NEUROANATOMY

THE MENINGES Note:

serves to protect the brain and spinal cord. Enables The two ayers of dura mater separate from each other
channeling of cerebrospinal fluid around the brain and spinal in certain places creating partitions within the cranial
cord. cavity which help hold the brain in place
there are four areas of dural infolding where the
meningeal layer reflects inwards, away from the
periosteal layer

DURAL INFOLDINGS

1. Falx Cerebri
- a sickle shaped projection of the
duramater
- extends downward into the
longitudinl fissure separating the
two cerebral hemispheres

2. Tentorium Cerebelli

- a Tent like structure that

spreads between the petrous
part of the temporal bone and
the transverse sinus
- separating the cerebellum
from the occipital lobe
- Divides the cranial cavity into
supratentorial and
infratentorial compartments.

3. Falx cerebelli
- another sickle shape dural
DURA MATER
projection situated at the
- also known as PACHYMENINX posterior part of the posterior
- “Hard mother” cranial fossa between the right
- thickest and toughest and left hemispheres of the
- derived from mesoderm cerebellum
- contributes to the subdural and epidural spaces
4. Diaphragma sellae
Two Layers: - a small sheath of dura that. covers the pituitary gland
Periosteal layer Note:
- the outer layer of the cranial dura mater The separation of two dural layers at the dural infoldings also
- forms the inner aspect of the skull creates cranial venous channels known as:
Meningeal Layer DURAL VENOUS SINUSES
- the inner layer of the dura mater
- forms the supporting capsule of the brain
- responsible of the dural infoldings DURAL VENOUS SINUSES
- tends to firmly attach to the underlying arachnoid mater
Subdural space
- the potential space between the meningeal layer and
arachnoid mater

Epidural space
- the space between the skull and the dura mater

Clinical Correlation
Subdural and Epidural hematomas are brain injuries
resulting from the entrapment and subsequent
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- allows venous blood to drain into the Internal Jugular The innervation of the dura mater causes it to be very
vein towards the heart sensitive therefore, the stretching of the dura mater can result
- receive blood from cerebral veins and CSF in headaches.
(cerebrospinal fluid) from the subarachnoid space
DURAL ARTERIAL SUPPLY
through arachnoid villi to ultimately drain into the
internal jugular veins Internal carotid, Maxillary, Ascending pharyngeal,
- valve less Posterior : Occipital and Vertebral
- connected to the diploic veins of the skull and mnemonic: I’M Ascending On Viagra

veins of the scalp via emissary veins 

Middle meningeal artery
Arachnoid granulations - clinically important
- also known as Pacchionian granulations, are - arise from maxillary
projections of the arachnoid membrane (villi) into the artery, enters cranial cavity
dural sinuses that allow CSF to pass from via foramen spinosum
the subarachnoid space into the venous system. - lie between meningeal &
endosteal layers
- divides into posterior and
SPINAL DURA MATER
anterior branches
Difference: The periosteal layer of the cranial dura mater
does not extend beyond the foramen magnum.
The spinal dura mater is only composed of the dural MENINGEAL VEINS
meningeal layer, the true dura mater
- lie in the endosteal layer of the dura
- middle meningeal vein follow branches of middle meningeal
thecal sac or dural sac - artery and drain into the pterygoid venous plexus or
membranous sheath (theca) or spheno-parietal sinus
tube of dura mater that surrounds
the spinal cord and the cauda
equina (a bundle of spinal nerves Notes from the visual presentation:
and spinal nerve rootlets) and INTRACRANIAL BLEED: CAUSES AND PRESENTATIONS
extends downwards together with
the filum terminale (the point at Four Types of Intracranial Bleed
which spinal cord ends, a thread EPIDURAL
of connective tissue) to the - blood is between skull
periosteum of coccyx and dura
- Ends at the lower border of SUBDURAL
the S2 vertebrae - underneath the dura
- Extradural space contains
loose areolar tissue and SUBARACHNOID
vertebralvenous plexus - beneath the arachnoid
INTRACEREBRAL/
Clinical Correlation PARENCHYMAL
Lumbar Puncture HEMMORHAGE
also called a spinal tap, is an invasive outpatient procedure - in the parenchyma of
used to remove a sample of cerebrospinal fluid (CSF) from the brain
the subarachnoid space in the spine.
Common Presentations
Symptoms:
Headache,
DURAL INNERVATION nausea, vx (increased Intracranial Pressure)
Signs:can be neurologically normal, with a normal
- Trigeminal Nerve (CN V) GCS, lethargic or unresponsive and may even show
V1 V2 V3 (according to teach me anatomy) signs of seizure activities.
- Vagus Nerve (CN X)
- C1, C2, and C3
Note:

