THE BRAIN

The brain along with the spinal cord constitute the central nervous system which will be
the subject of an entire separate course but a basic introduction to the brain is
appropriate in gross anatomy. This section will explore the gross structure and general
function of the brain, the ventricular system and the blood supply of the brain. The
meninges have been covered in the previous section.

The major parts of the brain are the cerebrum, the cerebellum and the brainstem each
of which has parts observable in a gross specimen. The Brain, in contrast to the spinal
cord has the gray matter (neurons) located externally and the white matter (nerve fibers)
located internally.

THE CEREBRAL HEMISPHERES

The cerebral (L. cerebrum, brain) hemispheres are the largest parts of the brain
occupying the anterior and middle cranial fossae and separated from the cerebellum by
the cerebellar tentorium. The external surfaces are covered entirely by a multilayered
cortex composed of neurons. The right and left cerebral hemispheres are the most
prominent structures one would see after removing the calvaria and the dura. The two
hemispheres are separated by the longitudinal fissure a midline cleft running from
frontal pole to occipital pole. Each hemisphere can be grossly divided into a lobe, a
parietal lobe, an occipital lobe and a temporal lobe. The term cerebrum is
commonly used to refer to the cerebral hemispheres and the diencephalon (not readily
seen).

• Frontal Lobe - extends from the frontal pole of the brain to the central sulcus.
Functions of this region include behavior and emotion, eye movements, motor
function and speech.

• Parietal Lobe - extends from the central sulcus to the parietooccipital sulcus.
Functions of this area include sensory integration, awareness of body parts,
identification of objects by feel without benefit of vision and localization of
visual stimuli and whether or not they are moving.

• Occipital Lobe - extends from the parietooccipital sulcus to the posterior pole of
the brain. The occipital lobe is entirely devoted to vision.

• Temporal Lobe - lies below the horizontal (Sylvian) fissure and extends from
the anterior boundary of the middle cranial fossa to the occipital lobe with which it is
continuous. Functions of this region include speech, memory, hearing, vestibular
function (balance), face recognition and the interpretation of form and color.

THE DIENCEPHALON

The diencephalon includes the epithalamus, thalamus and hypothalamus and

surrounds the third ventricle.

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 • Thalamus - major relay center for relaying all forms of sensory input to
appropriate cortical areas of the cerebral cortex and relaying input from
subcortical motor areas to the cerebral cortex to influence motor function.

• Hypothalamus - major center regulating the autonomic and endocrine

systems of the body to maintain the proper internal environment of the body.

• Epithalamus - includes the pineal gland which is involved in maintaining the

circadian (daily) rhythms of the body and the development of sexual maturity.

THE CEREBELLUM

The cerebellum lies dorsal to the pons and medulla and inferior to the occipital
lobes of the cerebrum and separated from them by the cerebellar tentorium. The
cerebellum occupies the posterior cranial fossa. It has two hemispheres
connected by a central potion called the vermis. The hemispheres are partially
separated by the cerebellar falx inferiorly. Like the cerebral hemispheres, the gray
matter is external and the white matter internal. Functions of the cerebellum include
control of posture, muscle tone, locomotion, equilibrium, coordination of
complex limb movements and the learning and memory of complex motor
routines such as in athletics.

THE BRAINSTEM

The brainstem includes the midbrain, the pons and the medulla (medulla oblongata).
In contrast to the cerebrum and cerebellum the gray matter of the brainstem is
located internally in nuclei and the white matter is located externally in various
tracts. The brainstem contains the nuclei of the cranial nerves.

• The Midbrain - located at the rostral end of the brainstem where the posterior
and middle cranial fossae meet. The midbrain contains nuclei involved in eye
movements, visual and auditory reflexes, hearing, modulation of pain with
endogenous opioids and motor control.

• The Pons - lies in the anterior part of the posterior cranial fossa and connects
the midbrain to the medulla. It is easy to distinguish due to it bulging appearance.
The pons contains nuclei involved in eye movements, salivation and lacrimation
(tears), balance and eye movement control, blood pressure control, hearing,
pain modulation, facial muscles, chewing muscles, somatosensory input from
the face and production of noradrenergic neurotransmitters.

