ANATOMY AND PHYSIOLOGY OF THE HUMAN BRAIN Skull Anatomy The skull is a rounded layer of bone designed to protect

the brain from penetrating injuries. Interior Skull Surface The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal lobe of the brain during rapid acceleration. Blood Vessels of the Skull The brain requires a rich blood supply, and the space between the skull and cerebrum contains many blood vessels. These blood vessels can be ruptured during trauma, resulting in bleeding. Arteries of the Brain The human brain requires a constant supply of oxygen. A lack of oxygen of just a few minutes results in irreversible damage to the brain. The Neuron Dendrites: Collects information from other neurons. Cell Body Axon: Transmits information to other neurons. The Meninges The meninges are layers of tissue that separate the skull and the brain. This layer are the dura mater, Arachnoid mater and Pia mater. External Brain Structures The Cerebrum o The largest portion of the brain is the cerebrum. It consists of two hemispheres that are connected together at the corpus callosum. o The cerebrum is often divided into five lobes that are responsible for different brain functions.

o The cerebrums surfacethe neocortexis convoluted into hundreds of folds. o The neocortex is where all the higher brain functions take place. o The cerebral cortex is a thin layer of cells about 1.5 to 4 mm thick. o The cortex provides the connections and pathways for the highest cognitive functions, such as language and abstract thinking. o The cerebral cortex contains about 25 billion neurons, more than 62,000 miles of axons, and 300,000,000,000,000 synapses. Lobes of the Cerebrum Frontal Lobe The frontal lobe is the area of the brain responsible for higher cognitive functions. These include: Problem solving, Spontaneity, Memory, Language, Motivation Judgment, Impulse control, Social and sexual behavior. Temporal Lobe The temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior. The temporal lobe also contains the language area of the brain. Parietal Lobe

The parietal lobe plays a role in our sensations of touch, smell, and taste. It also processes sensory and spatial awareness, and is a key component in eye-hand co-ordination and arm movement. The parietal lobe also contains a specialized area called Wernickes area that is responsible for matching written words with the sound of spoken speech. Occipital Lobe The occipital lobe is at the rear of the brain and controls vision and recognition. Limbic Lobe The limbic lobe is located deep in the brain, and makes up the limbic system. The limbic system is the area of the brain that regulates emotion and memory. It directly connects the lower and higher brain functions.

Cerebellum The cerebellum is connected to the brainstem, and is the center for body movement and balance.

Thalamus Thalamus means inner room in Greek, as it sits deep in the brain at the top of the brainstem. The thalamus is called the gateway to the cerebral cortex, as nearly all sensory inputs pass through it to the higher levels of the brain.

Hypothalamus The hypothalamus sits under the thalamus at the top of the brainstem. Although the hypothalamus is small, it controls many critical bodily functions:

Controls autonomic nervous system Center for emotional response and behavior Regulates body temperature Regulates food intake Regulates water balance and thirst Controls sleep-wake cycles Controls endocrine system The Medulla Oblongata The medulla oblongata merges seamlessly with the spinal cord and creates the base of the brainstem. The medulla is primarily a control center for vital involuntary reflexes such as swallowing, vomiting, sneezing, coughing, and regulation of cardiovascular and respiratory activity. The medulla is also the origin of many cranial nerves.

The Pons The pons is the rounded brainstem region between the midbrain and the medulla oblongata. In fact, pons means bridge in Latin. The main function of the pons is to connect the cerebellum to the rest of the brain and to modify the respiratory output of the medulla. The pons is the origin of several cranial nerves.

The Ventricles The ventricles are a complex series of spaces and tunnels through the center of the brain. The ventricles secrete cerebrospinal fluid, which suspends the brain in the skull. The ventricles also provide a route for chemical messengers that are widely distributed through the central nervous system. Cerebrospinal Fluid Cerebrospinal fluid is a colorless liquid that bathes the brain and spine. It is formed within the ventricles of the brain, and it circulates throughout the central nervous

system. Cerebrospinal fluid fills the ventricles and meninges, allowing the brain to float within the skull. The Brainstem The brainstem is the most primitive part of the brain and controls the basic functions of life: breathing, heart rate, swallowing, reflexes to sight or sound, sweating, blood pressure, sleep, and balance. The brainstem can be divided into three major sections.