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EPIDURAL HEMATOMA SUBDURAL HEMATOMA SUBARACHNOID INTRACEREBRAL/

HEMORRHAGE PARENCHAL HEMMORHAGE

caused by direct trauma, to when there is rapid head TRAUMA: TRAUMA:

the temporal bone acceleration and deceleration

tends to occur in direct head injury associated with
combination with other other traumatic bleeds.

can be caused by falls and even traumatic bleeds

with no direct head trauma small volume with no focal NON TRAUMATIC:
signs + Subdural /Epidural Hypertention is the main risk
disruption of Middle are bleeding from bridging veins (wherein there may be focal factor.

Meningeal Artery = rapid signs, decreased LOC, GCS,

bleeding increased by used of common sites includes the

anticoagulants)

Basal Ganglia

NON TRAUMATIC: Thalamus

Rupture of aneurysm (80%)

Pons

minor: ruptured AVM Cerebellum

Neoplasm

blood accumulates pushes Low pressure in nature, thus circle of willis Presentations:

the brain, SDH can grow slowly

Px with anticoagulants are more Sx: H/A, VX, , decreased LOC,

likely to develop SDH focal neurological deficits that
corresponds to what part of the
Presentations: younger patients: since they do brain is affected

“quick decline of GCS” not have a lot of brain atrophy:

: after initial impact brief Presentations: risk also increase with use of
normal declines to a GCS of acute after trauma
sympathomimetic drugs.
3, rapid herniation occurs headache + decrease LOC + (are agents which in general
neurological deficits
mimic responses due to

stimulation of sympathetic

elderly patients: since they have nerves.)

High incidence:

more brain atrophy there is more FHx of aneurysm , PCKD

time for blood to accumulates

Marfan's syndrome

increase size > rupture >

SAH > Herniation > death

Sentinel Bleed: findings for

an aneurysm that has not

Presentations: ruptured yet

Presentations:
very subtle:

RUPTURE: H/A, Vx, SZ,

slow chronic change in
Dec. lOC and coma

personality

Sentinel bleed: no mass

focal deficits

effect, normal GCS no focal

increasing falls / confusion

deficit, severe headache,

peaks at onset, thunderclap
Pediatric:
headache neck pain, nausea
diagnosis of SDH -> abuse
and vx,

Presentations:
TAKE NOTE:
Headache, Vx, decreased LOC,
Aneurysm at Posterior
focal deficits, seizures

Common artery compresses

Examination: enlarged Head
CN III thus EYE: Down + out
circumference, bulging
and dilated pupil

fontanelles, failure to thrive.

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NICE TO KNOW SUBDURAL HEMATOMAS

- most common type of traumatic intracranial mass lesion
fontanelles should feel firm and very - 72% - falls and assault
slightly curved inward to the touch. A - 24% - vehicular trauma
tense or bulging fontanelle occurs
when fluid builds up in the brain or the acute - less than 72 hours
sub-acute – 3 - 7 days after acute
brain swells, causing increased injury
pressure inside the skull. chronic – develop over weeks

Mechanism: high speed impact to

the skull causing brain tissue to
A child is said to have failure to thrive when they don't meet
accelerate or decelerate relative to
recognized standards of growth. Failure to thrive isn't a
fixed dural structures tearing blood
disease or disorder. Rather, it describes a situation in which a
vessels
child is undernourished. They either don't receive or are
unable to process enough calories
other causes: coagulopathies;
ruptured intracranial aneurysms
A neurologic deficit refers to abnormal function of a body
area. This altered function is due to weaker function of the
brain, spinal cord, muscles, or nerves. Examples include:
Abnormal reflexes. Inability to speak. CAVERNOUS SINUSES
Glasgow Coma Scale (GCS) is the most common scoring - middle cranial fossa on each side of the body of
system used to describe the level of consciousness in a the sphenoid bone
person following a traumatic brain injury. Basically, it is used - extends from the superior orbital fissure to the apex of
to help gauge the severity of an acute brain injury. the petrous part of the temporal bone (2.0 – 2.5 cm.);
width = 1 cm.
- receives venous flow from multiple sources
INTRACRANIAL EPIDURAL HEMATOMAS
- occurs in 2% of patients with head injury
- occurs in 5- 15% of patients with
fatalhead injury
occurence:
acute - 58%
sub-acute – 31%
chronic – 11%

