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Cranial nerves III and IV Transcript Powerpoint: Jeong Neuroanatomy Lecture 1-13-14b.

pptx starting at slide 15 Question [on podcast]: Which of the following is TRUE for a patient whose left CN III is severed? A. Exhibit ptosis in the left eye B. When the left eye is illuminated, neither eye shows pupil constriction C. When the right eye is illuminated, the right eye shows pupil constriction but the left eye does not D. A and B E. A and C Script: Only the left CN III is severed so the right eye should show reflex normally. When right eye is illuminated, the right eye shows pupil constriction but the left eye does not. True or false? True. Because the right eye is illuminated so the stimulation is received and goes to both eyes, and the right eye can um, the pupils can constrict because CNIII is normal on the right side. The left eye can not. The answer is E, A and C Slide 15: Trochlear (IV) So now lets look at CN IV, trochlear nerve. This is a very small nerve right here attached to the midbrain. Has only one functional modality, general somatic efferent (GSE). So this is also a motor function. Slide 16: Trochlear (IV) contd Trochlear nerve originates from the trochlear nucleus, in the midbrain. So in the brain stem, heres the trochlear nucleus here. And there are a couple of unique things about CN IV. One of them is that CN IV exits brain stem dorsally. The only cranial nerve to do so. So this is the lateral view of the brainstem showing the different nerves exiting the brainstem (image on left). And you can see the trochlear nerve, this one, goes dorsally. But eventually it will eventually turn around and it will exit the brainstem you can see it coming out from the ventral side. Slide 17: Trochlear (IV) contd Another thing unique about the trochlear nerve is it is the only cranial nerve to originate entirely from a contralateral nucleus. For the optic nerve I told you it was a mixture depending on what muscle it innervates. Some nerves come from the ipsilateral nucleus, some nerves come from the contralateral nucleus. For trochlear nerve it comes entirely from the contralateral nucleus. So if you look at this side, this would be the ventral view of the brain stem. And these two you can see here are trochlear nuclei. Right and left here. And as soon as the nerve fibers come out of the nucleus, they cross midline and go to the opposite side. As soon as they come out of the nucleus, the axon fibers come out of the nucleus, they cross the midline and go to the opposite side. So right CN IV originates from the left trochlear nucleus. Left CN IV originates from right trochlear nucleus. So in this case if you have damage to the trochlear nucleus, versus damage to the trochlear nerve on one side, the answer will be different.

Lets say you have damage to the right side trochlear nucleus, it will effect the left eye. If you say you have damage to the right CN IV, that means you are cutting the fiber somewhere here. This is CN IV, the fiber tract. So if you say you have damage to the right CN IV, it will effect the ipsilateral eye. Does this make sense? Ok. Slide 18: Trochlear (IV) contd So trochlear nerve innervates only one muscle, superior oblique. And it moves eye downward and laterally. So this is just in case you are curious, location of the superior oblique muscle somewhere at the eye socket and attaches to the eyeball. So this is involved in moving the eye downward and laterally. So damage to CN IV results in diplopia (couldnt understand) when looking down and laterally. So when you are going down the stairs, you have to look down, and then you may have to look at it laterally, depending on the situation. And thats when you will have problems on the effected eye. So you will have diplopia. Ok? Slide 19: Abducens (VI) So now this is the last one of the three cranial nerves that innervates eye muscle. Abducens nerve. So CN VI is here, attached to pontomedullary junction at the brain stem. Carries again general somatic efferent, only one functional modality, motor function. Slide 20: Abducens (VI) contd Originates from abducens nucleus, which is now in the pons here. CN VI fibers originate from an ipsilateral nucleus, and innervates ipsilateral eye muscles. So this is the, for this one it is all ipsilateral, ipsilateral so it is very simple. I will get into the details of the consequences of having damage to the abducens nucleus and the abducens nerve in a little bit. Slide 21: Abducens (VI) contd It innervates the lateral rectus muscle, which moves the eye more laterally. Which is called abduction. Moving the eye medially is called adduction. Damage to CN VI results in medial strabismus. Again this is the opposite of what I explained about CN III. Now strabismus means the two eyes are not aligned. And in this case the lateral rectus is paralyzed, then the medial rectus is normal, it will be pulling, so its unbalanced, the