both the jaws,
sensative components of eye, mucous membrane of mouth and part of tongue, and also air sinuses. So irritation
of any of the branches may lead to perception of pain along the distribution of branches of trigeminal nerve
which is called trigeminal neuralgia. Pain is felt over the whole area of one side of face, ear, temple and scalp.
It happens to be excruciating pain originating from teeth (caries), cancer of tongue, severe sinusitis,
ophthalmitis.
Trigeminal block: In case of excruciating pain due to trigeminal neuralgia, if it is not relieved by
medication, local anesthetic is injected at the site of trigeminal ganglion or the nerve roots arising from it.
Localized nerve block: For extraction of tooth from upper or lower jaw maxillary (infraorbital) and
mandibular nerve block are the choice close to the site of infraorbital foramen and mandibular foramen
respectively.
Fig. 19.32 Distribution of auriculotemporal nerve
Headache: If site of origin of pain is ear, eyes or teeth, pain is felt as generalized headache.
Referred pain: When site of origin of pain is one, referred pain is felt over the area of skin supplied by
same nerve or its branch.
1. In case of frontal sinusitis pain is felt over the skin area of forehead as both frontal sinus as well as skin of
forehead are supplied by supraorbital nerve.
2. Incaseofcariestooth(upperorlowerjaw)painis felt in ear.

3. Incaseofcanceroftongue,patientfeelspainover ear as well as temple.
ABDUCENT NERVE
Introduction
It is VIth cranial nerve. It is so called because the only muscle supplied by this nerve, the lateral rectus, causes
abduction or lateral deviation of eyeball.
Type
Abducent nerve is a purely motor nerve.
Functional Component
Only motor fiber component is somatic efferent supplying one of the seven extrinsic (extraocular) muscle of
eyeball which are developed from preoccipital myotome of paraxial mesoderm.
Nucleus
Somatic efferent nucleus of abducent nerve is situated on the dorsal surface of pons on the floor of IVth
318
Superior medullary velum forming upper part of root of fourth ventricle
Dura mater
Abducent nerve
Middle cranial fossa
Facial colliculus
Medial eminence
Floor of fourth ventricle
Fig. 19.33 Abducent nerve nucleus is situated beneath facial colliculus which is situated in upper part of median eminence
on floor of 􏲠th ventricle
ventricle on upper part of medial eminence beneath a round bulge called facial colliculus. It is so called because
abducent nerve nucleus is hooked on its surface by emerging fibers of facial nerve (Figs 1􏲠.33 and 1􏲠.3􏲠).
1. The nerve nucleus is connected to motor area of cerebral cortex (opposite side as well as same side) by
corticonuclear or corticobulbar tract.
Posterior cranial fossa
Exit of abducent nerve from brainstem
Abducent nerve nucleus
Exit of facial nerve
Exit of abducent nerve

Intraneural course (Fig. 19.34)
Abducent nerve fibers, arising from the nucleus, proceed from behind forwards traversing—
i. Trapezoid body
ii. Medial lemniscus iii. Basilar part of pons.
Exit from brainstem (Fig. 19.35)
The nerve comes out of brainstem above olive of medulla oblongata at pontomedullary junction.
Intracranial course
In posterior cranial fossa
Abducent nerve, in posterior cranial fossa, runs upwards and forwards and pierces dura mater posterolateral
to posterior clinoid process (Figs 1􏲠.35 and 1􏲠.3􏲠).
In middle cranial fossa
The nerve crosses upper border of patrous part of temporal bone, close to apex, to reach middle cranial
2.
Fig. 19.35 Abducent nerve fibers, arising from nucleus in the pons, emerge from brainstem above olive, pass upward and forward to reach
middle cranial fossa from posterior cranial
fossa piercing dura mater and crossing petrous part of temporal bone
Abducentnucleus,alongwithnucleiofoculomotor and trochlear nerve is connected to vestibular nucleus through

medial longitudinal fasciculus which is concerned with reflex movement of eyeball on alteration of balance of
body.
Petrous part of
temporal bone Olive of medulla
Medial lemniscus
Facial nerve nucleus
Fig. 19.34 Intraneural course of abducent nerve
Facial colliculus Abducent nerve nucleus
Trapezoid body
Cranial Nerves
Foramen magnum (anterior margin)
Abducent nerve piercing dura
Lateral rectus Abducent nerve
Superior division of oculomotor nerve
Abducent nerve
Nasociliary nerve
Inferior division of oculomotor nerve
Fig. 19.38 􏲠xit of abducent nerve through middle compartment of superior orbital fissure and its distribution to lateral rectus
CLINICAL ANATOMY
FACIAL NERVE
Introduction
Facial nerve is the VIIth cranial nerve.

It is the nerve which supplies muscles developed
from mesoderm of 2nd branchial arch. These are – a) Muscles of scalp, auricle and of facial expr-
ession with platysma
2. b) Stapedius muscle of middle ear

3. c) Posterior belly of digastric and stylohyoid.
It supplies secretomotor fibers to submandibular and sublingual salivary glands, lacrimal gland, mucous glands
of pharynx, palate and nasal cavity.
It carries taste sensation from anterior two-thirds of tongue and form palate.
It carries proprioceptive sensation from muscles of facial expression.
Type
It is a mixed nerve with multiple motor and sensory components.
Fig. 19.36 Abducent nerve pierces dura mater in posterior cranial fossa posterolateral to posterior clinoid process and reaches
inferolateral to interal carotid artery
fossa where it comes in relation to inferomedial aspect of cavernous sinus. At this site abducent nerve is
inferolateral to internal carotid artery (Fig. 1􏲠.37).
Exit from cranium
To reach orbital cavity, abducent nerve emerges through central or middle compartment of superior orbital fissure
inferolateral to two divisions of oculomotor nerve which are interposed by nasociliary nerve (Fig. 1􏲠.38).
Extracranial distribution (in the orbit)
Reaching the orbit, abducent nerve runs forwards and laterally between optic nerve and lateral rectus muscle. It
ends by supplying the only muscle, lateral rectus, through its ocular (medial) surface (Fig. 1􏲠.38).
Hypophysis cerebri
Cavernous sinus
Oculomotor nerve (sup div)
Oculomotor nerve (inf div) Trochlear
nerve
Ophthalmic nerve
Meningeal dura
Maxillary nerve

Abducent nerve
Endosteal dura
Fig. 19.37 Abducent nerve in relation to cavernous sinus and internal carotid artery
Selective lesion of abducent nerve is rare. If it occurs, it will cause medial strabismus (squint) due to nonfunction of
lateral rectus leading to unopposed action of medial rectus.
319
320
Nuclei of facial nerve
Motor nucleus
{
Medulla oblongata
Facial colliculus Abducent nerve nucleus
Cross section of pons
Vestibulocochlear nerve
Sensory root of facial nerve (nervus intemedius)
Fig. 19.39 Nuclei of facial nerve with its intraneural course and exit from brainstem
 􏱧􏱧 􏱧􏱧e􏱧i􏱧l􏱧is􏱧er􏱧le􏱧􏱧ere􏱧􏱧fibers:Supplymuscles developed from mesoderm of second branchial

arch as mentioned above.
 􏱧􏱧 􏱧e􏱧er􏱧l􏱧is􏱧er􏱧le􏱧􏱧ere􏱧􏱧fibers:Supplysecret- omotor fibers to submandibular and sublingual
salivary glands, lacrimal glands and mucous glands of palate, pharynx and nasal cavity.
 􏱧􏱧 􏱧􏱧e􏱧i􏱧l 􏱧is􏱧er􏱧l 􏱧􏱧􏱧ere􏱧􏱧 fibers: Carries taste fibers from anterior two-thirds of tongue and
form palate.
 􏱧􏱧 􏱧e􏱧er􏱧lso􏱧􏱧􏱧i􏱧􏱧􏱧􏱧ere􏱧􏱧fibers:
1. a) Carries proprioceptive sensation from muscles
of facial expression through communication of terminal branches of facial nerve with terminal
branches of trigeminal nerve in face. These fibers end in mesencephalic nucleus of trigeminal
nerve.
2. b) Carries general somatic exteroceptive sensation from auricle via auricular branch of vagus
nerve which communicates with terminal branches of facial nerve. These fibers entering the
brainstem end in spinal nucleus and superior sensory nucleus of trigeminal nerve.
Nuclei (Fig. 19.39):
1. Motor nucleus of facial nerve: It is the special
visceral efferent nucleus of facial nerve which is known as motor nucleus of facial nerve. It
is situated in lower half of pons.
2. General visceral efferent nucleus: It is the parasympathetic nucleus of facial nerve. This
nucleus is also situated in lower part of pons adjacent to motor nucleus. This nucleus is
called superior salivatory nucleus.
3. Nucleus tractus solitarius: This nucleus is situated in medulla oblongata. It is a composite special
visceral afferent nucleus whose upper part is the nucleus of facial nerve.
Supranuclear Connection (Fig. 19.40)
It is the motor nucleus (branchial efferent nucleus) of facial nerve which is divided into dorsal and ventral
parts. Motor fibers of facial nerve arising from dorsal part of nucleus supply muscles of upper part of face and
those from ventral part of the nucleus supply muscles of lower half of face.
Corticobulbar or corticonuclear fibers from contralateral motor area of cerebral cortex project in both dorsal as
well as ventral parts of nucleus. In addition, dorsal part of the nucleus receives supranuclear connections from
motor area of cerebral cortex of same side.
Intraneural Course (Fig. 19.39)
Three different types of fibers of facial nerve arising from three different nuclei follow their independent
intraneural course.
Among these, efferent fibers from motor nucleus and superior salivatory nucleus first wind round abducent
nerve nucleus on floor of fourth ventricle to from facial colliculus at the level of lower half of pons
􏱧li􏱧i􏱧􏱧l si􏱧􏱧ifi􏱧􏱧􏱧􏱧e: In case of supranuclear lesion, i.e. lesion of corticonuclear fibers of one side
projecting on opposite sided motor nucleus, dorsal part of the nucleus still receive supranuclear connection from
same side which is thereby spared. Therefore, supranuclear lesion causes paralysis of muscles of lower half of
face and upper half is not affected.
Cranial Nerves
321
􏱺psilateral corticonuclear fibers
Dorsal part
Contralateral
corticonuclear fibers
Facial nerve
{ nucleus
Ventral part Facial nerve
􏱺acial nerve fiber for
upper half of face
􏱺acial nerve fiber for
lower half of face
and ultimately extend forwards and laterally through tegmentum and basilar part of pons to come out from
ventral surface of brainstem at pontomedullary junction.
Afferent fibers from nucleus tractus solitarius initially ascend from the level of medulla oblongata to reach
pontomedullary junction where they come close to emerging fibers of motor and superior salivatory nuclei.
These fibers form lateral sensory root of the nerve.
Exit from Brainstem (Fig. 19.39)
Both the motor as well as sensory fibers of the nerve converge at pontomedullary junction but motor and
sensory roots come out of brainstem separately like those of trigeminal nerve. Like trigeminal nerve, motor root
is medial. Both the roots emerge from pontomedullary junction lateral to olive. Further laterally emerges
vestibulocochlear (VIIIth) cranial nerve.
Intracranial Course
Coming out of brainstem both motor and sensory roots of facial nerve run forwards and laterally in the
posterior cranial fossa for a very short course to
Fig. 19.40 Supranuclear connection of facial nerve
reach internal acoustic (auditory) meatus on posterior surface of petrous part of temporal bone.
Entry through the meatus: Facial nerve (motor and sensory roots still separate) enters through internal
auditory meatus along with vestibulocochlear nerve and internal auditory (labyrinthine) artery, a branch of
basilar artery.
Intrapetrous Part of Facial Nerve (Fig. 19.41)
Inside the petrous part of temporal bone facial nerve has a complicated course which is briefed in a simple
manner as follows.
1. Passing through internal auditory meatus, sepa-
2. 3.
rate roots of facial nerve pass laterally above the level of vestibule of labyrinth or internal ear.
Thenitreachesmedialwallofmiddleearcavityto enter a bony canal called facial canal.
Atthecommencementoffacialcanalonthemedial wall of middle ear cavity two roots of the nerve unite where it
shows two changes—
i. The canal transmitting the nerve changes its direction to pass backwards forming a bend or genu.
ii. At the site of bend or genu, the nerve presents a ganglion called geniculate ganglion.
Motor and sensory roots of facial nerve
Internal auditory meatus Vestibule of internal ear
322
Geniculate ganglion
􏱺reater superficial petrosal
nerve Promontary
Medial wall of middle ear
Facial nerve in facial canal