• The Medulla - the medulla is the most rostral portion of the brainstem being
continuous with the spinal cord at the foramen magnum. The medulla contains
nuclei involved with tactile and vibratory sensation from the body and limbs,
facial pain, the trapezius muscle, function of the digestive tract, hearing,
muscles of the pharynx and larynx, cardiovascular and respiratory function.

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THE VENTRICULAR SYSTEM OF THE BRAIN

The brain and spinal cord develop from a hollow neural tube and the space persists
in the adult as the central canal of the spinal cord and the ventricles of the brain.
The central canal and ventricles are filled with CSF. The CSF is produced in the
ventricles, circulates through them and then into the subarachnoid space
surrounding the spinal cord and brain. The CSF is absorbed through connections
between the subarachnoid space and the dural venous sinuses maintaining a
balance between production and absorption.

Ventricles

There four ventricles in the brain , two lateral ventricles (they can be thought of as
one and two but are not spoken of as such) and two midline ventricles are called the
3rd and 4th ventricles.

• Lateral Ventricles - each lateral ventricle is a large C-shaped space occupying

parts of the frontal, temporal and occipital lobes. Each lateral ventricle empties
into the 3rd ventricle through an interventricular foramen (of Monro).

• Third Ventricle - the 3rd ventricle is a slit-like space between the right and
left thalami. The 3rd ventricle communicates with the 4th ventricle through the
cerebral aqueduct, a narrow tube passing rostrally to caudally through the
midbrain.

• Fourth Ventricle - the 4th ventricle is a rhomboid shaped cavity in the pons
and medulla. The floor of the cavity is formed anteriorly by the pons and the
medulla and the roof is formed posteriorly by thin membranes covered by the
cerebellum. The 4th ventricle communicates anteriorly with the cerebral
aqueduct and posteriorly with the central canal of the medulla which is
continuous with the central canal of the spinal cord. The 4th ventricle also has
three additional openings, a median aperture (foramen of Magendie) and two
lateral apertures (foramina of Luschka) through which the 4th ventricle
communicates with the subarachnoid space.

Cerebrospinal Fluid

The cerebrospinal fluid has two clear functions, one is to cushion the brain against
contact with the skull during normal movements and during more violent situations such
as blunt force and the second is to compensate for blood volume changes in the cranial
cavity. The brain is denser than the CSF and does not float in the CFS. Many areas on
the base of the brain are in contact with the base of the skull when we stand erect but
the CSF helps keep cranial nerve and vessels from being compressed. Other functions
such as nourishment for surrounding tissues are not as clear.

• Formation of CSF - the CSF is secreted by modified pial cells in the ventricles
called the choroid plexuses. The secretion of CSF involves active transport
mechanisms. The osmotic pressure and sodium content of CSF is similar to

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 plasma but chloride concentration is somewhat higher while the concentrations
of potassium and glucose are much less.

• Circulation pattern of CSF - The CSF flows from the lateral ventricles into the
3rd ventricle through the interventricular foramina then from the 3rd ventricle to the
4th ventricle through the cerebral aqueduct - The CFS then exits from the 4th
ventricle through the median and lateral foramina into the subarachnoid space and
cisterns of the brain and spinal cord - the majority of the CSF is finally absorbed by
the venous system by passing through arachnoid villi and granulations into the dural
venous sinuses, primarily the superior sagittal sinus. The following diagram will help
illustrate the pattern and pinpoint area where blockage can lead to a clinical
situation called hydrocephalus.

interventricular
foramina
lateral
ventricle subarachnoid dural
3rd ventricle space & venous
4th ventricle
lateral cisterns sinuse
ventricle s
cerebral
aqueduct arachnoid
median and
lateral villi
foramina
Subarachnoid Cisterns
At certain locations the subarachnoid space is enlarged producing subarachnoid
cisterns (L. cisterna, reservoir). These are the cranial equivalents of the lumbar cistern.
Three of the larger are the:

• Dorsal Cerebellomedullary Cistern (Cisterna Magna) - the largest

subarachnoid cistern. This is the cistern into which the 4th ventricle empties via the
median and lateral apertures.