effected eye will be deviated medially, so now its called medial strabismus. Ok? And this is the position of the lateral rectus. Ok. Slide 22: Eye Muscle Coordination Now this is right, where it gets a little complicated. So if you have damage to the abducens nerve, CN VI, I just explained, it will cause medial strabismus. If you have a damaged abducens nucleus, you will have medial strabismus, plus you will have an additional symptom called lateral gaze paralysis. So now to explain this, I have to explain how our eyes get coordinated when we look laterally. Whats explained here does not apply when you are looking straight ahead. Its only for when you are trying to look laterally. Either, um, right side or left side. Ok? So, whenever we try to look to one side, lets say one eye moved to this direction, automatically the other eye moved to the same direction also. Right? One eye moved this direction the other eye will also move to the same direction. And

this is because of the nerve pathway described here. Theres a cross talk between the Abducens nucleus and oculomotor nucleus. So the abducens nucleus contains not only lateral rectus motor neurons, but also internuclear neurons. So here, the dark green spot is the abducens nucleus and the purple nerve is CN VI Abducens nerve. And you see bright green nucleus here, this is the internuclear neurons which is also in the abducens nucleus. And they send out the axon that crosses the midline immediately and then ascend to the oculomotor nucleus through the contralateral medial longitudinal fasciculus. So these fiber tracts are called MLF or medial longitudinal fasciculus. And they originate from the abducens nucleus of the contralateral side. Because the nerves decussate immediately after exiting the neuronal cell bodies ok. So kind of like the trochlear nerve and trochlear nuclei. As soon as the nerves exit the cell bodies they decussate immediately. So the MLF of the right side comes from the left abducens nucleus. And the MLF of the left side comes from the right abducens nucleus. And then this MLF sends the information to the oculomotor nucleus which will activate the medial rectus muscle which will move the eyeball. Slide 23: Eye Muscle Coordination So you will understand better after you see the examples of the consequences of the lesions. So we have four different kinds of lesions here in this picture. Cutting the abducens nerve, CN VI, so again this means its cutting the fiber. Abducens nucleus means close to the cell body, destroying this one. Left MLF, again this would mean cutting the fiber, the nerve fiber. And combination of B and C means you destroyed the abducens nucleus and cut the fiber of MLF. So lets go one by one. Slide 24: Eye Muscle Coordination You have damage of abducens nerve. And so this is the answers for looking straight ahead, and try to look to the left, and look to the right. So lets start with the looking straight ahead. When you look straight ahead, this does not involve the function of the MLF or internuclear neurons or something like that. So this is simple. You get medial strabismus of the ipsilateral eye because the eyeball is deviated slightly medially because of the paralysis of the lateral rectus muscle of ipsilateral eye. So now lets see this. Try to look to the left side. For the left eye, if you are going to look to the left, left eye should move laterally, and you cannot do it because lateral rectus is paralyzed and eyeball is still sort of deviated medially. However the damage is only in the nerve fiber of the motor neurons for the lateral rectus. So here, internuclear neurons are intact. It can still send out the fiber through the MLF on the contralateral side and signal to the right oculomotor nucleus, which will cause contraction of the medial rectus of the right eye. So right eye will move to the left side, which is what should happen normally. So right eye will move to the left side, left eye is still deviated towards the right side. Thats what it means by strabismus made worse. So normally it was like this, now its like this. [Student question, cant hear]. So thats why strabismus causes double vision. Diplopia. So I would say in this case strabismus is even worse so you will have even more severe double vision. Ok. When you try to look to the right side, right side. So lets look at the right eye. You have to contract your lateral rectus muscle of the right eye which is not affected. So you will move to the right side. What about the left eye? So right eye Abducens nucleus, the information will travel to the, through the MLF to the left oculomotor nucleus and travels through the