Nerve to stapedius
Stapedius muscle through pyramid
Posterior wall of middle ear
Geniculate ganglion is the peripheral sensory ganglion of facial nerve. Being homologous to posterior root
ganglion of spinal nerve, it is composed of cell bodies of 1st order of neuron of sensory pathway through facial
nerve.
􏲠. Duringitscoursehorizontallybackwardsthrough the facial canal, the nerve passes above promontory on

medial wall of middle ear cavity (tympanic cavity).
5. At the junction of medial wall and posterior wall of middle ear cavity, the facial canal lodging the nerve
presents a second bend to pass vertically downwards.
􏲠. Vertical part of facial canal, in the posterior wall of tympanic cavity, is related in front to conical elevation
called pyramid which lodges stapedius, a tiny muscle of tympanic cavity.
7. Apex of pyramid present a small aperture through which stapedius muscle comes out forwards to be
inserted at neck of stapes.
8. Vertical part of facial canal ends at stylomastoid foramen of temporal bone.
􏲠. So intrapetrous part of facial nerve is in between internal auditory meatus and stylomastoid foramen.
Branches of Intrapetrous (Intracranial) Part of Facial Nerve
1. 􏱧re􏱧􏱧er su􏱧erfi􏱧i􏱧l 􏱧e􏱧ros􏱧l 􏱧er􏱧e: This nerve arises from geniculate ganglion of facial nerve. It
comes out through hiatus for greater superficial petrosal nerve on anterosuperior surface of petrous part of
temporal bone and run over foramen lacerum where it is joined by deep petrosal nerve (sympathetic fibers from
internal carotid plexus) to form nerve of pterygoid canal. Via nerve of pterygoid canal, fibers of greater
superficial petrosal nerve end in sphenopalatine (pterygopalatine) ganglion. Postganglionic secretomotor fibers
(general visceral efferent) are distributed to lacrimal gland and mucous glands of pharynx, palate and nasal
cavity.
Greater superficial petrosal nerve also contains special visceral afferent fibers carrying taste sensation from
palate and upper part of pharyngeal wall to upper part of nucleus tractus solitarius. Cell bodies of 1st order of
this neuronal pathway are situated in geniculate ganglion.
2. Nerve to stapedius: It is short branch arising from facial nerve in vertical part of facial canal. It enters the
muscle lodged in pyramid.
Stylomastoid foramen
Fig. 19.41 Intrapetrous part of facial nerve with its branches

Contraction of stapedius pulls the neck of stapes backwards and this damps down the conduction of sound wave
passing through solid medium formed by chain of ear oscicles. So lesion of nerve to stapedius, leading to release
of damping down effect, makes the sound audible more loudly in the affected ear. This defect is called
hyperacusis.
3. Chordatympaninerve:Thisbrancharisesfrom facial nerve 􏲠 mm above stylomastoid foramen (Fig.1􏲠.􏲠1).

From posterior wall of tympanic cavity, the nerve
passes through the lateral wall formed by tympanic membrane.
Chorda tympani nerve runs forwards through the plane between fibrous and mucous layers of trilaminar
tympanic membrane. 323
The nerve comes out through petrotympanic fissure.
It passes medial to spine of sphenoid bone to join lingual nerve at an acute angle at infratemporal fossa.
Distribution of Chorda Tympani Nerve (Fig. 19.42)
Fibers of chorda tympani nerve are distributed through lingual nerve.
The nerve contains following functional components of fibers.

1. Special visceral afferent: These fibers are
the peripheral processes of geniculate ganglion
Cranial Nerves
carrying taste sensation from anterior two-thirds of tongue. Central processes reach upper part of nucleus
tractus solitarius.
2. General visceral efferent: These are preganglionic secretomotor parasympathetic fibers of the nerve,
which arise from superior salivatory nucleus. Postganglionic fibers are distributed from submandibular
ganglion to submandibular and sublingual salivary glands.
Exit of Facial Nerve from Cranium

Facial nerve comes out through stylomastoid foramen, crosses lateral aspect of styloid process of temporal bone
and immediately enters parotid gland through upper part of its posteromedial surface.
Extracranial Part of Facial Nerve (Fig. 19.43)
􏲠merging through stylomastoid foramen, facial nerve runs forwards crossing lateral aspect of styloid process of
temporal bone. Before it enters parotid gland through upper part of posteromedial surface, facial nerve gives
following branches –
1. Posterior auricular nerve: It gives auricular and occipital branches. Auricular branch send branches to
the extrinsic as well as intrinsic muscles of medial or cranial surface of auricle which includes auricularis
posterior muscle. Occipital branch supplies occipital belly of occipitofrontalis.
Lingual nerve
Sublingual gland
Lingual nerve hooking round submandibular duct
Hyoglossus muscle
Submandibular ganglion Deep part of submandibular gland
Fig. 19.42 Components and distribution of chorda tympani nerve
324
T
Z UB
LB
Posterior auricular nerve
Facial nerve
• emerges through
stylomastoid foramen
• crosses lateral aspect of
styloid process
• enters parotid gland through
posteromedial surface
Fig. 19.43 􏲠xtracranial part of facial nerve with its terminal branches: T—Temporal, 􏲠— 􏲠ygomatic, 􏲠B—􏲠pper buccal, LB— Lower
buccal, M—Marginal mandibular, and C—Cervical
2. Nerve to digastric and stylohyoid: This branch arises near stylomastoid foramen. It sends branches to
stylohyoid and posterior belly of digastric muscles which form posterior boundary of digastric triangle.
Facial Nerve in Parotid Gland (Fig. 19.44)
Entering through upper part of posteromedial surface of parotid gland facial nerve divides into terminal
branches. These branches pass from behind forwards through a plane between superficial and deep parts of the
gland.
Terminal Branches of Facial Nerve (Figs 19.43 and 19.44)
These are five in number.

These branches come out of the gland piercing
anteromedial surface very close to anterior border of parotid gland.
They run in temporofrontal region and face to supply muscles of those areas.
1. Temporalbranch:Suppliesfrontalis,corrugator
supercilii, muscles on external surface of auricle,
upper part of orbicularis oculi.
2. Zygomatic branch: Supplies lower part of orbic-

ularis oculi, zygomaticus major and minor.
3. Buccal branches: 􏱧pper and lower, running
a) Upper buccal branch: Supplies muscles of external nose and upper lip.
b) Lower buccal branch: Supplies buccinator and orbicularis oris.
4. Marginal mandibular branch: Supplies muscles of lower lip and chin.
5. Cervicalbranch:Itcomesthroughapexofparotid gland and supplies platysma on the subcutaneous plane of

neck.
Nerve to stylohyoid and posterior belly of digastric
above and below parotid duct respectively.
CLINICAL ANATOMY
Clinical Test to Judge Function of Facial Nerve
1. Frowning: Appearance of small parallel vertical creases on root of nose by corrugator supercilii and
transverse creases on forehead by frontalis.
2. Tight closure of eyelids: By contraction of orbicularis oculi.
3. Smiling: It is associated with bilateral symmetrical contraction of levator anguli oris of both side. In
paralysis of one side, there will be asymmetrical elevation of angle of mouth on the normal side.
4. Blowingofmouth:Thepersonisaskedtofillup the mouth cavity with air with tight closure of lips. Then finger
pressure is applied over the cheeck to feel resistance offered by buccinator.
Cranial Nerves
325
Anteromedial surface of parotid gland
Base of parotid gland Facial nerve
Posteromedial surface of parotid gland
Temporal
Zygomatic
Upper buccal
Parotid duct Lower buccal
Mandibular
Cervical
Terminal branches of facial nerve
Fig. 19.44 Facial nerve enters through upper part of posteromedial surface of parotid gland. Its terminal branches emerge close to anterior
border. (Medial view of the gland)
Facial Nerve Lesion
Lesion of facial nerve is very common. This lesion may be intraneural, intracranial or extracranial.
But as per the site of lesion of the nerve, it is classified into following types—
Nuclear
Supranuclear
Infranuclear.
Nuclear lesion
It is intraneural, at the level of pons where motor nuclei of facial nerve are situated. It is vascular in origin due
to ischemic change of branches of basilar artery supplying basilar part of pons. It leads to lesion of nuclei of
pons with emerging nerve fiber and fibers of corticospinal tract passing through basilar part of pons. The lesion
is called Millard Gubler syndrome which is characterized grossly by contralateral hemiplegia and ipsilateral
total facial paralysis.
Supranuclear lesion (Fig. 19.40) (this lesion is also intraneural)
Fibers from dorsal part of facial nerve nucleus supply muscles of upper half of face, whereas those from ventral
part of nucleus supply lower half facial muscles. Both the parts of nucleus receive corticobulbar
(corticonuclear) fibers from opposite cerebral cortex. In addition, dorsal part of nucleus also receives projection
from motor area of same sided
cerebral cortex. So, understanding the above note and consulting the (Fig. 1􏲠.􏲠􏲠), it is clear that lesion of
corticonuclear fibers of one side will lead to paralysis of muscles of lower half of face of opposite side sparing
upper half as it has supranuclear control from the same side in addition.
Infranuclear lesion (Fig. 19.45)
It is extraneural, but may be intracranial or extracranial: Infranuclear lesion means lesion of facial
nerve anywhere after its exit from the brainstem. It may be at different level with different manifestations as
mentioned below. The level of lesion is to be correlated with the (Fig. 1􏲠.􏲠5).
1. Lesion beyond stylomastoid foramen: It is called Bell􏲠s paralysis. Cause of this lesion is compression of
the nerve within stylomastoid foramen. Very often it results due to inflammation of the neural sheath following
exposure to cold. 􏲠ffect is temporary.
Clinical manifestation of Bell􏲠s palsy is due to paralysis of all muscles of facial expression on the affected side.
The affected side seems to be motionless with abolition of emotional expression. There is widening of palpebral
fissure between two eyelids. If attempted, tight closure of eyelids will be failed. Nasolabial furrow will be less
prominent. Patient will complain of accumulation of masticated food in vestibule of mouth due to
326
Internal auditory meatus
Geniculate ganglion
􏱺reater superficial petrosal
nerve
Temporal
Zygomatic
Upper buccal Lower buccal