Brain Functions

Vision- The visual cortex resides in the occipital lobe of the brain.

Sensory impulses travel from the eyes via the optic nerve to the visual cortex. Damage to the visual cortex can result in blindness. Taste-The gustatory complex is the part of the sensory cortex that is responsible for taste.

Cognition-The prefrontal cortex is involved with intellect, complex learning, and personality. Injuries to the front lobe can cause mental and personality changes.

Emotion-Emotions are an extremely complex brain function. The emotional core of the brain is the limbic system. This is where senses and awareness are first processed in the brain. Mood and personality are mediated through the prefrontal cortex. This part of the brain is the center of higher cognitive and emotional functions.

Speech- Brocas area is where we formulate speech and the area of the brain that sends motor instructions to the motor cortex.Injury to Brocas area can cause difficulty in speaking. The individual may know what words he or she wishes to speak, but will be unable to do so.

Language- Wernickes area is a specialized portion of the parietal lobe that recognizes and understands written and spoken language. Wernickes area surrounds the auditory association area. Damage to this part of the brain can result in someone hearing speech, but not understanding it.

Hearing- There are two auditory areas of the brain: The primary auditory area (brown circle) is what detects sounds that are transmitted from the ear. It is located in the sensory cortex. The auditory association area (purple circle) is the part of the brain that is used to recognize the sounds as speech, music, or noise.

Motor Cortex- The motor portion of the cerebrum is illustrated here. The light red area is the premotor cortex, which is responsible for repetitive motions of learned motor skills. The dark red area is the primary motor area, and is responsible for control of skeletal muscles.Different areas of the brain are associated with different parts of the body. Injury to the motor cortex can result in motor disturbance in the associated body part.

Sensory Cortex- The sensory portion of the cerebrum is illustrated here. Different areas of the brain are associated with different parts of the body, as can be seen below. Injury to the sensory cortex can result in sensory disturbance in the associated body part.

ANATOMY AND PHYSIOLOGY OF THE HEART

The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a whole.

Structure and Function of the Heart Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart

The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium. Valves

Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic valve is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. Cardiovascular System The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are:

Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself

Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs

The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues.

Anatomy of the cerebral circulation The brain receives its blood supply from the heart by way of the aortic arch that gives rise to the brachiocephalic (innominate) artery, left common carotid artery (CCA) and the left subclavian artery (Sheldon 1981). A. Carotid Arterial System 1. Common Carotid artery (CCA):

The left CCA arises from the aortic arch while the right arises from the bifurcation of the innominate artery. 2. External carotid artery (ECA): It starts at the CCA bifurcation. Its branches supply the jaw, face, neck and meninges. The bulk of the meningeal circulation is supplied by the middle meningeal artery, the most important branch of the maxillary artery which is one of the two terminal branches of the ECA (the other terminal branch is the superficial temporal artery). These two terminal branches in addition to the occipital artery can serve as collateral channels for blood supply to the brain in instances of obstruction of the ICA. The ascending pharyngeal artery can serve as a source of blood in instances of occlusion of the ICA (Lasjaunias and Moret 1976). 3. Internal carotid artery (ICA) It starts at the carotid sinus at bifurcation of CCA at the level of the upper border of the thyroid cartilage at the level of the fourth cervical vertebra. It ascends just behind and lateral to the hypopharynx where it can be palpated (Hollinshead 1982). It passes up the neck without any branches to the base of the skull where it enters the carotid canal of the petrous bone. It then runs through the cavernous sinus in an S-shaped curve (the carotid siphon), then it pierces the dura (beginning its subarachnoid course) and exits just medial to the anterior clinoid process and then ascends to bifurcate into anterior cerebral artery and the larger middle cerebral artery. B. Vertebrobasilar System 1. Vertebral artery It arises from the proximal subclavian artery and ascends through the transverse foramina of the first cervical vertebra. It then passes posteriorly around the articular process of the atlas to enter the skull through the foramen magnum. The two vertebral arteries join each other at the level of the pontomedullary junction to form the basilar