CN III to the medial rectus of the left eye and none of these pathways are effected. So left eye will move to the right side also. So you should be able to gaze normally. Ok? Slide 25: Eye Muscle Coordination What about the consequences of having damage to the left abducens nucleus? Now left abducens nucleus, this would effect both the CN VI, the mnerve fibers going to the lat rec m, and also it will eliminate the internuclear neurons also bc the cell bodies are in the abducens nucleus. So it will effect both this purple neuron and the light green neuron coming out of the left abducens nucleus. So lets look at this again from looking straight ahead. You dont need to worry about MLF so you will just have medial strabismus because the lateral rectus is paralyzed. Try to look to the left side, so your left eye needs to move laterally which cannot happen because you dont have the function of CN VI, so again, left eye will remain deviated medially. What about the right eye? It cannot receive the signal from the left side because now the internuclear neurons are damaged. So theres no communication going to the right eye. The right eye will not move either. Neither eye will move in this case. Ok. What about looking at the right side. Looking at the right side, right eye needs to move laterally (or temporally). Thats the function of the right CN VI which is intact here. So that should happen normally. What about the left eye? So from the right abducens nucleus, the internuclear neurons, located in the right abducens nucleus, will send out the fiber and send the information to the left oculomotor nucleus. Again this pathway is not damaged. Not affected at all. So the information will go to CN III and contract the medial rectus. So the left eye will move normally also. So both eyes should be able to look to the right side. Slide 26: Eye Muscle Coordination Damage to the left MLF. Lets start with looking straight ahead. MLF is not involved when you are looking straight ahead, so theres no effect when you look straight ahead. When you try to look to the left side, so left side you need the function of the lateral rectus muscle, left CN VI. The left CN VI in this case is not affected. You are cutting MLF here, so left eye should be able to look to the left normally. What about the right eye? So when you try to look to the left, Left abducens nucleus has the internuclear neurons. They will send fibers through the right MLF and go to the oculomotor nucleus and to the medial rectus of the right eye. And this is not affected, so right eye should be able to move also, to the left side normally. If you try to look to the right side, lets start with the right eye. Looking to the right side, right eye needs the function of CN VI which is not affected. Right CN VI is here, so right eye can move to the right normally. What about the left eye? So normally, when you try to look to the right side, the right abducens nucleus, which has the internuclear neurons, will send the signal through the left MLF to the left oculomotor nucleus and to the medial rectus of the left eye. But now the left MLF is cut so you cannot send the information to the left eye. So left eye will not move. Slide 27: Eye Muscle Coordination Last one. Combination of B and C. If you damage left abducens nucleus and left MLF. Ok looking straight ahead, again this doesnt involve MLF. So the consequence would be medial strabismus just like in the previous examples because you dont have the function of left CN VI. Try to look to the left side. For the left eye you need to look laterally, which cannot

happen because you dont have the function of the left CN VI. So left eye cannot move laterally. What about the right eye? The R eye needs to receive the signal from the internuclear neuron within the left abducens nucleus. But it cannot because if you damage the left abducens nucl it will eliminate the internuclear neurons also. So right eye does not receive the information it needs to move to the left side. So right eye will not move either. Try to move to the right side. For the right eye you need the function of the right CN VI to contract the lateral rectus. Which is unaffected so the right eye will move laterally normally. What about the left side. The signal has to come from the right abducens nucleus to the left oculomotor nucleus via left MLF to cause the coordination of left eye. But left MLF is damaged so this coordination does not happen and left eye does not move. OK? I know its complicated but if you take time looking at this, you know take time staring at the slides and thinking about it step by step it should more make sense based on the function of the MLF and abducens nucleus and so on. Question [on podcast] Which of the following occurs when the right abducens nucleus is damaged? A lateral strabismus of the right eye when trying to look straight ahead B when trying to gaze to the right side, neither eye can move to this direction C when trying to gaze to the left side both eyes can move to this direction normally D A and B E B and C Answer is E, both B and C are true Which of the following occurs when the right abducens nucleus is damaged? A. lateral strabismus of the right eye when trying to look straight