• Superior (Quadrigeminal - Dorsal to the superior and inferior colliculi.

• Interpeduncular Cistern - between the cerebral peduncles of the midbrain. It

contains parts of the arterial circle of Willis and the oculomotor nerve .

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 Clinical Note: An overproduction of CSF, a blockage in its circulation or a problem
with absorption can lead to a situation called hydrocephalus in which there is a
buildup of CSF in the ventricle dilating them and enlarging the brain. hydrocephalus
is described as either being obstructive hydrocephalus or communicating
hydrocephalus.

Obstructive hydrocephalus - blockage is usually in the cerebral aqueduct or the

interventricular foramina. A narrowing of the cerebral aqueduct in particular can be
caused by tumors or by clogging by cellular debris associated with infections.

Communicating hydrocephalus - in this form there is no problem with the flow from
ventricles to subarachnoid space. The blockage occurs at the point of passage
through the arachnoid villi and into the venous system. The blockage can be a
congenital lack of arachnoid villi or blockage of villi due to RBC's in the CSF as a
result of a subarachnoid hemorrhage.

Dilation of the ventricles will occur upstream from the point of blockage. As the
ventricles enlarge the brain is compressed between the CSF and the skull. In
infants where the bones of the calvaria are not yet united by the sutures the bones
will spread apart enlarging the entire head. Surgical implantations of shunts can
relieve the pressure and limit damage.

Clinical Note: In adults the lumbar puncture is the preferred way of obtaining a
sample of CSF. In infants and young children the preferred site is the
cerebellomedullary cistern which can be reached by inserting a needle through the
posterior atlantooccipital membrane (the membrane attaching the atlas to the
posterior rim of the foramen magnum). This method can also be used to deliver
drugs or contrast media and can be used to measure CSF pressure.

Leakage of CSF from the nose (rhinorrhea) or ears (otorrhea) can indicate fractures
of the skull base that have resulted in tearing of the meninges; the petrous portion
the temporal bone in the case of otorrhea and the cribriform plate of the ethmoid
bone in the case of rhinorrhea. Such situations are doubly dangerous as bacteria
and other contaminants may be able to gain access to the subarachnoid space
through the tears.

BLOOD SUPPLY OF THE BRAIN

The blood supply of the brain is derived solely from the internal carotid and
vertebral arteries. The branches of internal carotid artery supply the parietal, frontal
and temporal lobes while those of the vertebral artery supply the occipital and temporal
lobes of the brain.

Internal Carotid Artery

The internal carotid artery arises in the neck when the common carotid artery divides
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into its two terminal branches, the external carotid artery and the internal carotid artery.
The internal carotid artery ascends to the base of the skull and traverses the carotid
canal to enter the cranial cavity. The internal carotid artery emerges from the carotid
canal lateral to the body of the sphenoid making a groove in the latter. It then
passes anteriorly through the cavernous sinus giving off branches to the pituitary
gland and meninges and exits from the sinus by tuning superiorly and piercing the roof
of the sinus between the anterior and middle clinoid processes, gives rise to the
ophthalmic artery and divides into its two terminal branches, the anterior and
middle cerebral arteries.

Vertebral Artery

The vertebral artery arises as the first branch of the first part of the subclavian artery in the
root of the neck. It ascends in the neck passing through the transverse foramina of the all of the
cervical vertebrae with the exception of number seven. As the artery emerges from the
transverse foramen of the atlas it turns and runs medially in a groove in the lateral mass of the
atlas then ascends to enter the foramen magnum passing through the posterior atlantooccipital
membrane, dura and arachnoid in that order. The two vertebral arteries unite at the caudal,
ventral border of the pons to form the basilar artery. The basilar artery ascends in a
groove on the pons to its upper border where it divides into its two terminal branches, the
posterior cerebellar arteries. The following table summarizes the blood supply of the brain.