- results from a brief linear contact

force to the calvaria that causes
separation of the periosteal dura
from bone and disruption of
interposed vessels due to
shearing stress

TM: temporoparietal region and

middle meningeal artery are
involved in 66% of cases

frontal injuries anterior ethmoidal artery

occipital injuries transverse or sigmoid sinus

trauma to the vertex sagittal sinus

NTK: EPIDURAL ANESTHESIA

CRANIAL NERVES

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Signs and Symptoms
CN III. Oculomotor Nerve - fever, headache
⁃ supply all extrinsic muscles of the eye EXCEPT the - swelling of the eyelids and chemosis (swelling or
superior oblique and lateral rectus edema of the conjunctiva)
⁃ Supplies the following intrinsic muscles: constrictor - proptosis (abnormal protrusion of the eye) and
pupillae of the iris and ciliary muscles swelling of the face
⁃ responsible for lifting the upper eyelid; turning the eye - ophthalmoplegia resulting from orbital congestion &
upward, downward, and medially; constricting the pupil infection of orbital muscles and ocular nerves
and accommodating the eye 
 - pupils dilated, fixed to light
- loss of sensation of cornea, forehead and cheek
CN IV. Trochlear nerve - blurred vision for near
⁃ supplies the superior oblique muscle of the eyeball - stiff neck, generalized headache, altered mental
⁃ assists in turning the eye downward and laterally status

CN V. Trigeminal nerve
⁃ V1 – Ophthalmic nerve – contain only sensory fibers Take Note:
⁃ V2 – Maxillary nerve – contain only sensory fibers - CN VI Abducent nerve usually first to be affected
⁃ sensations of pain, temperature, touch and pressure because of its direct course through the sinus


CN VI. Abducent nerve
⁃ small motor nerve supplying the lateral rectus muscle 

turns eye laterally 
 NICE TO KNOW

Chemosis: Swelling around the iris

(the colored circle that surrounds the
pupil) due to edema (swelling) of the
bulbar conjunctiva (the clear
membrane that coats the outer surface
of the eye).

Proptosis: forward projection or

displacement especially of the eyeball.

Ophthalmoplegia is the paralysis or weakness of the eye

muscles. It can affect one or more of the six muscles that
hold the eye in place and control its movement. There are two
CAVERNOUS SINUS THROMBOSIS types of ophthalmoplegia: chronic progressive external
ophthalmoplegia and internal ophthalmoplegia.
septic thrombosis via the following routes:
SENSORY INNERVATION OF THE DURA MATER
from the

Face via Angular and Opthalmic veins Anterior and Middle Cranial Fossa – Trigeminal n.
Middle Ear via Superior Petrous Sinus
Posterior Cranial Fossa - upper three cervical nerves,
Teeth, Maxillary Sinus & via Pterygoid plexus which empties branches of Vagus n. and Hypoglossal n.
Cervical Vertebrae into the inferior opthalmic vein Tentorium Cerebelli
is located in the posterior cranial fossa; it is a
Sphenoid Sinus as a direct extension or draining semi-circular transverse septum covering the
emissary vein
cerebellum, with occipital lobes of the cerebral
Infected Internal Jugular Vein, lateral sinus, petrosal sinus hemispheres lying on it

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ANATOMY OF HEADACHE Subarachnoid cisterns:

Trigeminocervical nucleus – essential nociceptive nucleus cisterna magma, pontine,
of the head, throat and upper neck 
 chiasmatic, suprasellar,
interpeduncular, cistern of
All nociceptive afferents from the Trigeminal, Facial, Sylvius
Glossopharyngeal, Vagus, C1-3 spinal nerves ramify into
this single column of grey matter 
 Arachnoid villi/ Arachnoid
granuations – site where the
pathology: mechanical (tension, raised or lowered CSF cerebrospinal fluid diffuses into the bloodstream
pressure, dilatation, stretch) or chemical (irritation,
inflammation) Subarachnoid space – filled with cerebrospinal fluid (CSF);

 where all cerebral arteries, veins and cranial nerves lie 


NICE TO KNOW *Arachnoid fuses with epineurium of cranial nerves at their

point of exit from the skull (ex. Optic n.) 