ahead, true or false? True or false? False. Why? It has to be medial strabismus because the abducens nerve innervates the lateral rectus which is paralyzed. And then medial rectus which is normal will pull the eye medially. It has to be medial strabismus. B. When trying to gaze to the right side, neither eye can move to this direction, true or false? Would the right eye move to the right side or no? No. To move the right eye to the right side you need CN VI function, lateral rectus. So right eye cannot move. What about the left eye, will it move or no. No, Why? Internuclear neruons. So no. This B is correct. The right abducens nucleus contains the internuclear neurons that would have to communicate to the other eye, the left eye. C. When trying to gaze to the left side both eyes can move to this direction normally, true or false? So can the left eye move to the left side or no? Yes. Can the right eye move the the left side or no? Yes. So this is true. Answer is E, B and C are true. So this is what I was supposed to finish last week, now lets go to the trigeminal. Powerpoint: Jeong Neuroanatomy Lecture 1-16-14.pptx Slide 1: Trigeminal (V) So this is what I was supposed to finish last week, now lets go to the trigeminal. So probably I think in dentistry the trigeminal nerve is the most important cranial nerve so I have material for one hour of the trigeminal nerve alone. So, lets get started. Theres a lot of stuff here. A lot of interesting stuff related to the trigeminal nerve that is actually

relevant to what you guys do. Or I should say the part around the mouth and oral cavity and things like that. So trigeminal nerve, which is attached to the pons here, carries two functional modalities. General somatic afferent, sensory function, special visceral efferent, motor function. Slide 2: Trigeminal (V) contd So lets start with the sensory function, general somatic afferent. This is the major sensory nerve for the head. Somatosensation like touch, proprioception, pain and temperature. All this somatosensory information of the face, scalp, cornea, nasal and oral cavities, dura mater, muscles of mastication, temporomandibular joint, essentially entire face and the head area. The somatosensory information is transmitted through CN V. And information is distributed to multiple places in the central nervous system. Cell bodies of the primary sensory neurons are mainly in the trigeminal ganglia, although there is one exception, the sensory neurons for the proprioception, which I will talk about in a little bit. So this is the head and the trigeminal ganglia, ganglion located somewhere here, sends out all these fibers in three different branches and they collect the somatosensory information from all over the face and head area. These three branches or three subdivisions of CN V are called opthalmic, V1, maxillary, V2, and mandibular, V3, subdivisions. And the this shows the map of which part of the face and head is innervated by which branch or subdivision of CN V. Opthalmic in this blue area, you can see on top of the nose and around the eye, and forehead and top of head here. Maxillary is in the middle part of the face, upper lip and space between the nose and lip and face and so on. Mandibular branch innervates the lower part of the face and also back towards the posterior part of the face, like this area. So you need to remember this map of which part of the face and head gets innervation from which subdivision of CN V. Slide 3: Trigeminal (V) contd So once the CN V nerves collect information from the periphery, afferent axons project to three sensory nuclei. Main sensory nucleus, also called principal sensory nucleus. Same thing. And then the spinal nucleus, or sometimes called spinal trigeminal nucleus, and the third one is mesencephalic nucleus. So the mesencephalic nucleus obviously as its name says, its in the mid brain area here. Principal nucleus or main nucleus of the trigeminal nerve is at the pons. Spinal nucleus, this long yellow structure here, extends from the caudal pons all the way down to rostral spinal chord. So if you combine all three of them this is a really long and almost continuous column from the mid brain to pons to medulla and then upper cervical spinal cord. And these nuclei, individual nuclei, receive information, different information based on what type of information it is. What type of information it is. So there is a segregation of afferent fibers depending on the sensory modality. Slide 4: Trigeminal (V) contd So lets look at this one again. So we will go one nucleus after the other. So start with the middle one. Main sensory nucleus. So here this is the ventral view of the brainstem showing the trigeminal nerve entering the brainstem. So this would be the trigeminal ganglion where cell bodies are. And you see the three subdivisions of CN V coming in. So these three subdivisions are based on which part of the face you get the info from.