BLOOD SUPPLY OF THE BRAIN

Artery Origin Course Distribution
Internal Carotid A. common carotid ascends neck, within the
a. in the neck at traverses carotid cavernous sinus it
superior border of canal and enters gives rise to small
thyroid cartilage the cranial cavity branches to walls of
sinus, trigeminal
ganglion,
pituitary gland and
meninges (anterior
cranial fossa) -
leaving the sinus it
gives rise to
branches supplying
the majority of the
brain
Ophthalmic A. internal carotid a. traverses the described with the
optic canal orbit
inferolaterally to
optic nerve to enter
orbit

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 BLOOD SUPPLY OF THE BRAIN (CONT.)
Artery Origin Course Distribution
Anterior Cerebral internal carotid a. courses medial and
A. (smaller anteromedially superior aspects
terminal branch) superior to the optic of the frontal and
chiasm to the parietal lobes -
longitudinal fissure areas supplied
connecting to its include olfactory
opposite fellow by areas, parts of the
the small anterior limbic system and
communicating a. sensory and
-continues motor areas of the
anteriorly, lower limb -
superiorly and
posteriorly lying on anterior
the corpus communicating a.
callosum stopping supplies branches
and turning to the
upwards at the hypothalamus and
boundary of the optic chiasm
occipital lobe
(parietooccipital
sulcus)
Middle Cerebral A. courses laterally branches supply the
(larger terminal then posteriorly in areas deep within
branch) the lateral fissure the lateral fissure
and the lateral
side of the
cerebral
hemisphere except
for relatively small
areas supplied by
the anterior and
posterior cerebral
arteries - areas
supplied include
motor and
sensory areas of
head, upper limbs,
upper trunk, parts
of the limbic
system, basal
ganglia, speech
and auditory areas

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 BLOOD SUPPLY OF THE BRAIN (CONT.)
Artery Origin Course Distribution
Posterior internal carotid a. courses posteriorly branches supply the
Communicating A. crossing the medial aspect of
oculomotor nerve the thalamus and
superiorly to the walls of the 3rd
anastomose with ventricle
the posterior
cerebral artery a
branch of the
basilar artery
Anterior Choroidal courses posteriorly supplies choroid
A. along the optic tract plexus of lateral
to enter the ventricle and other
choroidal fissure small but important
areas of the interior
brain
Vertebral A. first part of transverse spinal branches to
subclavian a. foramina of spinal cord and
cervical vertebrae meninges, nutrient
1-6, through branches to
foramen magnum vertebrae and
to cranial cavity - periosteum,
joins opposite muscular
vertebral artery to branches to deep
form basilar artery neck muscles,
on anterior aspect small meningeal
of pons branches -
anastomoses with
occipital, deep
cervical arteries
Posterior Spinal vertebral a. (or the descends on the supplies dorsal
A. posterior inferior posterior aspect of gray horn, dorsal
cerebellar a.) the spinal cord near column and part
the dorsal root of the lateral
column
Anterior Spinal A. vertebral a. joins with branch supplies ventral
from opposite gray horn, anterior
vertebral artery to and lateral
form a single columns
artery that
descends in the
anterior sulcus of
the spinal cord