The spinal arachnoid mater is a delicate
membrane, located between the dura Cerebrospinal fluid
mater and the pia mater. It is separated - provides buoyancy to the brain; protects nervous
from the latter by the subarachnoid tissue from mechanical forces applied to the skull
space, which contains cerebrospinal removes waste products associated with neuronal
fluid.Distal to the conus medullaris, the activity, produced by the choroid plexuses found
subarachnoid space expands, forming within the lateral, third and fourth ventricles
the lumbar cistern. This space
accessed during a lumbar puncture (to
obtain CSF fluid) and spinal SUBARACHNNOID HEMORRHAGES
anaesthesia.
- head trauma; ruptured cerebral aneurysm (80%) or
RECALL: arteriovenous malformations

- diagnosis is confirmed by emergency CT scan

without contrast; CT angiography (99% sensitivity);
lumbar puncture

SPINAL ARACHNOID MATER

⁃ delicate impermeable membrane that covers the spinal

cord
⁃ continuous with the arachnoid covering the brain
through the foramen magnum
⁃ ends at the filum terminale at the level of the lower
border of S2 vertebra
⁃ subarachnoid space is filled with CSF

ARACHNOID MATER

- 1⁄2 leptomeninges
- avascular, impermeable membrane
- arachnoid bridges over the sulci on the surface of the
brain

There are areas where the CSF will accumulate due to

spaces between the two innermost brain layers (meninges).
These areas are known as the subarachnoid cisterns.

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BRAIN SPINAL CORD

EPIDURAL POTENTIAL ACTUAL

SUBDURAL POTENTIAL POTENTIAL

SUBARACHNOID ACTUAL ACTUAL

Subarachnoid actual in both brain and spinal cord
Epidural is actual only in spinal cord.

In adults, spinal cord typically terminates

at the level of L1

In neonates and infants, spinal cord

approximately ends in the level of L2 or
L3

SPINAL EPIDURAL

What is injected local anesthetic

Where is it injected CSF Epidural Space

What is affected cord nerve roots

dose small large

PIA MATER
- vascular membrane
LATERAL VENTRICLE
that closely covers
- C-shaped; level of the cerebral hemispheres
the cord Anterior horn → frontal lobe Body → parietal lobe

- ligamentum Posterior horn → occipital lobe Inferior horn →
denticulatum temporal lobe
passes laterally to THIRD VENTRICLE
adhere to the - slit-like cleft
arachnoid and dura between the two
- extends along each thalami/
nerve root and diencephalon
becomes CEREBRAL AQUEDUCT
- continuous with the - midbrain
FOURTH VENTRICLE
connective tissue
- level of the pons
surrounding each spinal nerve and cerebellum
CENTRAL CANAL
THE VENTRICLES - level of the
medulla oblongata
- fluid filled cavities located within the brain and spinal cord
- lined with ependyma and filled with cerebrospinal fluid
- lateral ventricles (2), 3rd ventricle, 4th ventricle
- interventricular foramen of Monro, cerebral aqueduct
(aqueduct of Sylvius)
- continuous with central canal of the spinal cord;
communicates with the subarachnoid space via three (3)
foramina in the roof of the 4th ventricle
- embryologically derived from the neural canal

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THE CEREBROSPINAL FLUID CIRCULATION OF CSF

⁃ produced by the choroid plexus (ependymal cells + ventricles→subarachnoidspace→ cerebellomedulary cistern

pia) and pontine cistern →inferior surface of cerebrum → lateral
⁃ found in the ventricles and subarachnoid space aspect of each cerebral hemisphere
⁃ serves to protect brain tissue from mechanical trauma
(cushioning effect); provides mechanical buoyancy ⁃ some CSF move inferiorly to bathe the spinal cord
⁃ assists in the removal of products of neuronal and cauda equina
metabolism ⁃ flow is assisted by the pulsations of the choroid
⁃ important role in the development, homeostasis and plexuses and cilia of ependymal cells; cerebral arteries;
repair of the Central Nervous System (CNS) spinal arteries; movements of the vertebral column;
respiration; coughing and changes in body position
⁃ absorption of CSF is via arachnoid villi that project into
PHYSICAL CHARACTERISTICS the dural venous sinuses
Appearance Clear and Colorless ⁃ absorption occurs when CSF pressure exceeds venous
sinus pressure
Volume 150 ml ⁃ rate of absorption controls CSF pressure 