Marginal mandibular Cervical
–
3 Nerve to stapedius
Stylomastoid foramen
Posterior auricular nerve
Nerve to stylohyoid and posterior belly of digastric
paralysis of buccinator muscle. Due to paralysis of lacrimal part of orbicularis oculi, action of lacrimal puncta
fails to drain lacrimal fluid into lacrimal sac, so lacrimal fluid may dribble from inner canthus of eye. Due to
paralysis of frontalis, abolition of transverse creases on forehead will be noted. If patient is asked to show teeth
or in case of attempt for smiling, angle of mouth will be asymmetrically raised on normal side due to unilateral
contraction of elevators of upper lip and angle of mouth.
2. Lesion above origin of chorda tympani branch: In addition to disabilities due to Bell􏲠s paralysis, there
will be loss of taste sensation from anterior two-thirds of tongue and salivation will be impaired due to lesion of
secretomotor fibers to submandibular and sublingual salivary gland.
3. Lesionabovetheoriginofnervetostapedius: In addition to above disfunctions, patient will suffer from

hemihyperacusis due to loss of 􏲠damping down􏲠 effect in conduction of sound wave through stapes of the
chain of middle ear ossicles.
4. Lesion proximal to origin of greater superfi􏱧i􏱧l 􏱧e􏱧ros􏱧l 􏱧er􏱧e: This branch of facial nerve carries
secretomotor fibers for lacrimal gland and taste fibers of soft palate. So lesion proximal to origin of this nerve
will cause loss of lacrimation and loss of taste sensation from soft palate.
VESTIBULOCOCHLEAR NERVE
Vestibulocochlear nerve is VIIIth cranial nerve and it is a purely sensory nerve made up of two components,
vestibular and cochlear.
Vestibular component of the nerve carries impulses required for maintenance of equilibrium or balance of body.
Cochlear component carries impulse for perception of hearing.
For both the components, receptor or peripheral sensory end organs are situated in specialized part of internal
ear (membranous labyrinth) (Fig. 1􏲠.􏲠􏲠).
Vestibulocochlear nerve is commonly known as auditory nerve.
As both the components of the nerve form the parts of respective sensory pathways, the nerve is to be studied
alongwith description of the sensory pathways.
VESTIBULAR PATHWAYS
It is the special somatic afferent pathway which functions for maintenance of equilibrium or balance of body.
Composition of Pathway (Fig. 19.47)
1. Receptor: It is the peripheral sensory end organ called vestibular receptor which is situated in specialized
area of wall of membranous labyrinth (Fig. 1􏲠.􏲠􏲠).
2. First order of neurons: These are bipolar cells (not pseudounipolar) whose peripheral processes are carried
from receptors and central processes enter brainstem. The collection of cell bodies form vestibular ganglion. The
processes from vestibular nerve.
3. Second order of neurons: Vestibular nuclei at pontomedullary junctions.
Fig. 19.45 Sites of lesion of facial nerve of various level
Cranial Nerves
Macula of utricle
Ampullary crest
Posterior semicircular duct
Endolymphatic duct with sac
Fig. 19.46 Membranous labyrinth showing positions of receptors for balance
327
Macular of saccule
Cochlear duct
􏲠fferent from vestibular nuclei project to—

i. Flocculonodular lobe of cerebellum.
ii. Interconnect nuclei of IIIrd, IVth, VIth and
􏲠Ith cranial nerves iii. Spinal cord.
4. Third order of neurons: Thalamus.

5. Sensory area of cerebral cortex: Postcentral
gyrus.
Vestibular receptors
These are end organs for balance which are specialized areas of some selective parts of wall of membranous
labyrinth.
These are of two functional types.

Organ of static balance is called static labyrinth. These are situated in anterior wall of saccule and utricle.
The specialized areas are called macula. Static labyrinth is for recognition of position of head in reference to
gravity. It also maintains the balance of head during the acceleration or decelaration phase of momentum, for
example for detection of position of head when a moving vehicle increase or decrease the speed.
Maculae(Fig.19.48):Maculaearethespecialized area in the anterior walls of saccule and utricle. These areas
of the labyrinth are lined by specialized cells. The receptor cells are hair cells. 􏲠air cells are interlaced with tall
columnar supporting cells resting on basement membrane. Free surface of the hair cells which are actual
receptor cells presents numerous stereocilia (nonmotile) and one motile kinocilium. Free ciliary surface of hair
cells are embedded into a thick pad of gelatinous material which consists of irregular particles of calcium
carbonate. These irregular particles of calcium carbonate are called otolith for which the membrane is named
otolithic
membrane. Gelatinous mass of the membrane moves in case of movements of head which stretches the
microvilli of hair cells, generating action potential.
Organ of kinetic balance: It is called kinetic receptor. It is stimulated during movements of head and
coordinates movements of eyeball and neck with head movements. Receptors for kinetic balance are situated in
the wall of ampulla of all the three semicircular ducts of membranous labyrinth. These are called ampullary
crests.
Ampullary crest (Fig. 19.50): This end organ for kinetic balance is present in the form of specialized area
of epithelial lining of ampulla of semicircular ducts.
Structure of Ampullary Crest (Fig. 19.49)
Surface epithelium from the wall of ampulla of each of the three semicircular ducts of membranous labyrinth
forms ridge or crest-like elevation, which is called ampullary crest. In each ampullary wall crest arise from
opposite pole giving the appearance of lumen like 􏲠figure of eight􏲠 (Fig. 1􏲠.5􏲠). Surface of the crest present
hair cells which are the receptors for kinetic balance. Free surface of these cells present stereocilia. From the
basal surface free endings of vestibular nerve start. The hair cells are supported by tall columnar cells
(supporting cells). A dome of gelatinous material covers the free surface of hair cells. It is known as cupola (Fig.
1􏲠.􏲠􏲠). Cupola differs from otolithic membrane of macula, as it does not contain particles of calcium carbonate.
Generation of action potential: For both the cases of vestibular receptors, vibration of endolymph causes
oscillation of gelatinous membrane (otolithic membrane and cupola) on the stereocilia of free
328
Postcentral gyrus
Ventroposterior nucleus of thalamus
III nerve nucleus IV nerve nucleus
VI nerve nucleus
􏱺estibulocerebellar fibers
Vestibular nuclei Vestibular nerve Vestibular ganglia
End organs of macula
End organs of ampullary crest
Spinal nucleus of accessory nerve
surface of hair cell receptors. Stretching of hair cells stimulates vestibular nerve endings at the basal surface of
hair cells which generate action potential.
Vestibular Ganglion and Vestibular Nerve
Vestibular ganglion is made up of cell bodies of bipolar neurons which are the first order of neurons in the
vestibular pathway. The ganglion is located at the bottom (fundus) of internal auditory meatus. The bipolar
neurons of vestibular ganglion are homologous to pseudounipolar neurons of posterior root ganglion of a spinal
nerve. Peripheral processes of the bipolar neurons of vestibular ganglion are in contact with base of hair cells.
Central processes continue as vestibular nerve.
Entry of Vestibular Nerve in Brainstem
􏲠ntry of this sensory nerve in the brainstem is at the site of surface attachment of the nerve at pontomedullary
junction lateral to olive of medulla oblongata. It is one of the two components of vestibulocochlear nerve,
attached just lateral to exit of facial nerve, fibers of vestibular nerve are lateral to those of cochlear nerve.
Fig. 19.47 Vestibular pathway
It is clinically important to note that both vestibulocochlear nerve as well as facial nerve are related to
cerebellopontine angle (CP angle) in the posterior cranial fossa after coming out from internal auditory meatus
and before entering brainstem. So, the nerves may be affected in CP angle tumors of brain.
Otolith
Cranial Nerves
Gelatinous otolithic membrane
Stereocilia
329
Hair cells
Peripheral processes of neurons of vestibular ganglion

Vestibular Nucleus
Supporting cells
Fig. 19.48 Structure of macula

Further Components of Vestibular Pathway
Vestibular nucleus is made up of second order of neurons in vestibular pathway. The nucleus is situated
beneath the ependyma of lateral angle of floor of fourth ventricle which is called vestibular area (triangle). The
nucleus is made up of four components, superior, inferior, lateral and medial.
Stereocilia
Supporting cells
Awareness of balance: From vestibular nucleus fibers ascend through central tegmental core of pons and
midbrain to the ventroposterior nucleus of thalamus which represents the third order of neurons. From
thalamus impulse reach postcentral gyrus of cerebral cortex via thalamocortical fibers of superior thalamic
radiation.
Gelatinous mass of cupola with no otolith
Hair cells
Peripheral processes of neurons of vestibular ganglion
Fig. 19.49 Structure of ampullary crest
330
Outline of ampulla of semicircular duct
located in cochlear duct of membranous labyrinth
of internal ear.
2. Chain of neurons:
a) First order of neurons: In internal ear. Cells are bipolar in nature.
2. b) Second order of neurons: In the pontomedullary junction of brainstem— Dorsal