Opthalmic, maxilla, and mandibular, the subdivisions are divided based on the location in the face and head where they get the information from. But they are combined at the trigeminal ganglia and they enter at the pons level. But here, the nerve fibers are segregated again. But this time, not based on which part of the face its getting the information from, but based on what type of information its carrying. They are segregated again after they pass through this route at the pons level. So the nerve fibers carrying the information about fine touch project to the main sensory nucleus. So again the fibers carrying fine touch information from all three subdivisions will go to the main sensory nucleus. So they are combined and then sorted again. And then the second order neurons from the main sensory nucleus give rise to two ascending pathways to the thalamus to get information to the brain. To the cerebral cortex ultimately. Slide 5: Trigeminal (V) contd So lets look at the two ascending pathways from the main sensory nucleus carrying the fine touch information from the face and head area. There are two ascending pathways. One is called crossed projection, the other is called uncrossed projection. Uncrossed projection is also called dorsal trigeminal tract. So lets look at the crossed projection first. So heres the trigeminal ganglion with the cell bodies of the primary sensory neurons. Collects the information from the target tissue, enters the pons level, makes the synapse at the main sensory nucleus. Second order sensory neuron, which is located in the main sensory nucleus, sends out the fiber that decussates and then joins the medial lemniscus pathway to the thalamus. So if you remember, the medial lemniscus pathway, the posterior column lemniscus pathway, was a part of the ascending pathway from the spinal chord carrying the fine touch and proprioception information from the body. From the neck down. So the fine touch information from the face and head joins the medial lemniscus here and they go to the contralateral side, they decussate here and go to the thalamus and.. which nucleus? VPM. Ventral posteromedial nucleus. So this is different from the spinal pathway if you remember. Somatosensory information carried from the body through the spinal pathways they go to the VPL of the thalamus. Ventroposterolateral nucleus. However the somatosensory information from the face and head area go to the VPM of the thalamus. Ok? And then again from thalamus the third order sensory neurons project to the cerebral cortex, the primary somatosensory cortex located in the postcentral gyrus of the parietal lobe. So there is a difference in which nuclei goes based on where the, where you receive the somatosensory info from whether its the body or the face and head. Lets look at the uncrossed projection. Dorsal trigeminal tract. So this one transmits the sensory information from inside the mouth. So thats the one thing that distinguishes this one from the other ones. And in this case, again the primary sens neurons are in the trigem ganglion which is the same as this one. And they get the info from the target tissue inside the mouth and they enter at the pons level. And then they synapse here at the main sensory nucleus. And then from here the second order sensory neurons sends out axon fiber that does not cross the midline, they stay on the same side and go to the same side thalamus but still its VPM. And then from thalamus the third order sensory neurons transmit the information to the somatosensory cortex. Ok. Any questions? [couldnt hear student question] Both pathways carry the fine touch information. Uncrossed projection carries information from inside the mouth, crossed is other parts of the face and head. But both pathways are for fine touch. We havent gotten to the other types of senses yet.

Slide 6: Trigeminal (V) contd So now lets go to the other kinds of senses. So the somatosensory information of pain and temperature are relayed at the spinal trigeminal nucleus. So its here, from the caudal pons to medulla to rostral spinal chord. Its very long. If you dissect out the three sensory nuclei of the trigeminal nerve, mesencephalic, main, and spinal nucleus, you can look at it like this. This is the three sensory nuclei disected out of the rest of the brain tissue. And what lies at the caudsal half would be spinal nucleus. Within the spinal nucleus there are three divisions again. Oral nucleus, interpolar nucleus, and caudal nucleus. From rostral to caudal direction. And the different nuclei receive the information from different parts of the face. So if you look at this map here there is a different intensity of the purple shown here. Darkest middle and then lightest. The boundaries separating these different domains are called Solder lines. So if you match this one, the Solder lines map and the diagram, you can see that the rostral portion of the spinal nucleus, the oral nucleus, receives information from the center of the face around your mouth. Then if you go caudally, caudal nucleus of the spinal nucleus receives the information from the periphery of the face. So you should not confuse this map with the other map we saw (on slide 2), they are two different maps. This map is based on which subdiv of CN V carry the info from. Whether it is CN V1, V2, V3. This map is which part of the spinal nucleus receives the pain and temp information from. So the, this area, pain and temp information ends up in the oral nucleus of the spinal nucleus. And this area, the periphery of the face, pain and temperature information from the periphery of the face ends up in the caudal nucleus of the spinal nucleus. So those two maps are different. Ok? Slide 7: Trigeminal (V) contd And then from spinal nucleus the information will have to be sent to the cerebral cortex ultimately. So lets look at the ascending pathway from the spinal nucleus carrying the pain and temperature information. Again the sensory neurons, the cell bodies of the primary sensory neurons are in the trigeminal ganglion. They collect the information from the target tissues of the face and head area. Pain and temperature information. And these fibers enter the pons and then turn caudally to make whats called the spinal trigeminal tract. And then they synapse at the the fibers enter the spinal nucleus and synapse at the spinal nucleus. And the axon fibers from the second order sensory neurons cross the midline and then they join the pathway the spinothalamic tract. If you remember from the spinal pathway lecture, spinothalamic tract carries the pain and temperature information from the body coming from the spinal cord. So here, pain and temperature information from the face and head region ultimately join the spinothalamic tract and go to the thalamus. But once again VPM. Somatosensory information, whether it is fine touch or temperature or pain. If they come from the head and face they go to VPM, if they come from the body it goes to VPL of the thalamus. So here it goes to VPM. And from VPM third order sensory neurons project to the somatosensory cortex in the post central gyrus. Ok? So if you see this little zoomed in image here, it says V1, V2, V3, and some other nerve names here. I need to explain to you what these mean. Slide 8: Trigeminal (V) contd So what these mean is the info coming from the different parts of the face travels through the different parts within the spinal trigeminal tract. So lets look at the first sentence first.