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 BLOOD SUPPLY OF THE BRAIN (CONT.)
Artery Origin Course Distribution
Posterior Inferior vertebral a. winds posteriorly supplies medulla
Cerebellar A. (may between the roots and cerebellum
be absent) of the hypoglossal and choroid
nerve and posterior plexus of 4th
to the vagus and ventricle
glossopharyngeal
nerves
Basilar A. fusion of right and courses from branches to the
left vertebral inferior to pons, cerebellum,
arteries superior border of midbrain, cerebral
pons in a shallow hemispheres and
sulcus on the inner ear
ventral surface
Pontine Branches basilar a. arise from both side pons
of the basilar a. and
go directly into the
adjacent pons
Anterior Inferior winds posteriorly to pons and
Cerebellar A. anastomose with cerebellum
the posterior
inferior cerebellar
artery
Superior courses laterally cerebellum, pons
Cerebellar A. caudal to the and pineal body
oculomotor nerve to
reach superior
aspect of
cerebellum
Posterior Cerebral courses parallel to inferior and medial
A. the superior surfaces of
(terminal branch) cerebellar a. and temporal and
separated from it by occipital lobes,
the oculomotor and choroid plexuses
trochlear nerves of lateral and 3rd
ventricles -
anastomoses with
the internal
carotid a. via the
posterior
communicating a.

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 BLOOD SUPPLY OF THE BRAIN (CONT.)
Artery Origin Course Distribution
Labyrinthine A,. basilar a. or from courses with inner ear
(Internal Auditory) anterior inferior facial and
cerebellar vestibulocochlear
nerves (CN VIII)
into the internal
acoustic meatus

The Arterial Circle (of Willis)

The arterial circle is an important anastomoses on the base of the brain connecting the
four arteries of the brain, the two internal carotids and the two vertebrals. The circle is
formed by the anterior communicating arteries, anterior cerebral arteries, internal
carotid arteries, posterior communicating arteries and the posterior cerebral
arteries. Individual variations are common in the circle including an absence of a
complete circle because the posterior communicating arteries are missing and
variations in the caliber of the vessels involved. Normally there is little mixing of
blood and the anastomosis probably functions primarily to ease slight variations
in flow that might occur during movements of the head. Acute deficits in flow
caused by blockages in the large vessels cannot not be adjusted quickly but the
vessels can enlarge over time to limit damage.

Venous Drainage

Venous drainage of the brain is by veins that drain into the dural venous sinuses. The
dural venous sinuses ultimately drain via the internal jugular veins. The veins of the
brain are thin walled and have no valves. The veins are sometimes categorized into
a superficial group and a deep group. Examples of the superficial group are the veins
on the surface of the cerebral hemisphere that drain into the superior sagittal sinus.
Deep veins drain into other sinuses, an example is the great cerebral vein, a single
midline vein draining into the straight sinus. The superficial veins draining into the
superior sagittal sinus are vulnerable to tearing at the point were they enter the
dural venous sinuses producing subdural hematomas.

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Clinical Note: The ultimate branches of the cerebral arteries anastomose with each
at the boundaries of their distribution areas. These anastomoses are however
generally very minute and cannot provide enough blood flow to prevent ischemia if
the artery to an area is blocked. If the ischemia lasts long enough an infarct will
result. If a reduced blood is a result of a progressive blockage over a long period of
time the anastomoses may have enlarged to the point where they may be at least
be able to limit damage.

It is important to remember that a complete blockage of a vessel is not necessary to

produce ischemia and an infarct. If the metabolic demands of a region exceeds the
supply of oxygen, ischemia will occur and an infarct will result in time. In general,
ischemia of 30 seconds duration will alter the metabolism of the tissues, one to two
minutes will result in loss of neural function, 5 minutes or longer will result in an
infarct and permanent damage. Restoration of oxygen to the area will limit damage
and restore function.

Clinical Note: In addition to blockages, brain tissues can also be compromised by

a rupture of the artery supplying the region.

Sudden blockages or hemorrhages resulting in permanent damage are called

strokes. Strokes are one of the three most common causes of death and disability
in the US and the most common neurological disorder. A sudden onset of
neurological symptoms is the chief symptom of a stroke.

Transient ischemic attacks (TIA's) - most last 15-20 minutes and all resolve with no
permanent damage within 24 hours.

Ischemic stroke - the most common stroke. Usually involves a thrombosis or

embolism of a major cerebral artery.

Hemorrhagic stroke - less common than ischemic stroke but more deadly. Involves
bleeding into the subarachnoid space from a ruptured artery or aneurysm.

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