and ventral cochlear nucleus.
3. c) Third order of neurons: Nucleus of Trapezoid body— Where relay second order of
neurons of both side, thus proving bilateral influence of the pathway.
4. d) Fourth order of neurons: At thalamic level. It is the medial geniculate body of
metathalamus.
3. Sensory(auditory)areaofcerebralcortex:It is the transverse gyrus of superior temporal gyrus
of cerebral cortex (area 􏱧1 and 􏱧2 of Brodmann).
Organ of Corti (Fig. 19.51) (Sensory End Organ for Hearing)
It is a composite cellular structure located inside internal ear. Throughout the whole length of spiral turn of
bony cochlear canal, similar turn of a membranous duct, much narrower in diameter, follows the total length of
bony canal. It is called cochlear duct, which is triangular in cross section. Its outer (peripheral) wall is bony
formed by part of wall of bony cochlear canal, other two layers are membranous formed by two membranes
called basilar membrane and vestibular membrane which extend to the bony wall from tympanic lip (lower)
and vestibular lip (upper) of osseous spiral lamina. Osseous spiral lamina is a spiral turn of bony lip, like
threads of a screw projecting from modiolus which is a conical bony pillar at the central axis around which
cochlear canal turns spirally.
Inside the cochlear duct (membranous labyrinth), on the surface of basilar membrane rest the spiral organ of
Corti.
Organ of Corti: This is the end organ for hearing made up various kinds of cells which are made up of two
fundamental types.
Supporting cells of various kinds
Receptor cells (􏲠air cells).
Architecture of organ of Corti is made up of two rows of pillar cells which are known as outer and inner rods of
Corti. Cells of both of the rows, resting on basilar membrane show inclination towards each other for which
their free ends meet forming tunnel of Corti. The tunnel contains a fluid called cortilymph. 􏲠air cells are also
present in the form of rows on outer and inner side of rods of Corti. These cells are present in the form of one
inner row and three
Ampullary crest
Fig. 19.50 Outline of ampulla of semicircular ducts showing ampullary crest
For stereotyped postural adjustment: Inputs are carried from vestibular nucleus to flocculonodular
lobe of cerebellum (archicerebellum) via vestibulocerebellar fibers which pass through inferior cerebellar
peduncle. Cerebellum, receiving the inputs, analyses these and command is given through
cerebellovestibulospinal pathway to anterior horn cells of spinal cord. Functioning of this pathway helps in
coordination of muscular movements in maintenance of upright posture.
􏱧or re􏱧e􏱧 􏱧o􏱧e􏱧e􏱧􏱧s o􏱧 e􏱧eb􏱧ll 􏱧􏱧􏱧 􏱧e􏱧􏱧 and neck during change of equilibrium: In conn-
ection with change of position of head, there occur reflex movement of eyeball head and neck. This is due to
functioning of neural pathway called medial longitudinal fasciculus. It passes through central core of brainstem
to interconnect vestibular nucleus with nuclei of oculomotor, trochlear and abducent nerve supplying
extraocular muscles and spinal nucleus of accessory nerve supplying sternomastoid and trapezius muscles.
COCHLEAR COMPONENT OF VESTIBULOCOCH- LEAR NERVE
Cochlear nerve is the part of cochlear pathway which is one special somatic sensory pathway concerned with
perception of hearing. Like any sensory pathway, it is made up of receptors, chain of neurons and specific
sensory area of cerebral cortex.
Fundamental components of cochlear pathway are following for the purpose of hearing.
1. Receptors or sensory end organs: Called organ
of Corti which is stimulated by sound waves and
Modiolus
Scela vestibuli
Vestibular membrane
Membrana tectoria 331

Hair cells
Cranial Nerves
Cells of Hensen
Cells of Claudius
Interphalangeal cells of Deiters
Rod cell of Corti
Central processes of bipolar

neurons of spiral ganglion Spiral canal containing spiral
forming cochlear nerve ganglion
Fig. 19.51 Organ of Corti (cochlear receptor) and origin of cochlear nerve
outer rows. Basal aspect of the hair cells present two characteristics. They are received or supported by cups of
columnar supporting cells whose free ends present finger-like projection in between hair cells for which they are
called interphalangeal cells of
Deiters. Secondly, basal aspect of hair cells present contact with synaptic knobs of bipolar type 1st order of
neurons which form spiral ganglion located in modiolus. Free surface of hair cells also present two
characteristics. One cell is covered by about 1􏲠􏲠
Basilar membrane
Peripheral processes of bipolar cells
Scela tympani
332 numbers of stereocilia. Stereocilia of hair cells pass through pores of a net-like membrane called reticular
membrane to come in contact with thick pad-like gelatinous membrane which is attached medially to the
limbus of osseous spiral lamina. It is called membrana tectoria. Peripheral to outer row of hair cells, supporting
cells are typical columnar called cells of 􏲠ensen. Most laterally, adjacent to bony wall of cochlear duct, cells are
shorter in height, called cells of Claudius.
First Order of Neuron and Cochlear Nerve
Cochlear nerve is the central process of first order of neuron in cochlear pathway. These neurons are bipolar
cells. Cell bodies of these bipolar neurons are present in the form of cluster called spiral ganglion (Fig. 1􏲠.51).
Spiral ganglion with adjacent part of their process are present in the bony canals of modiolus which are called
spiral canal. Peripheral process of cells of spiral ganglion form contact with basal aspect of hair cells. Central
processes form cochlear nerve which finally comes out of petrous part of temporal bone through internal
auditory meatus along with vestibular component of eight cranial (auditory) nerve. The nerve
Lentiform nucleus Auditory radiation
Medial geniculate body

enters brainstem through anterolateral aspect of pontomedullary junction. 􏲠ntering brainstem, fibers of
cochlear nerve divides into two groups to end in ventral and dorsal cochlear nuclei, ventral and dorsal to
inferior cerebellar peduncle (Fig. 1􏲠.52).
Second Order of Neurons – Cochlear Nuclei (Fig. 19.52)
Axons of both ventral and dorsal cochlear nuclei pass horizontally and, forwards and medially through central
tegmental part of pons.
􏱧e􏱧uss􏱧􏱧io􏱧 o􏱧 fibers 􏱧o 􏱧or􏱧 􏱧r􏱧􏱧e􏱧oi􏱧 bo􏱧􏱧: In central tegmental part of pons of this level, fibers
of both cochlear nuclei partly run in the same side and partly decussate to pass to other side and relay in a
nucleus. As the fibers of both side partly decussate and partly run ipsilateral, these give the appearance of a
trapezium, for which called trapezoid body. So the nucleus is called nucleus of trapezoid body (Fig. 1􏲠.52).
So, it is clear that nucleus of trapezoid body of one side receives fibers from ventral and dorsal cochlear of both
sides. It proves that, impulse from one ear, via trapezoid nuclei of both sides ascends to higher sensory centers
of both sides.
Auditory cortex of superior temporal gyrus (area 41, 42)
Inferior colliculus
Nucleus of lateral lemniscus
Lateral lemniscus
Dorsal cochlear nucleus
Cochlear nerve
Spiral ganglion
Ventral cochlear nucleus
Nucleus of trapezoid body

Trapezoid body
Fig. 19.52 Cochlear pathway
Third Order of Neurons – Nucleus of Trapezoid Body (Fig. 19.52)
This nucleus is situated at the tegmentum of lower end of pons. Axons of this nucleus form a compact bundle which
ascend through pons to dorsal part of lower end of midbrain. This compact bundle on either side forming a part of
cochlear pathway is called lateral lemniscus. The term lemnisci (pl) mean compact bundle of afferent fiber tracts
passing through central core of brainstem. It is so called because, it is lateralmost in position among four lemnisci.
Medial to lateral they are medial lemniscus, trigeminal lemniscus, spinal lemniscus and lateral lemniscus.
Fourth Order of Neurons – Medial Geniculate Body (Fig. 19.52)
In the cochlear pathway, the ascending route for perception of hearing, fourth order of neurons lie in thalamic level.
This cell station is the medial geniculate body of metathalamus.
Other cell stations in this path: While ascending, some fibers of lateral lemniscus show a diversion while
passing through inferior colliculus of midbrain to medial geniculate body. Following points are to note in connection
with the fibers passing to inferior colliculus.
1. Thesefibersfromafferentpartofareflexpathway called spinoauditory reflex, efferent component of which is
formed by tectospinal tract. This reflex pathway in concerned with reflex movement of head, neck and trunk
in response to an audible sound.
2. Fibers from inferior colliculus passing to medial geniculate body form inferior brachium.
3. Before relaying in cells of inferior colliculus (tectum), some fibers of lateral lemniscus relay in intermediate
cell stations known as nucleus of lateral lemniscus.
Termination of Cochlear Pathway (Fig. 19.52)
From thalamus level (medial geniculate body) cochlear pathway pass to auditory cortex at temporal lobe of
cerebrum through inferior thalamic radiation. It forms sublentiform part of internal capsule, as these fibers are
related to inferior aspect of lentiform nucleus. It is called auditory radiation. Fibers end in auditory cortex which is
the transverse gyrus on upper surface of superior temporal gyrus, at the lower lip of stem of lateral sulcus (area 􏲠1
and 􏲠2 of Brodmann).
CLINICAL ANATOMY
Cranial Nerves
Méniére’s Syndrome
This is a clinical condition which occurs due to increase of endolymphatic volume in membranous labyrinth due to
imbalance between synthesis and absorption of endolymph. Rise of endolymphatic pressure leads to ballooning of
cochlear duct, saccule and utricle. Patient complains of recurrent attacks of vertigo and tinnitus. Vertigo may be
associated with nausea. Patient suffers from progressive loss of hearing due to pressure degeneration of receptors.
Further complication may be sense of pressure in the ear, sensitivity to noise and distortion of sound.
Hearing Loss (Deafness)
Injury of the peripheral vestibulocochlear system causes hearing loss (deafness). This disability is associated with
following two conditions.
1. Vertigo(dizziness):Thissymptomisduetoinvo-
lvement of semicircular ducts containing receptors
for kinetic balance.

2. Tinnitus: It is the feeling of buzzing or ringing
sound which is due to lesion in cochlear duct. 􏱧earing loss (deafness) may occur due to lesions
anywhere in peripheral or central cochlear path-
way. Following are the two types of hearing loss.
Conductive hearing loss: It results from any pathology in external or middle ear which interferes with
conduction of sound waves through air medium and solid medium of chain of oscicles respectively. Patient with this
type of hearing loss speaks with a low voice because his􏲠her own voice is audible louder than the surrounding
sounds.
This type of hearing loss is corrected surgically or through use of mechanical hearing aid.
Neural hearing loss: This condition occurs due to lesion of cochlear neuronal pathway anywhere from cochlear
receptor in internal ear to cochlear center in brain. 􏲠sually defect may be in organ of Corti, cochlear neuronal
pathway, brainstem or cortical area for hearing.
Motion Sickness
When a person is moving through a running vehicle, a coordination is maintained between sense of position of head
and visual sensation of moving objects. Patient suffering from motion sickness experiences vertigo, nausea and
vomiting due to incoordination between vestibular and visual stimulation.
333
334
LAST FOUR CRANIAL NERVES
Last four cranial nerves are
I􏲠 – Glossopharyngeal nerve
􏲠 – Vagus nerve
􏲠I – Accessory nerve
􏲠II – 􏲠ypoglossal nerve.
Before each of these four cranial nerves are
discussed separately, following points are to be noted. 1. Fourcranialnervescomeoutofthecraniumthro- ugh two

bony apertures, jugular foramen and
hypoglossal canal.
2. Intermediate component of jugular foramen tran-
smits I􏲠th, 􏲠th and 􏲠Ith nerves. 􏲠ypoglossal
(􏲠IIth) nerve comes out through hypoglossal canal.
3. Coming out of cranial cavity, in the base of skull they are initially closely related to each other where
they lie in between internal carotid artery
and internal jugular vein.
􏲠. I􏲠th and 􏲠th cranial nerves being mixed in
nature, present at the base of skull superior and inferior ganglia for their sensory component of fibers. Superior
as well as inferior ganglia of both the nerves are homologous to dorsal root ganglia of spinal nerves or
semilunar ganglion of trigeminal nerve.
5. Accessory (􏲠I) and hypoglossal nerve (􏲠II) are motor nerves.
Accessory nerve Hypoglossal nerve
􏲠. Atthesiteofbaseofskull,inbetweengreatartery and vein of neck, cranial root of accessory joins the vagus losing
its own identity. The spinal root courses thereafter independently as accessory nerve.
7. Fromthegapbetweeninternalcarotidarteryand internal jugular vein, finally four cranial nerves follow

different course as follows (Fig. 1􏲠.53)— Glossopharyngeal (I􏲠) nerve runs downwards,
forwards and medially passing superficial to internal carotid artery and deep to external carotid artery, i.e.
between two arteries to reach tongue and pharynx.
Vagus (􏲠) nerve descends vertically downward between carotid artery and internal jugular vein.
Accessory (􏲠I) nerve (spinal root) passes downwards and backwards either superficial or deep to internal
jugular vein.
􏲠ypoglossal (􏲠II) nerve runs downwards, forwards and medially superficial to both internal and external
carotid artery to reach the tongue.
GLOSSOPHARYNGEAL NERVE
Introduction
Glossopharyngeal nerve is ninth (I􏲠th) cranial nerve. It is the nerve to supply muscle developed from third
branchial arch.
Vagus nerve
Glossopharyngeal nerve Internal carotid artery
External carotid artery
Glossopharyngeal nerve
Hypoglossal nerve Lingual artery
Common carotid artery