Different parts of the ipsilateral half of the face have somatotopic representation in the spinal tract and spinal nucleus. So first of all its ipsilateral. If you look at this pathway (on previous slide), target tissue would be somewhere here, trigeminal ganglion, spinal trigeminal tract, spinal nucleus. All the steps up to here stay on the same side as the target tissue. Decussation only happened after the spinal nucleus. So spinal tract, spinal nucleus, they receive the information from the ipsilateral half of the face. Information from left half of face goes to the left spinal tract and to the left spinal nucleus ok? [Back to this slide]. But then within the spinal tract and within the spinal nucleus the nerve fibers are divided again. So if you remember this map from the beginning of the trigeminal nerve lecture, V1, V2, V3 carries information from different parts of the face. And they pass through the different parts within the spinotrigeminal tract and enter the different parts within the spinal nucleus. Now this becomes very confusing. What about this one and what about this one? What is the difference here? So this is the spinal nucleus here. Its a long structure, long rod-like structure so you can divide it from rostral to caudal. So this is that division. Rostral, middle, and then caudal end. So information coming from here will go to the rostral end and from here to the caudal end. But if you cut the cross section of the spinal nucleus within each level, within the cross section, you can further divide dorsal-ventral areas within each region, each subdivision. Within the oral nucleus if you cut the cross section there is a dorsal - ventral. Within the interpolar nucleus if you cut the cross section you can distinguish dorsal to ventral. Same if you cut through the caudal nucleus within the plane of the section you can divide dorsal to ventral. So along that dorsal ventral axis the fibers are divided based on which nerve they carry the information from. So within the spinal tract. So this is the cross section of the spinal tract and spinal nucleus. The light brown area means the axon fibers spinal tract, which are nerve fibers. Dark brown area means the cell bodies of the spinal nucleus. Ok? So information carried, that was collected through V3 travelled through the dorsal portion of the spinal tract and entered the spinal nucleus at the dorsal region. And info collected through V2 travels within the spinal trigeminal tract at the middle position enters the spinal nucleus at the middle position. Information thats been collected through V1 travels through the spinal trigeminal tract at the ventral position, enters the spinal nucleus at the ventral position. So now if you combine this map and this map, this is actually the combination of the two, see these dotted lines? They mean the Solder lines. So now you have 3x3 so 9 subdivisions within the face. And they are mapped at different locations within the spinal nucleus. And thats what it means by the face has somatotopic representation in the spinal tract and spinal nucleus. So different areas of the face the info ends up in different location within the spinal nucleus. Based on the solder lines it will end up here, here, or here. Based on this blue, green or red color it will be dorsal, medial, ventral part of the spinal nucleus. You are considering the two different axes. Rostral caudal and dorsal ventral. So now it becomes really complicated. So lets say you feel something here, green and in center of face, where would the info end up in the spinal trigeminal nucleus? Its in the center of the face so if you look at the solder line the information would go to the oral nucleus. And also at the same time its in the green area where the information is collected from V2, so it will end up in the middle, in terms of the dorso-ventral axis it will end up in the portion of the spinal nucleus. So the information will go to the oral nucleus, middle part. So this kind of organization has very important clinical relevance. And I will take a 5 minute break here.