artery. The vertebral artery gives rise to anterior and posterior spinal arteries, the posterior inferior cerebellar artery and branches to the medulla (Francke et al., 1981). 2. Basilar artery It is formed by the two vertebral arteries joining each other in the midline. It ascends along the ventral aspect of the pons. It ends at the ponto-midbrain junction where it divides into two posterior cerebral arteries. It gives rise to anterior inferior cerebellar artery, superior cerebellar artery and numerous paramedian, short and long circumferential penetrators. The internal auditory (labyrinthine) artery arises from the basilar artery in about 20 % of the population whereas in the remainder it arises from the anterior inferior cerebellar artery. 3. Posterior cerebral artery (PCA): The basilar artery ends by dividing into the two posterior cerebral arteries. They encircle the midbrain close to the occulomotor nerve at the level of tentorium cerebelli and supply the inferior part of the temporal lobe and the occipital lobe (Marinkovic et al., 1987). Soon after their origin, they anastomose with the posterior communicating arteries to complete the circle of Willis. Many small perforating arteries arise from PCA to supply the midbrain, the thalamus, hypothalamus and geniculate bodies. In fifteen per cent of the population, the PCA is a direct continuation of the PoCA, its main blood supply then comes from the ICA rather than from the vertebrobasilar system. C. Collateral blood supply of the brain Fields et al. described this in 1985. The actual pattern of collateral blood flow depends on where the major vessels are stenosed or occluded and on which collateral channels are available and free from disease. On the whole, the development of collateral channels is more effective if the major vessel occlusion occurs over weeks or months rather than suddenly. Collateral blood flow may develop via:

A. Extracranial connections:

In the orbit, branches of ECA anastomose with branches of ophthalmic artery. Branches of ECA anastomose with branches of vertebral artery. Branches of vertebral artery anastomose with branches of subclavian artery. Branches of ECA anastomose with branches of subclavian artery.

B. Intracranial connections:

Circle of Willis

It is a network of blood vessels present at the base of the brain. This polygon of blood vessels is formed by the proximal parts of the two anterior cerebral arteries connected by the ACoA and the proximal parts of the two posterior cerebral arteries connected to the distal internal carotid arteries by the posterior communicating arteries. However fifty per cent of circles have hypoplastic or absent segments and the potential for collateral flow is not always as good as it might first appear.

Leptomeningeal anastomoses:

It lies on the surface of the brain. They develop between the cortical branches of the anterior, middle and posterior cerebral arteries.

Dural anastomoses

It occurs between meningeal branches of the ICA, ECA and the vertebral arteries.

Anterior choroidal artery

It is a branch of ICA can anastomose with the posterior choroidal artery

posterior choroidal artery

D. Venous drainage Venous blood flows peripherally via superficial cerebral veins and centrally via the deep cerebral veins into the venous sinuses (which lie between the outer endosteal and the inner meningeal layer of the dura) which drain into the internal jugular vein. The cerebral veins are thin walled and have no valves. There are numerous venous connections between cerebral veins and dural sinuses and venous systems of the meninges, skull, scalp and nasal sinuses so facilitating propagation of thrombus or spread of infection between these vessels (Sheldon 1981). Physiology of the cerebral circulation A. Blood Brain Barrier This barrier insulates the brain and its extracellular fluid, including the cerebrospinal fluid (CSF), from many of the bodys blood borne chemical perturbations, such as circulating drugs, immunogenic antigens and electrolyte changes. The anatomic barrier lies in the intracranial endothelium, where tight intracellular junctions weld the entire inner vascular surface into a continuous membranous sheet. As a result, only nonpolar materials that have a small molecular size are lipid soluble or are transported across the membrane by specific carrier systems or pumps transgress the endothelium with any rapidity (Bronner et al., 1995). Transient breaches of the barrier occur under a variety of circumstances but have little ill effect on brain function. Sustained, partial barrier alterations occur in areas of cerebral neoplasms, inflammation or edema associated with such conditions. Severe damage to barrier transport mechanisms can intensify brain infarction during ischemia (Bronner et al., 1995). B. Regulation of cerebral blood flow Cerebral blood flow (CBF) in man is about 50 ml / 100 g of brain / minute. It has been shown that CBF, cerebral blood volume (CBV) and cerebral energy metabolism measured as cerebral metabolic rate of oxygen (CMRO2) or of glucose (CMRglu) are all