Spinal accessory nerve
Vagus nerve
􏱺nternal 􏱺ugular vein
Fig. 19.53 Last four cranial nerves related to great vessels of neck
Type
It is a mixed cranial nerve.
Nuclei 335
Motor nucleus: It is special visceral efferent nucleus called nucleus ambiguous. Nucleus ambiguous is a
composite nucleus of I􏲠th, 􏲠th and 􏲠Ith cranial nerves. 􏲠pper part of nucleus is part for glossopharyngeal
nerve. Fibers pass to supply stylopharyngeus which is the muscle developed from mesoderm of third
branchial arch.
Inferior salivatory nucleus: It is also the motor nucleus of general visceral efferent group. This is one of
the four parasympathetic nuclei of cranial nerves. Nucleustractussolitarius:Itisalsoacomposite nucleus for
VIIth, I􏲠th and 􏲠th cranial nerve of special visceral afferent group.
All the three nuclei of glossopharyngeal nerve are situated in medulla oblongata.
Motor
1. Specialvisceralefferent:Thesefibercomponent is made up of axons arising from nucleus amb-

iguous to supply only one muscle developed from third branchial arch mesoderm which is
stylopharyngeus.
2. General visceral efferent: These are preganglionic parasympathetic secretomotor fibers of
the nerve, which arise from inferior salivatory nucleus, for parotid gland.
Sensory
1. Special visceral afferent: This fiber component is made up sensory fibers of the nerve which carries taste
(gustatory) sensation from posterior
Nucleus tractus solitarius (IX)
Inferior salivatory nucleus (IX) Nucleus ambiguous (IX)
Glossopharyngeal nerve (IX)
Cranial Nerves
one-third of tongue and also same sensation from circumvallate papillae of anterior two-thirds. The fibers are
carried to nucleus tractus solitarius.
2. General visceral afferent: These fibers carry general sensation from viscera like pharynx, carotid body and
carotid sinus. Fibers carry general sensory impulse to nucleus tractus solitarius.
3. General somatic afferent: These fibers of glossopharyngeal nerve carry general somatic sensation, e.g.
touch, pain and temperature from posterior one-third of tongue, palate, tonsil and pharynx. 􏲠aving no general
somatic afferent nucleus of its own, these fibers of glossopharyngeal nerve, after entering brainstem end in
nucleus of spinal tract of trigeminal nerve.
All the nuclei of glossopharyngeal nerve are situated more close to the dorsal aspect of medulla oblongata.
Fibers from all the nuclei converge and run forwards and laterally through the tegmental core of medulla.
During ventrolateral course, the emerging nerve fibers are related medially to medial lemniscus and
spinothalamic tracts and laterally to nucleus of spinal tract of trigeminal nerve. The nerve traverses reticular
formation of medulla oblongata.
Exit from Brainstem (Fig. 19.54)
Glossopharyngeal nerve comes out through the upper end of a vertical sulcus between olive and inferior
cerebellar peduncle. It lies in a vertical row with roots of vagus and accessory nerves arranged serially from
above downwards.
Intracranial Course
In the posterior cranial fossa it runs forwards and laterally to approach jugular foramen. Intracranial course of
the nerve is short and insignificant.
Nucleus of spinal tract of trigeminal nerve
Glossopharyngeal nerve Lateral spinothalamic tract
Medial lemniscus
Fig. 19.54 Intraneural course of glossopharyngeal nerve
􏱺ostganglionic fibers
to parotid gland
Soft palate
Tonsillar and palatal branches
Lingual branch to posterior 1/3 rd of tongue
Middle constrictor muscle of pharynx
Common carotid artery
Otic ganglion
336
􏱺reganglionic fibers from
tympanic plexus to otic ganglion Tympanic plexus
Glossopharyngeal nerve
Jugular foramen
Superior ganglion
Tympanic branch arising from inferior ganglion
Carotid branch
Muscular branch to stylopharyngeus
Pharyngeal branch
􏱺nternal 􏱺ugular vein
Fig. 19.55 􏲠xtracranial course and distribution of glossopharyngeal nerve

Exit from Cranium
Glossopharyngeal nerve along with vagus and accessory nerves leaves the cranium through intermediate
component of jugular foramen. The nerve is covered by separate (independent) dural sheath. Anterior and
posterior compartments of jugular foramen are venous compartments transmitting inferior petrosal sinus and
beginning of internal jugular vein respectively.
Beyond jugular foramen the nerve lies in relation to base of skull between internal jugular vein and internal
carotid artery. 􏲠ere it presents two ganglia, superior and inferior.
Superior ganglion is smaller and considered to be the detached portion of inferior ganglion.
Both these ganglia, being homologous to posterior root ganglia of spinal nerve, present cell bodies of sensory
fibers (both special as well as general visceral afferent) of glossopharyngeal nerve.
A slender tympanic branch arises from inferior ganglion. It ascends through a slit on jugular fossa (tympanic
cavity floor) to enter tympanic cavity. The branch forms tympanic plexus on promontory of medial wall of the
cavity along with sympathetic fibers (caroticotympanic branches) from internal carotid plexus. Tympanic
branch carries preganglionic parasympathetic secretomotor fibers for the parotid gland. From tympanic plexus
fibers are carried through lesser superficial petrosal nerve to relay in otic ganglion. Postganglionic fibers reach
parotid gland through auriculotemporal nerve.
Beyond inferior ganglion, glossopharyngeal nerve changes direction to pass downwards, forwards and medially
deep to styloid process of temporal bone. It crosses superficial to internal carotid artery but deep to external
carotid artery. While in between two arteries, it sends a carotid branch which descends to supply carotid body
and carotid sinus.
The nerve while passing in relation to wall of pharynx it sends following two branches.
Muscular branch: This is the only motor (bran- chiomotor) branch of the nerve which supplies stylo-
pharyngeus developed from mesoderm of third pharyngeal arch.

Pharyngeal branch: This carries sensory fibers for the wall of pharynx through formation of pharyngeal
plexus of nerves on the surface of middle constrictor muscle of pharynx. Pharyngeal plexus is formed by –
1. Pharyngeal branch of glossopharyngeal nerve – Sensory in nature.

2. Pharyngeal branch of vagus nerve – Motor for all muscles of pharynx except stylopharyngeus. These
fibers are actually from cranial root of accessory nerve carried through vagus nerve.
3. Laryngopharyngeal branch of sympathetic which is vasomotor in nature.
After giving above two branches, glossopharyngeal
nerve changes direction further to pass upwards, forwards and medially deep to stylohyoid ligament and ends
by giving following terminal branches.
1. Tonsillarbranch:Itcarriesgeneralsomaticsen- 337
sory fibers to the tonsillar fossa.
2. Palatalbranch:Thisbranchformsaplexuswith
lesser palatine nerve. It is general somatic sensory
to the soft palate.

3. Lingual branch: It carries both general somatic
afferent and special visceral afferent fibers for posterior one-third of tongue.
General somatic afferent fibers carry touch, pain
and temperature sensation from posterior one-third of tongue.
Special visceral afferent fibers carry taste (gustatory) sensation from not only posterior one-third of tongue but
also circumvallate papillae which are in front of and parallel to sulcus terminalis.
Lesion of Glossopharyngeal Nerve
Isolated lesion of glossopharyngeal nerve or its nuclei are uncommon and no perceptible disability is observed.
If there occurs lesions at all, patient suffers from loss of taste sensation on the posterior one-third of tongue.
Gag reflex will be absent on the side of lesion. Due to paralysis of stylopharyngeus, ipsilateral weakness in
swallowing may be noticed.
Jugular foramen syndrome: It is the effect of infection or tumor in the vicinity of jugular foramen.
Because of close relation of I􏲠, 􏲠 and 􏲠I cranial nerve at this site, this syndrome will present features of
multiple cranial nerve palsies.
In case of tumor in the neck adjacent to route of glossopharyngeal nerve, pain may be felt along the line of
distribution of nerve.
VAGUS NERVE
Introduction
Vagus nerve is the 􏲠th cranial nerve. It is so called because it is vagarant or wandering in nature.
Distribution of vagus nerve is extensive for head, neck, thorax and abdomen.
Vagus nerve receives whole of the fiber component of cranial root of accessory which is made up of special
visceral efferent fibers to supply muscles developed from mesoderm of VIth branchial arch.
Widespread distribution of vagus nerve is for following two reasons—
1. Vagus nerve supplies smooth muscles of whole
tracheobronchial tree and, foregut and midgut.
2. It gives secretomotor fibers for mucous glands of whole of the above mentioned areas of respiratory
and alimentary tracts.
Functional Component
1. Special visceral efferent: Special visceral efferent fibers of vagus nerve of its own are to supply muscle
developed from mesoderm of IVth branchial arch which is cricothyroid.
Besides, vagus also carries special visceral efferent fibers which are borrowed through joining of cranial root of
accessory nerve. These fibers supply muscles developed from mesoderm of VIth branchial arch which are –
All muscles of palate except tensor palati
Allmusclesofpharynxexceptstylopharyngeus All muscles of larynx except cricothyroid.
2. General visceral efferent: These are parasympathetic, preganglionic secretomotor fibers to supply
smooth muscle and mucous glands of tracheobronchial tree, foregut and midgut.
3. General visceral afferent: This component of fibers of vagus nerve carries general sensations from above
mentioned areas of respiratory and alimentary tracts. Visceral sensations are sense of compression, distension
and pain due to ischemia.
4. Special visceral afferent: These fibers carry taste (gustatory) sensations from posteriormost part of
tongue, vallecula and epiglottis.
Cell bodies of first order of neurons of above mentioned two sensory pathways through vagus are situated in
inferior ganglion of vagus nerve.
5. General somatic afferent: This component of fibers of vagus nerve carries general somatic sensation from
skin of conchal area of external ear. Cell bodies of first order of neurons of this pathway are situated in superior
ganglion of vagus nerve.
Cranial Nerves
Nuclei
All the following nuclei of vagus nerve are situated in medulla oblongata.
1. Nucleus ambiguous (IX, X, XI): This is a comp-
osite nucleus for I􏲠th, 􏲠th and 􏲠Ith cranial nerve. Its lower end is continued as spinal part upto Vth cervical
segment of spinal cord.
338
Special visceral efferent fibers of vagus nerve arising from this nucleus supply cricothyroid which is the only
muscles developed from IVth branchial arch mesoderm.
2. Dorsal nucleus of vagus: 􏲠nlike nucleus ambiguous, it is the nucleus for vagus nerve only. But it is also
considered to be a composite nucleus as dorsal nucleus of vagus is made up of a motor and a sensory component.
Motor component gives out general visceral efferent fibers of the nerve while sensory component of the nucleus
receives general sensations from the viscera.
3. Nucleus tractus solitarius (VII, IX, X): Like nucleus ambiguous, this is also a composite nucleus made up
of components for VIIth, I􏲠th and 􏲠th cranial nerve. Fibers carrying taste (gustatory) sensation from
posteriormost part of tongue, vallecula and epiglottis, carried through special visceral afferent fibers of vagus
end in this nucleus.
Dorsal nucleus of vagus Nucleus tractus solitarius
Nucleus of spinal tract of trigeminal nerve receives general somatic sensory fibers of vagus
Nucleus ambiguous
Vagus nerve
Spinothalamic tract
Hypoglossal nerve
Nucleus tractus solitarius is also considered to share with sensory component of dorsal nucleus of vagus to
receive general sensation from viscera.
4. Nucleus of spinal tract of trigeminal nerve: Though it is the nucleus of Vth cranial nerve, this nucleus is
well known for its cordial nature to receive general somatic sensory fibers carried through many cranial nerve.
General somatic afferent fibers carried through vagus nerve from external ear end in nucleus of spinal tract of
trigeminal nerve.
All the nuclei of vagus nerve are situated in dorsal part of tegmentum of medulla oblongata. Fibers from nuclei
converge and course inside medulla forwards and laterally. While proceeding through the substance of medulla
oblongata, fibers are related medially to medial lemnicus, intraneural part of hypoglossal nerve, medullary
reticular formation, spinothalamic tract and inferior olivary nucleus. Laterally the nerve fibers are related to
nucleus of spinal tract of trigeminal nerve and inferior cerebellar peduncle.
Exit from Brainstem
Vagus nerve comes out from brainstem in the form of multiple roots. These roots exit through the vertical
sulcus between olive and inferior cerebellar peduncle.
Hypoglossal nerve nucleus
Medial longitudinal bundle
Tectospinal tract Reticular formation
Medial lemniscus
Pyramid
Arcuate nucleus
Fig. 19.56 Intraneural course of vagus nerve
Through this sulcus I􏲠th, 􏲠th and 􏲠Ith cranial nerves come out in vertical row sequentially from above
downwards.
Intracranial Course
Intracranial course of the nerve is short. Multiple rootlets of the nerve unite to form a large trunk which runs
forwards and laterally across the jugular tubercle towards jugular foramen.
Exit from the Cranium