Slide 9: Trigeminal (V) contd Ok everyone lets get started again. So I know its very complicated. Its about how the pain and temperature information from our face and head region is transmitted through the spinotrigeminal tract and spinotrigeminal nucleus and its very complicated but I wanted to mention it because it has clinical relevance. So lets look at the first one. Onion skin distribution. So this refers to the characteristic pattern of sensory loss from the damage to the spinal trigeminal tract. The farther caudally the lesion is, the larger area surrounding the mouth is spared from sensory loss. Here the sensory talking about is pain and temperature sensation because we are talking about the spinotrigeminal tract. What the second sentence means, so lets look at this diagram for the nerve pathway sending the pain and temp information from our face and head. Cell bodies of the primary sensory neurons are at the trigemenal ganglia. Collects information from target in face and head area. And if you remember the axons from the primary sensory neurons, they enter the brainstem and then they turn caudally. They go down a little bit varying distance, depending on whether the information is coming from here or here. You can imagine that information coming from here would have to descend less than information coming from here. Right, this would have to go even further down because the nerve fibers all enter at the pons level. So information from here needs to end up here so it would ascend less. Information from here needs to end up here so it would have to go down even more. So there is a difference. And then they synapse, decussate, goes to the thalamus and then to the cerebral cortex. So here the lesion they are talking about is damage to the spinal trigeminal tract. So spinal trigeminal tract is from here to here. Here to here is called spinal trigeminal tract. Basically up until you get to the spinal nucleus. Thats the spinal trigeminal tract. So you could cut here, you will loose the pain and temperature sensation coming from the periphery of the face. And this one, the fibers carrying information from the center of the face will not be affected. If you cut the spinal trigeminal tract up here, you will cut both fibers. Ones coming from the center of the face and ones coming from the periphery of the face. So thats why the farther caudally the lesion is the larger area surrounding the mouth is spared from the sensory loss. Slide 10: Trigeminal (V) contd And then another clinically relevant piece of information. Lesions spreading from spinal cord into the brainstem cause sensory loss starting from back of the head converging on the mouth. So again, this here the sensory means pain and temperature sensation. So I mentioned syringomyelia when I was talking about the spinal cord. Its an enlargement of the central canal of the spinal cord. And when the central canal gets enlarged it destroys the neural tissues surrounding it. In some cases it spreads from the spinal cord to the brain. So caudal medulla is continuous to the rostral spinal cord. So it will come from the spinal cord to the caudal medulla. So when the enlargement spreads into the brainstem, its called syringobulbia. Bulb means brainstem, so when it gets into the brainstem its called syringobulbia. And it will cause sensory loss starting at the back of the head converging on the mouth. So again it has to do with the organization of the nerve pathway sending pain and temperature information. So information from the back of the head is located in the caudal side of the spinal nucleus. So when the lesion spreads from the caudal end to more and more rostrally rostrally within the brainstem, this area (light pink) will be affected first, then you will have an effect on this area which receives sensory information from the

middle part, and then finally you will loose the sensation from this area which goes to the spinal nucleus right here. And uh, yeah. And the fibers , if you look at the point of the decussation, its also the ones at the back of the head they decussate more caudally, the ones at the center of the face decussate more rostrally. So thats why when the lesion spreads from inferior to superior you loose pain and temperature sensation from back to the front of the face. Slide 11: Trigeminal (V) contd Ok this is another example of the disease involving spinal nucleus called trigeminal neuralgia. I dont know how to pronounce this thing. Maybe you should ask Dr. SaintJeannet. Anyway trigeminal neuralgia means the brief attack of excruciating pain in the distribution of one or more division of CN V. And there is no significant sensory abnormalities between attacks. And often there is a trigger zone where tactile stimulation can precipitate a pain attack. And usually this is caused by compression of the CN V nerve by a blood vessel or a tumor. And so resulting in demyelination and spontaneous activity in the nerve fibers. These parts you can ask Dr. Schiff about when he talks about the neurophysiology. Usually treated pharmacologically. But if the pharmacological treatment doesnt work you can consider a surgical treatment also. So one option would be sectioning the involved nerve root. So here that means V1, V2, V3, so usually the trigeminal neuralgia will affect