coupled and higher in gray than white matter. This means that the oxygen extraction fraction (OEF) remains about the same (approximately forty per cent) throughout the brain, therefore, in normal resting human brain, CBF (i.e. flow) is a reliable reflection of CMRO2 (i.e. function) (Leenders et al., 1990). CBF depends on cerebral perfusion pressure (CPP) and cerebrovascular resistance. The perfusion pressure is the difference between systemic arterial pressure and venous pressure at exit of the subarachnoid space, the latter being approximated by the intracranial pressure. Human Heart Valves The heart has four chambers. The upper chambers are known as the atria and the lower chambers are the ventricles. The atrium and ventricle on each side are separated by a valve, as are the exit points to the lungs and the body. The heart valves are flaps of cardiac tissue held in place by connective tissue anchored in the fibrous skeleton of the heart, called chordate tendineae. One valve is bicuspid, having two flaps, the others are tricuspid, having three flaps. Atrioventricular Valves The atrioventricular (AV) valves separate the atria and ventricles. Also known simply as the tricuspid valve, the right AV valve is a tricuspid valve separating the right atrium and right ventricle. When the right ventricle contracts, blood pushes against the valve forcing the flaps shut and preventing backflow into the atrium. When the ventricle relaxes, the flaps relax and blood can flow from the right atrium into the ventricle. The mitral valve, also known simply as the bicuspid valve, is the left AV valve separating the left atrium and left ventricle. Unlike the other AV valve, it only has two flaps, but it works in the same manner. The chordate tendineae extend from papillary muscles that react to the contraction of the left ventricle to keep the valve closed as the aortic valve opens. Pulmonary Semilunar Valve

Blood is pumped from the right ventricle to the pulmonary artery on the way to the lungs. At this junction in the heart is the pulmonary semilunar valve, a tricuspid valve. The valve is forced open by the contraction of the right ventricle, and it is forced shut by the backflow of blood when the ventricle relaxes. The chordate tendineae supporting the valve extend from papillary muscles that contract with the right ventricle and prevent the valve flaps from inverting.

Aortic Semilunar Valve Blood is pumped from the left ventricle through the aorta, the muscular blood vessel initiating the artery system. At this junction in the heart is the aortic semilunar valve, which opens when the left ventricle contracts. The valve closes when the ventricle relaxes. MITRAL VALVE ANATOMY The mitral apparatus is composed of the left atrial wall, the annulus, the leaflets, the chordae tendineae, the papillary muscles, and the left ventricular wall. The valve is located obliquely behind the aortic valve. Left atrial wall The left atrial myocardium extends over the proximal portion of the posterior leaflet. Thus, left atrial enlargement can result in mitral regurgitation by affecting the posterior leaflet. The anterior leaflet is not affected, because of its attachment to the root of the aorta. Mitral annulus The mitral annulus is a fibrous ring that connects with the leaflets. It is not a continuous ring around the mitral orifice and appears to be more D-shaped, rather than circular as prosthetic valves.

The straight border of the annulus is posterior to the aortic valve. The aortic valve is located between the ventricular septum and the mitral valve. The annulus functions as a sphincter that contracts and reduces the surface area of the valve during systole to ensure complete closure of the leaflets. Thus, annular dilatation of the mitral valve causes poor leaflet apposition, which results in mitral regurgitation. Mitral valve leaflets Harken et al have described the mitral valve as a continuous veil inserted around the circumference of the mitral orifice. The free edges of the leaflets have several indentations. Two of these indentations, the anterolateral and posteromedial commissures, divide the leaflets into anterior and posterior (see the first image below). These commissures can be accurately identified by the insertions of the commissural chordae tendineae into the leaflets (see the second image below). Normally, the leaflets are thin, pliable, translucent, and soft. Each leaflet has an atrial and a ventricular surface. Anterior leaflet The anterior leaflet is located posterior to the aortic root and is also anchored to the aortic root, unlike the posterior leaflet. Accordingly, it is also known as the aortic, septal, greater, or anteromedial leaflet. The anterior leaflet is large and semicircular in shape. It has a free edge with few or no indentations. The 2 zones on the anterior leaflet are referred to as rough and clear zones, according to the chordae tendineae insertion. These 2 zones are separated by a prominent ridge on the atrial surface of the leaflet, which is the line of the leaflet closure. The prominent ridge is located approximately 1 cm from the free edge of the anterior leaflet. Distal to the ridge is a rough zone that has a crescentic shape. During systole or mitral valve closure, the rough zone of the anterior leaflet will appose to the rough zone of the posterior leaflet. The rough zone is thick and has chordae tendineae insertions on the ventricular surface. Therefore, it appears to be opaque on transillumination. Conversely,