339
Vagus nerve leaves the cranium passing through middle compartment of jugular foramen along with
glossopharyngeal and accessory nerve. 􏲠ere the nerves are related to inferior petrosal sinus in front and
sigmoid sinus continued as internal jugular vein behind which pass through anterior and posterior
compartments of jugular foramen respectively.
While passing through jugular foramen, vagus nerve is enclosed by a common dural sheath with accessory
nerve.
Cranial root of accessory nerve joins vagus nerve at the level of jugular foramen or just beyond it at base of
skull.
Common dural sheath Vagus nerve
Accessory nerve (both roots)
Spinal accessory nerve Pharyngeal branch
Superior laryngeal branch Carotid (sinus branch)
Vagus nerve
Cervical part of vagus nerve Right recurrent laryngeal nerve
Cardiac branches
Cranial Nerves
Immediately beyond jugular foramen, at the base of skull, vagus nerve presents a small round superior and a
long fusiform inferior ganglia. Superior ganglion is considered to be the detached part of inferior one.
Extracranial Course and Distribution
Extracranial course is divided into three segments, in head and neck, thorax and abdomen.
Vagus Nerve in Head and Neck (Fig. 19.57)
It is the part of the nerve extending from base of skull to root of neck. This part is enclosed by carotid sheath
where it presents a vertical course between internal jugular vein laterally and carotid arteries medially. The
nerve lies in a more posterior plane than the great vessels inside carotid sheath.
Branches in Head and Neck
From superior ganglion, following two branches of vagus take origin.

Meningeal branch: It reenters cranial cavity through jugular foramen and supplies meninges of posterior
cranial fossa.
Jugular foramen
Meningeal branch
Auricular branch of vagus arising from superior ganglion of vagus
Inferior ganglion of vagus nerve
Internal laryngeal branch
External laryngeal branch supplying cricothyroid muscle
Right recurrent laryngeal nerve approaching tracheoesophageal groove

Fig. 19.57 Course and distribution of cervical part of vagus nerve
340
Auricular branch: A reader should not bother for its complicated course. But its distribution is important
to note. It gives branches to –
i. Concha and root of auricle
ii. Posterior half of external auditory meatus
iii. Posterior half of outer surface of tympanic
membrane.
Branches from inferior ganglion of vagus are the following:
Pharyngeal branch: This branch arising from vagus carries fibers of cranial root of accessory nerve.
Pharyngeal branch topographically arising from upper part of inferior ganglion of vagus runs downwards,
forwards and medially superficial to internal carotid artery and deep to external carotid artery. It then runs
on middle constrictor of pharynx close to its upper border. One branch ascends as palatal branch to supply all
muscles of soft palate except tensor palati which is supplied by mandibular nerve. Pharyngeal branch finally
forms a plexus on middle constrictor muscle of pharynx called pharyngeal plexus. The plexus is contributed by
pharyngeal branch of glossopharyngeal nerve (sensory) and laryngopharyngeal branch of sympathetic chain
(vasomotor). Pharyngeal branch of vagus carries special visceral efferent fibers to supply all muscles of pharynx
except stylopharyngeus.
Carotid branch: It is a long descending branch from inferior ganglion of vagus running between carotid
arteries to supply carotid body and carotid sinus at the site of bifurcation of commom carotid artery.
Superior laryngeal nerve: It arises from lower part of inferior ganglion of vagus. It runs downwards,
forwards and medially deep to both internal carotid as well as external carotid arteries. First it lies on superior
constrictor and finally on middle constrictor of pharynx where it divides into internal and external laryngeal
branches.
Internal laryngeal nerve is the upper and thicker branch accompanied by superior laryngeal artery. It pierces
thyrohyoid membrane to supply mucous membrane of upper part of larynx upto level of vocal cord.
􏲠xternal laryngeal nerve is the lower division of superior laryngeal nerve. It accompanies superior thyroid
artery and pierces middle constrictor muscle to supply cricothyroid muscle. It also supplies cricoph- aryngeus
portion of inferior constrictor muscle of pharynx. 􏲠xternal laryngeal nerve may also have contribution to
pharyngeal plexus.
Other Branches from Cervical Part of Vagus
Right recurrent laryngeal nerve: It arises from the right vagus nerve while the nerve crosses in
front of subclavian artery. This branch of vagus winds round the inferior aspect of subclavian artery to pass
backwards and finally run upwards and medially to approach tracheoesophageal groove. 􏲠ere it is related to
inferior thyroid artery.
The recurrent laryngeal nerve, while approaching tracheoesophageal groove has some important relation of
clinical significance. The nerve may be superficial or deep to the artery. Branches of inferior thyroid artery may
be intermingled in tracheoesophageal groove, while the nerve is passing through ligament of Berry or
suspensory ligament of thyroid gland. While performing thyroid surgery, the surgeon is to take into
consideration of these important relations of recurrent laryngeal nerve.
Branches of recurrent laryngeal nerve are following: 1. All muscles of larynx except cricothyroid.
2. Inferior constrictor muscle of pharynx (cricopha-
ryngeus component).
The above mentioned fibers are borrowed from cranial root of accessory nerve.
3. Cardiac branch: To deep cardiac plexus.

􏲠. Sensory branches to mucous membrane of larynx
below vocal cord.
5. Sensory branches to trachea and esophagus.
Cardiac Branches of Cervical Part of Vagus
From cervical part of vagus nerve, two cardiac branches take origin, superior and inferior. Thoracic part of
vagus also gives rise to cardiac branches.
All cardiac branches carry parasympathetic fibers which are cardioinhibitory in nature.
Out of cervical cardiac branches, left inferior cervical cardiac branch takes part in formation of superficial
cardiac plexus. All other branches join deep cardiac plexus. Cardiac plexuses are located in middle mediastinum
of thorax.
On the right side, out of two cardiac branches, one may arise from right recurrent laryngeal nerve.
Vagus Nerve in the Thorax (Fig. 19.58)
At the root of neck right vagus nerve enters the thorax crossing in front of 1st part of right subclavian artery.
Then it runs downwards and medially behind right brachiocephalic vein to reach right side of trachea. Left
vagus enters thorax passing between left common carotid artery and left subclavian artery, behind left
brachiocephalic vein.
Further downwards vagus nerve passes behind root of lung of respective side in the middle mediastinum of
thorax.
Cranial Nerves
341
Right recurrent laryngeal nerve hooks round right subclavian artery
Right vagus nerve enters thorax crossing in front of right subclavian artery
Left recurrent laryngeal nerve hooks round ligamentum arteriosum
Left vagus nerve enters thorax crossing in front of arch of aorta
Posterior pulmonary plexus Anterior pulmonary plexus
Cardiac branches
Right bronchus
􏱺sophageal orifice of diaphragm
through which both vagi enter abdomen from thorax
Anterior gastric nerve
Both vagi supply parasympathetic
fibers upto right two􏱺thirds of
transverse colon
Loop of small intestine
Distribution in the thorax
In the thorax, vagus nerve of both sides, gives following branches—
1. Cardiac branches
2. Pulmonary branches
3. 􏲠sophageal branches.
It is the time for a reader to recapitulate that any branch of vagus going to the target organ reach as
preganglionic parasympathetic fiber. They relay close to the wall (surface) of the organ from where
postganglionic fibers are distributed.
In the thorax, postganglionic fibers of vagus, along with the sympathetic fibers form plexuses for the
Fig. 19.58 Distribution of vagus nerve in thorax and abdomen
342
respective organs which are named as cardiac plexus, pulmonary plexus and esophageal plexus.
Cardiac plexus
Cardiac plexus is formed by cervical and thoracic cardiac branches of vagus along with sympathetic fibers from
upper four or five thoracic sympathetic ganglia.
Vagal fibers are cardioinhibitory to slow down the heart rate and diminish the force of contraction of
myocardium whereas sympathetic being cardioac- celeratory in function, increases heart rate and force of
contraction with coronary vasodilation.
Cardiac plexus is made up of two components, superficial and deep.
Superficial cardiac plexus is the smaller component and considered to be detached portion of main (deep)
cardiac plexus. It is situated below arch of aorta and in front of right pulmonary artery. Deep cardiac plexus,
being more prominent, is situated behind arch of aorta and in front of bifurcation of trachea. Superficial cardiac
plexus is formed by superior cervical cardiac branch of left sympathetic trunk and inferior cervical cardiac
branch of left vagus. All other vagal and sympathetic contributions take part in formation of deep cardiac
plexus.
From cardiac plexuses postganglionic fibers are distributed along the course of coronary artery.
Pulmonary plexus
Pulmonary plexus is formed by branches of vagus nerve (parasympathetic) and also sympathetic fibers from T 2–
T5 sympathetic ganglia. Nerve fibers from both sympathetic and parasympathetic (vagal) contributions form
anterior and posterior pulmonary plexuses which are situated in front and behind root of lung respectively.
From these plexuses branches follow the course of tracheobronchial tree as postganglionic fibers.
Vagal (parasympathetic) fibers of pulmonary plexuses possess following functions.
i. 􏲠xcitatory to the muscles of tracheobronchial tree. Their stimulation causes bronchoconstriction.
ii. Secretomotor to mucous glands of whole respiratory tract.
iii. Sensory in nature for mucous membrane of respiratory tree. It responds to stretch or cough reflex.
Sympathetic fibers exert inhibitory effect on musculature and mucous gland. So, it results bronchodilatation
and diminished secretion of mucous glands.
Esophageal plexus
It is the lower half of esophagus which receives esophageal branches from vagal trunk of both sides. 􏲠pper half
is supplied by esophageal branch of both recurrent laryngeal nerve while they run upwards along the
tracheoesophageal groove of corresponding sides. Sympathetic fibers for upper half of esophagus come from
middle cervical sympathetic ganglion. Lower half receives fibers from first four thoracic (T 1– T4) ganglia.
Vagal (parasympathetic) fibers are motor, secretomotor and sensory for the esophagus. Sympathetic fibers are
vasomotor.
Left Recurrent Laryngeal Nerve
Left recurrent laryngeal nerve arises from vagus in the thorax while the vagus nerve crosses in front of left
(anterior and left) side of arch of aorta. It hooks round the ligamentum arteriosum and finally reaches the
tracheoesophageal groove. Its distributions are similar to the right nerve.
Vagus Nerve in Abdomen (Fig. 19.58)
In the abdomen vagus nerve is concerned with parasympathetic innervation of foregut and midgut with
associated structure like liver, gallbladder, pancreas. Parasympathetic fibers of vagus are for following
functions to gastrointestinal tract.
1. 􏲠xcitatory to smooth muscles of the gut for which it promotes peristalsis.