Rate of production 0.5 ml/minute
ANATOMY OF HYDROCEPHALUS
Pressure 60 - 150 mm of water
⁃ disturbance of formation, flow or absorption of CSF that
COMPOSITION leads to an increase in volume occupied by the CSF in
the CNS
Protein 15 - 45 mg/ 100 ml
⁃
Glucose 50 - 85 mg / 100 ml Communicating Hydrocephalus
– caused by overproduction of CSF, defective
Chloride 720 - 750 mg / 100 ml absorption of CSF, venous drainage insufficiency 

Number of cells 0 - 3 lympocytes / cu mm
Non-communicating Hydrocephalus
– CSF flow is obstructed within the ventricular system
THE CHOROID PLEXUS or in its outlets to the subarachnoid space 


⁃ highly specialized tissue that synthesizes trophic and

angiogenic factors, chemorepellants, and carrier
proteins
⁃ part of the blood-CSF barrier – controls entry of
nutrients such as amino acids and nucleosides, peptide
hormones BLOOD BRAIN BARRIER
⁃ composed of tightly packed villous folds consisting of a
single layer of cuboidal epithelial cells overlying a
central core of highly vascularized stroma
⁃ choroidal epithelium is continuous with ependymal
lining but is different morphologically and functionally
⁃ epithelial cells joined by tight intercellular junctions that
form the blood-CSF barrier together with the arachnoid
membrane

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BLOOD BRAIN BARRIER VASCULAR TERRITORIES – Anterior Circulation

⁃ Central Nervous System needs a stable environment
CORTICAL BRANCHES medial frontal and
to function normally
⁃ parietal lobes
permeability of the BBB is inversely related to the size
of the molecules MEDIAL caudate head,
⁃ permeability of the BBB is directly related to the lipid Anterior LENTICULOSTRIATE globus pallidus,
solubility of the molecule Cerebral BRANCHES anterior limb of
internal capsule
circumventricular organs – areas of the CNS that do not
have the BBB

Pituitary gland, median eminence, area

postrema, preoptic recess, paraphysis, pineal CORTICAL BRANCHES lateral frontal &
gland, endothelium of choroid plexus parietal lobes;
lateral & anterior
⁃ characterized by their small size, high permeability and temporal lobe
fenestrated capillaries Medial
Cerebral LATERAL globus pallidus,
Cerebral Circulation LENTICULOSTRIATE putamen, internal
BRANCHES capsule
CIRCLE OF WILLIS

⁃ 2 internal carotid arteries

⁃ 2 vertebral arteries
ANTERIOR CIRCULATION Anterior Optic tracts, medial temporal lobe,
- cortex, basal ganglia, thalamus, internal capsule Choroidal ventrolateral thalamus, corona
- lenticulostriate arteries artery radiata, posterior limb of internal
capsule
POSTERIOR CIRCULATION
- posterior cortex, midbrain, brainstem
- posterior inferior cerebellar & anterior inferior cerebellar
arteries* VASCULAR TERRITORIES – Posterior Circulation

CORTICAL BRANCHES occipital lobes,

medial and
posterior temporal
& parietal lobes
Posterior
Cerebral
Perforating branches brainstem,
posterior
thalamus,
midbrain

Posterior Inferior vermis, posterior &

inferiorcerebellar inferior
(PICA) cerebellar (PICA)
cerebellar hemispheres

Anterior inferior Anterolateral cerebellum

cerebellar (AICA)

Superior cerebellar Superior vermis, superior

cerebellum

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STROKE
⁃ Characterized by sudden loss of blood circulation to an
area of the brain which results to corresponding loss of
neurologic function
⁃ ischemic (thrombotic vs embolic) vs hemorrhagic
⁃ 4th leading cause of adult morbidity and mortality;
82-92% ischemic 



BORDER ZONE OR WATERSHED INFARCTS
⁃ ischemic lesions that occur in characteristic locations at
the junction between two main arterial territories
⁃ 10% of brain infarcts
⁃ decreased perfusion in the distal regions of 

the vascular territories

two types: external (cortical) or internal (subcortical)

BLOOD SUPPLY OF SPINAL CORD

Posterior spinal arteries (2)
– supply the posterior 1/3 of the cord
Anterior spinal artery
– supply anterior 2/3 of the cord
Segmental spinal arteries
– branches of arteries outside the vertebral column
Great anterior medullary artery of Adamkiewicz
– arise from the aorta; lower thoracic or upper
lumbar vertebral level; unilateral; may be major
blood source of lower 2/3 of the cord 


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fides spes et caritas

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