the clear zone is defined as clear on transillumination and has no chordae tendineae insertion. It is located between the rough zone and the annulus. Posterior leaflet The posterior leaflet is also known as the ventricular, mural, smaller, or posterolateral leaflet. The posterior leaflet is the section of the mitral valve that is located posterior to the 2 commissural areas. It has a wider attachment to the annulus than the anterior leaflet. It is divided into 3 scallops by 2 indentations or clefts. The middle scallop is larger than the other 2 (the anterolateral and posteromedial commissural scallops). The 3 zones on the posterior leaflets are referred to as rough, clear, and basal zones, according to the chordae tendineae insertion. The rough zone is defined in the posterior leaflet. It is distal to the ridge of the line of the leaflet closure. It is broadest at the distal part of the scallops and tapers toward the clefts or indentations between the scallops. Like that of the anterior leaflet, the clear zone of the posterior leaflet is clear on transillumination and has no chordae tendineae insertion. It is located in the middle part of the posterior leaflet, between the rough zone and the basal zone. The basal zone is located between the clear zone and the mitral valve annulus and has the insertion of basal chordae tendineae. This zone is only seen in the posterior leaflet and is best visualized on the middle scallop (because most of the basal chordae insert into this scallop). Chordae tendineae The chordae tendineae are small fibrous strings that originate either from the apical portion of the papillary muscles or directly from the ventricular wall and insert into the valve leaflets or the muscle. These 2 types are called true chordae tendineae and false chordae tendineae, respectively. This article will discuss only true chordae tendineae. Commissural chordae

Commissural chordae are the chordae that insert into the interleaflet or commissural areas located at the junction of the anterior and posterior leaflets. Two types of commissural chordae exist. Posteromedial commissural chordae insert into the posteromedial commissural area; anterolateral commissural chordae insert into the anterolateral commissural area. Most of the main stems of the commissural chordae point toward the center of the commissural areas. Leaflet chordae The leaflet chordae are the chordae that insert into the anterior or posterior leaflets. Two types of chordae tendineae are connected to the anterior leaflet. The first is rough zone chordae, which insert into the distal portion of the anterior leaflet known as the rough zone. The second is strut chordae, which are the chordae that branch before inserting into the anterior leaflet. The posterior leaflet has 3 types of chordae tendineae. The first is rough zone chordae, which are the same as the rough zone chordae of the anterior leaflet. The second is basal chordae, a type unique to the posterior leaflet; these insert into the basal zone of the posterior leaflet, which is located between the clear zone and the mitral valve annulus. Unlike the anterior leaflet, the posterior leaflet does not have strut chordae. The third type of chordae on the posterior leaflet is cleft chordae; these insert into the clefts or indentations of the posterior leaflet, which divide the posterior leaflet into 3 scallops. Papillary muscles and left ventricular wall These 2 structures represent the muscular components of the mitral apparatus. The papillary muscles normally arise from the apex and middle third of the left ventricular wall. The anterolateral papillary muscle is normally larger than the posteromedial papillary muscle and is supplied by the left anterior descending artery or the left circumflex artery. The posteromedial papillary muscle is supplied by the right coronary artery. Extreme fusion of papillary muscle can result into mitral stenosis. On

the other hand, rupture of a papillary muscle, usually the complication of acute myocardial infarction, will result in acute mitral regurgitation. Conduction System of the Heart

The heart is a muscle with a special electrical conduction system. The system is made of two nodes (special conduction cells) and a series of conduction fibers or bundles (pathways). The normal heart begins with an electrical impulse from the SA (sinoatrial) node, located high in the right atrium. The SA node is the pacemaker of the normal heart, responsible for setting the rate and rhythm. The impulse spreads through the walls of the atria, causing them to contract. Next, the impulse moves through the AV (atrioventricular) node, a relay station, into the conduction bundles which are located in the ventricles themselves. As the impulse travels down the bundles, the ventricles contract. The cycle then repeats itself.