2. Inhibitory to all sphincters of gut which get relaxed.
3. Secretomotorformucousglandsinthewallofgut upto right two-thirds of transverse colon.
􏲠. Sensorytothewallofthegutduetocompression, distension or ischemic change.

Both the vagi enter abdomen through esophageal
orifice of diaphragm. Because of rotation of foregut to the right, left and right vagi lie in relation to anterior and
posterior aspects of stomach respectively. After anterior and posterior gastric nerves are distributed to the
stomach, vagus nerve fibers are continued further distally to supply successive part of gut.
The fibers of both vagi proceed to the viscera of upper abdomen with foregut and midgut through corresponding
vascular plexus related to the artery supplying that particular organ. But in these vascular plexuses,
parasympathetic vagal fibers are still preganglionic until they reach the wall of gut. These preganglionic fibers
are axons of connecter neurons which are the cells of dorsal nucleus of vagus in medulla oblongata.
Reaching the wall of gut these preganglionic fibers relay in effector neurons in two levels to form following two
plexus from where postganglionic fibers are distributed.
1. Myenteric (Auerbach) plexus: It is placed in between of muscular coats of the gut. From this plexus
postganglionic fibers of vagus are distributed to muscles of the gut. Stimulation of these fibers increases
peristalsis and relaxes sphincters.
2. Submucosal (Meissner) plexus: This forms the relay stations in submucous coat of the concerned portions
of gut. Postganglionic fibers promotes secretion of glands.
Parasympathetic fibers derived from vagus are motor fibers for smooth muscles of wall of gallbladder and
biliary tree and inhibitory to the musculature of sphincter of Oddi.
For kidney, postganglionic parasympathetic fibers of vagus form renal plexus along with sympathetic. Vagal
fibers for the kidney are vasodilator in function.
ACCESSORY NERVE
343
Introduction
Accessory nerve is the 􏲠Ith cranial nerve. It is made up of two roots, cranial and spinal. Cranial root arises
from brainstem and spinal root arises from upper five (C 1–C5) segments of spinal cord. Accessory nerve is so
called as it is considered to be accessory to vagus nerve, because its cranial root totally joins with vagus through
which fibers are distributed.
Type
Accessory nerve is a purely motor nerve to supply muscles developed from sixth branchial arch along with
sternomastoid and trapezius.
The nerve (both cranial and spinal roots) is made up of only special visceral efferent fibers which supply
muscles developed from mesoderm of sixth branchial arch.
These muscles are –
1. All muscles of soft palate except tensor palati

2. All muscles of pharynx except stylopharyngeus
3. All muscles of larynx except cricothyroid
􏲠. Sternomastoid and trapezius.
Muscles of 1st three groups are supplied by cranial root of accessory nerve through vagus. Spinal root supplies
sternomastoid and trapezius which are also considered to be of VIth branchial arch origin.
Fibers of spinal root supplying sternomastoid and trapezius are sometimes considered to be somatic efferent in
nature.
Nucleus
Nucleus of accessory nerve is single and composite called nucleus ambiguous. It is the nucleus of special
visceral efferent column and present in lower two- thirds or lower three-fourths of medulla oblongata. Its upper
part belong to the nuclei of I􏲠th and 􏲠th cranial nerve. Lower part being the nucleus of accessory nerve is
known as nucleus for cranial root. It is continuous below with central group of anterior horn cells of spinal cord
of upper five (C1 – C5) cervical segments of spinal cord. It is known as spinal nucleus of accessory nerve.
Spinal nucleus of accessory nerve is also altern- atively considered to be of somatic efferent group.
Cranial Nerves
CLINICAL ANATOMY
Isolated lesion of vagus nerve is uncommon. Injury to individual branch may occur independently or together.
Injury to pharyngeal branch produces difficulty in swallowing (dysphagia). Injury to superior laryngeal branch
produces loss of sensation (anesthesia) of upper-half (supraglottic part) of mucous membrane of larynx. Due to
paralysis of cricothyroid, voice becomes weak and tires easily.
Lesions of Recurrent Laryngeal Branch
Lesions of recurrent laryngeal nerve may occur due to cancer of larynx or thyroid, or from injury of the nerve
following surgical operation in thyroid gland, esophagus, heart and lungs. Due to longer course, left nerve is
more prone to be lesioned than right. Paralysis of recurrent laryngeal nerve will cause hoarseness of voice and
dysphonia (difficulty in speech) due to loss of function of vocal cord. Paralysis of both recurrent laryngeal nerve
cause aphonia (loss of voice) and inspiratory stridor which is characterized by harsh, high pitched respiratory
sound.
Central lesion of vagus nerve may occur in a condition called lateral (posterior) medullary syndrome due to
occlusive disorder of posterior inferior cerebellar artery. In this case disorder of swallowing and speech will be
associated with manifestations of cerebellar ataxia.
344
Nucleus ambiguous (II)
Nucl. of sp. tr. of V nerve

Cranial root of accessory nerve
Inferior olivary nucleus
Fig. 19.59 Intraneural course of cranial root of accessory nerve Intraneural Course
Cranial root (Fig. 19.59)
Cranial root of accessory nerve arises from nucleus ambiguous. The fibers run ventrolaterally through
tegmental portion of medulla oblongata being flanked medially by medullary reticular formation, spin-
othalamic tract, medial lemniscus, and laterally by nucleus of spinal tract of trigeminal nerve and inferior
cerebellar peduncle to reach posterolateral sulcus between olive and inferior cerebellar peduncle (Fig. 1􏲠.5􏲠).
Spinal root (Fig. 19.60)
Spinal root is formed by multiple branch of fibers which arise from central group of anterior horn cell neurons
present from C1–C5 segments of spinal cord. These fibers come out from lateral surface of spinal cord as five
roots between ventral and dorsal roots of spinal nerve. The five roots ascend and converge to meet together to
form single spinal root of the nerve. Spinal root finally enter cranium through foramen magnum to join cranial
root, thus forming composite accessory nerve, that is of course for a shorter length.
Surface Attachment of Nerve Roots
Cranial root (Fig. 19.61)
Multiple rootlets come out from posterolateral sulcus of medulla oblongata between olive and inferior cerebellar
peduncle. These fibers are in the same vertical plane with glossopharyngeal and vagus
Hypoglossal nucleus
Medial longitudinal bundle
Tectospinal tract
Dorsal nerve root
Spinal nerve
Ventral nerve roots
Spinal root of accessory
nerve ascends to 􏱺oin
cranial root
Central group of anterior horn cells from C1–C5 segments forming spinal nucleus accessory nerve
Pyramid
Medial lemniscus
Spinothalamic tract
Fig. 19.60 Intraneural course of spinal root of accessory nerve
nerves. Rootlets of cranial accessory nerve unite to form single nerve trunk as they approach jugular foramen.
Spinal root (Figs 19.60 and 19.61)
Spinal roots are five pairs in origin, each arising from lateral surface of spinal cord in between sites of
attachments of ventral and dorsal roots of spinal nerve. The nerve roots ascend vertically and join successively
with adjacent one to form a single trunk which enter cranium through foramen magnum.
Intracranial Course (Fig. 19.61)
Intracranial course of both the roots are very short and join together to approach jugular foramen.
Exit from cranium (Fig. 19.61)
Couple of cranial and spinal accessory nerve starts the journey together to come out through intermediate
compartment of jugular foramen along with glossopharyngeal and vagus nerve. Accessory nerve is enclosed
with vagus nerve here in a common dural sheath.
Extracranial Course and Distribution
Cranial root
While studying, and particularly while asked in examination the course and distribution of whole accessory
nerve, a learner must not forget or ignore the course and distribution of cranial root.
Cranial root of accessory nerve joins the vagus nerve immediately after the nerve comes out of jugular foramen.
It joins proximal to inferior ganglion
Cranial Nerves
345
Combined cranial and spinal roots of accessory nerve
Cranial root of
accessory nerve 􏱺oining
vagus nerve
Spinal root of accessory nerve entering through foramen magnum

Right recurrent laryngeal nerve
Right vagus nerve
Rootlets of vagus nerve
Rootlets of cranial accessory nerve
Jugular foramen
Sup. ganglion of vagus
Inf. ganglion of vagus
Pharyngeal branch of vagus nerve
Left recurrent laryngeal nerve
Left vagus nerve
Fig. 19.61 Surface attachment, intracranial course and exit from cranium of accessory nerve and its relation with vagus nerve
of vagus. Beyond this, cranial root does not possess its own identity. Its fibers are distributed through following
two branches of vagus.
1. Pharyngeal branch of vagus: Though topogr-
aphically it is a branch of vagus, it contains special visceral efferent fibers of accessory nerve to supply—
1. a) All muscles of palate except tensor palati.

2. b) All muscles of pharynx except stylopharyngeus.
2. Recurrent laryngeal nerve: This branch of vagus is a mixed nerve. Special visceral efferent fibers are
contributed by cranial root of accessory which supply all muscles of larynx except cricothyroid. Sensory
component of the nerve are the fibers of vagus which supplies infraglottic part of
mucous membrane of larynx.
Spinal root (spinal accessory nerve) (Fig. 19.62)
Being separated from cranial root, it descends vertically between internal carotid artery and inte-
rnal jugular vein, deep to parotid gland and styloid process. 􏲠ere it lies in the point midway between angle of
mandible and mastoid process. Next it changes its direction to pass downwards, backwards and laterally,
superficial to internal jugular vein and deep to sternocleidomastoid. 􏲠ere it is related to number of lymph
nodes.
The nerve pierces or passes deep to anterior border of sternocleidomastoid at its junction of upper one- fourth
and lower three-fourths. 􏲠ere it communicates (forms a network) with IInd and IIIrd cervical nerves.
The nerve appears in posterior triangle of neck coming out of posterior border of sternocleidomastoid at the
junction of upper one-third and lower two- thirds of the muscle. 􏲠ere also the nerve is related to a group of
lymph nodes.
In the posterior triangle of neck, spinal accessory nerve runs downwards, backwards and laterally over levator
scapulae, being embedded in the investing layer of deep cervical fascia forming the roof of
Congenital Torticollis
The term torticollis means a clinical condition that is characterized by contraction or shortening of cervical muscles
which presents twisting of neck and slanting of head. Congenital torticollis occurs due to fibrous tissue tumor in
sternocleidomastoid (fibromatosis colli). It causes head to tilt towards and face to turn away from affected side.
􏲠owever, it is not related to lesion of spinal accessory nerve.
Spasmodic (acquired) torticollis: It gives rise to similar kind of muscular disability which results due to
irritation of spinal accessory nerve because of inflamed cervical lymph nodes lying in the vicinity of the nerve.
Clinical Test for Competence of Spinal Accessory Nerve
Action of sternocleidomastoid is tested by asking the patient to turn the face and head to the opposite side against
the resistance applied. Functioning of trapezius is tested by asking the patient to shrug (elevate) the shoulders
upwards against resistance by application of pressure with both hands of examiner over both shoulders of the
patient. Weakness of the
CLINICAL ANATOMY
Central lesion of accessory nerve (jointly both the roots) may occur due to two reasons—
Lateral medullary syndrome
􏲠ugular foramen syndrome.
In these cases common manifestations of the lesion of I􏲠, 􏲠 and 􏲠I cranial nerve are observed.
Independent lesion of spinal accessory nerve may occur due to local cause in posterior triangle of neck. 􏲠sually the
spinal accessory nerve, instead of being damaged, gets irritated causing reflex spasm of sternocleidomastoid (with
trapezius). The condition is known as torticollis (wry-neck)
346

Levator scapulae
Sternocleidomastoid
Lymph nodes
Lymph nodes
IInd and IIIrd cervical nerves

IIIrd and IVth cervical nerves
Trapezius
posterior triangle. The nerve leaves posterior triangle of neck passing deep to anterior border of trapezius muscle 5
cm above the level of lateral end of clavicle. 􏲠ere spinal accessory nerve forms a network with fibers of IIIrd and
IVth cervical nerves.
Muscular branches of spinal accessory nerve supply sternocleidomastoid and trapezius.
Proprioceptive supply to these muscles are derived from IInd, IIIrd and IVth cervical nerves.
Fig. 19.62 Course and distribution of spinal accessory nerve
muscle of the affected side can be comfirmed when compared with normal side.
Cranial Nerves
347
HYPOGLOSSAL NERVE
Introduction
It is the 􏲠IIth cranial nerve supplying muscles of tongue.
Type
􏲠ypoglossal nerve is a purely motor nerve.
􏲠ypoglossal nerve consists of only somatic efferent fibers which supply muscles developed from occipital
myotome of para-axial mesoderm. These are all extrinsic as well as intrinsic muscles of tongue except
palatoglossus.
Nucleus
􏲠ypoglossal nucleus is elongated of about 2 cm length. It is subependymal in position in the lower part of
medial eminence of floor of fourth ventricle corresponding to hypoglossal triangle.
􏲠ypoglossal nucleus possesses connections with following areas of brain.
1. Supranuclear connections: Motor area of opposite
cerebral hemisphere.
2. Sensory nuclei of trigeminal nerve.

3. Nucleus tracts solitarius.
􏲠. Reticular formation. 5. Cerebellum.
Hypoglossal nerve nucleus Medial longitudinal bundle
Tectospinal tract
Medial lemniscus
Pyramid Arcuate nucleus
Somatic efferent fibers of hypoglossal nerve arises from its nucleus in the posterior part of medulla oblongata.
The fibers run forwards traversing central core of medulla oblongata. While passing forwards the fibers are
flanked medially by medial lemniscus and pyramid and laterally by spinothalamic tract and inferior olivary
nucleus.
Exit from brainstem: The nerve comes out in the form of multiple rootlets through anterolateral sulcus
between pyramid and olive.
Intracranial Course
Intracranial course of the nerve is very short in posterior cranial fossa. The multiple rootlets unite to form two
trunks which join to form a single nerve at hypoglossal (anterior condylar) canal.
Exit from the cranium: 􏲠ypoglossal nerve leaves cranium through hypoglossal or anterior condylar
canal.
Only following points are to be remembered for extracranial course.
First it lies behind internal jugular vein from where it appears in the interval between upper ends of the vein
and internal carotid artery.
The nerve descends for a while crossing in front of vagus nerve and joined by fibers from C1 nerve.
At the lower border of posterior belly of digastric and stylohyoid, the nerve turns its direction upwards,
forwards and medially hooking round lower sternocleidomastoid branch of occipital artery. The nerve crosses
superficial to internal carotid, external carotid and loop of lingual arteries to run forwards over hyoglossus
muscle.
Nucleus of spinal tract of trigeminal nerve
Inf. cerebellar peduncle Spinothalamic tract
Vagus nerve Inferior olivary nucleus
Hypoglossal nerve (left) exits through anterolateral sulcus of medulla oblongata
Fig. 19.63 Intraneural course of hypoglossal nerve
348
Styloglossus muscle Fibers of hypoglossal nerve
Hypoglossal nerve Recurrent meningeal branch
C1 nerve root
Fibers from C1 nerve
􏱺oining 􏱺􏱺􏱺 nerve
C2 nerve root C3 nerve root
Descendens cervicalis
Ansa cervicalis to supply infrahyoid muscles
Descendens hypoglossi
Hyoglossus muscle
Nerve to geniohyoid (C1
fibers carried through
hypoglossal nerve
Nerve to thyrohyoid (C1
fibers carried through
hypoglossal nerve
Hypoglossal nerve crossing loop of lingual artery
Beyond anterior border of hyoglossus, the nerve divides into terminal branches inside the tongue.
Branches
1. Terminal branches: For better understanding, terminal branches are to be discussed first. Terminal
branches of hypoglossal nerve are the only fibers of the nerve itself, which supply all the extrinsic as well as
intrinsic muscles of tongue except palatoglossus.
Others are topographically the branches of hypoglossal nerve, but these fibers are contributed by Ist cervical
nerve. These branches are as follows:
2. Recurrent meningeal branch: This branch re-
enters cranial cavity through hypoglossal canal to
supply meninges of posterior cranial fossa.

3. Descendens hypoglossi: This branch, arising from hypoglossal nerve descends first in front of carotid
arteries, and joins with descendens cervicalis formed by twigs from C 2 and C3 nerve to form ansa cervicalis.
Ansa cervicalis is a loop of nerve, so formed, which is embedded in the
anterior wall of carotid sheath. From the ansa (C1,

C2, C3) infrahyoid muscles are supplied.
4. : Some fibers of C1 nerve are carried further forwards with hypoglossal nerve and bifurcate to
supply geniohyoid and thyrohyoid muscles.
Fig. 19.64 􏲠xtracranial course and distribution of hypoglossal nerve
CLINICAL ANATOMY
Lesion of hypoglossal nerve is central in origin and it is for vascular cause occurring as a result of occlusion of
medullary (paramedian) branches of vertebral artery. It causes damage to the ventral part of medulla
oblongata. The clinical condition is called ventral medullary syndrome. It causes crossed paralysis characterized
by contralateral hemiplegia and paralysis of muscles of tongue of same half. If the lesion is extensive, it will
cause loss of sense of position and movement and discriminative touch of opposite side due to involvement of
medial lemniscus. If spinal lemniscus lateral to emerging fibers of hypoglossal nerve is affected, it will cause
contralateral hemianesthesia.

Samar Deb Easy and Interesting A

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Samar Deb Easy and Interesting A

Caricato da

Copyright:

Formati disponibili

Introduction to Human Neuroanatomy

PRINCIPLES OF FUNCTIONS OF NERVOUS SYSTEM (FIG. 1.1)

2. Secretion of exocrine glands.

glands is mostly under the hormonal control.

the skin named the Arrectores pili.

So result of functions of nervous system may be summarized as follows—

movement of a joint. It may result movement of

some organs, like tongue, eyeball.

a) Viscera: It is called visceral muscle.

attached to the root of hair follicle. 3. Secretion of exocrine glands like:

a) Salivary glands or lacrimal gland: Large and solitary.

2. It perceives or acknowledges the informations at its center.

3. It analyzes, integrates and coordinates the infor- mations or inputs.

classified regionally as Cervical-8, Thoracic-12,

Lumbar-5,Sacral-5 and Coccygeal-1.

a) Proximal (Cranial): Cranial nerves, 12 pairs arising as outflow from brain.

Sensory information • Received

Command or directions given

Motor effect Produced in the

Fig. 1.1 Diagrammatic representation of principles of function of nervous system

voluntary muscles • Secretion of exocrine glands

Lower spinal nerve forming cauda equina

ii. Contractions of involuntary muscles like—

3. c) Smooth muscles in the root of hair follicle of

skin, known as Arrectores pili.

iii. Secretions of exocrine glands which may be either

Fundamental difference between the Cranial and Spinal nerves:

Fig. 1.2 Central nervous system

Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)

Each of the 31 pairs of spinal nerves

• Motor fibers of cranial nerves carry out command or effects

• Sensory fibers of cranial nerve carry sensory information

• Sensory fibers of cranial nerve carry sensory information

Motor fibers of spinal nerve

carry out command or effects

Central nervous system

Peripheral nervous system

• Acts as field staff

Two parallel components of autonomic nervous system:

Fig. 1.3 Central and peripheral part of nervous system

Pain – Temperature Pressure – Touch

Proprioceptive sensory fibers

from muscles and tendons

From all viscera

1.Motor fibers to involuntary

Introduction to Human Neuroanatomy

Somatic nervous system Centers:

Autonomic nervous system Centers:

T1 – L2 (L3) segments of spinal cord

• Nuclei of 3rd, 7th, 9th, 10th

Autonomic peripheral outflow

CENTERS OF NERVOUS SYSTEM

That’s why it is called Central nervous system.

COMPOSITION OF NERVOUS SYSTEM

may be maximum as in connective tissue. But every- where it is noncellular.

The structural as well as functional units of nervous system is Neuron.

Structure of a Typical Neuron (Fig. 1.5)

A typical neuron is composed of—

Fig. 1.5 A typical neuron

Introduction to Human Neuroanatomy

travels towards the cell body.

travels away from the cell body.

Target organ (Skeletal muscle)

Easy and Interesting Approach to Human Neuroanatomy (Clinically Oriented)