one or more division of the V nerve. It may effect only your forehead area of the v1 division. Or it may effect only your lower jaw and this area of the v3 division. So you can section the involved nerve root. Basically you cut entire V1 or entire V3. Or destroying or mechanically disrupting the trigeminal ganglion which has the cell bodies of the primary sensory neurons. But this has severe side effects. Because the CN V not only has pain and temperature nerves but also the nerves carrying the touch information so patient will loose all of it in the area. So a smarter alternative would be sectioning the spinal trigeminal tract in the caudal medulla. Spinal trigeminal tract is only for the nerve fibers carrying pain and temperature information. The ascending pathway that I discussed earlier for fine touch information does not go through the spinal trigeminal tract. So if you cut the spinal trigeminal tract you will not affect the fine touch sensation. You will only affect pain and temperature sensation. Slide 12: Trigeminal (V) contd A couple of more examples about the illnesses involving spinal nucleus. Syringobulbia I just said is an enlargement of the central cavity of the caudal medulla and it destroys the fibers from the spinal nucleus. So again its just like the syringomyelia when you have an enlargement of the central canal in the spinal cord, it destroys the decussating fibers going through the anterior white commissure. And if you have an enlargement of the central canal at the medulla level it will also destroy the fibers that are crossing the center, decussating here[showed diagram on slide 7]. And cause the loss of pain and temperature sensation from the face. Lets look at the herpes zoster. So this is caused by the virus for chicken pox. So if you have had chicken pox at some time in your life then you can have the virus in your body and they remain usually quiet. But sometimes they infect the nerve root. And when they do it can cause a painful skin rash in the corresponding dermatome in the face. So lets say this virus infects the V1, opthalmic nerve of the CN V, then you would have a skin rash and pain in the

upper part of the face. So thats the herpes zoster. It can effect the nerve roots in the spinal cord as well. But it can infect the roots of the CN V which will lead to symptoms in the face area. Question slide: For a patient experiencing episodes of brief pain attacks in the forehead and around the eye on one side of the face, a potential surgical treatment to remove the pain is to sever A. A ventral portion of the ipsilateral dorsal trigeminal tract B. A dorsal portion of the contralateral spinal trigeminal tract C. A ventral portion of the ipsilateral spinal trigeminal tract D. A dorsal portion of the contralateral dorsal trigeminal tract E. A dorsal portion of the ipsilateral spinal trigeminal tract Oh yes this one. Sorry its kind of complicated question and I want to say that Im sure you are thinking about the first quiz but for the second quiz Dr. Saint-jeannet uploaded the quiz questions from the last year on nyu classes s you can look at those questions. And if you look at the second quiz questions and if thats scare you dont be. Because I know that they were difficult. And so on average this years quiz two will not be as difficult as last years quiz 2. On average though. I may mix in one or two questions that are difficult. Ok this is an example of the one or two questions I may mix in. For a patient experiencing episodes of brief pain attacks in the forehead and around the eye on one side of the face. So this is talking about the trigeminal neuralgia. Brief pain attacks. A potential surgical treatment to remove the pain is to sever: So you have to make here three different choices. Ventral or dorsal portion, ipsilateral or contralateral, and dorsal trigeminal tract or spinal trigeminal tract. So lets start with the easier ones. Would you cut the dorsal trigeminal or spinal trigeminal tract? Spinal trigeminal tract. You are trying to eliminate the pain. The spinal trigeminal tract carries the pain information so you have to cut this one. Would you want to cut the ipsilateral or contralateral spinal tract? Ipsilateral. Because if you look at the pathway for pain and temp sensation. Nerve fibers come from the trigeminal ganglion spinal tract and spinal nucleus. Within the spinal tract and up until the spinal nucleus, they all stay at the same side as the target tissue. Decussation only happens afterward. So spinal tract and spinal nucleus are on the same side as the target tissue, so you need to cut the ipsilateral one. And finally, do you want to cut the ventral portion or dorsal portion of the spinal trigeminal tract? So this one is about where the pain is coming from. Forehead around the eye. This is the area innervated by V1 division of CN V, opthalmic nerve. And where does the V1 travel? Which domain does the V1 fibers travel? Well, I should say the info coming from V1 travels within the spinal trigeminal tract along the dorsal ventral axis. Travels to the ventral portion of the spinal trigeminal tract. If you cut the dorsal part you will cut info coming from V3. So you need to cut the ventral part. Because that is where the info from V1 is travelling through. Does it make sense? Any questions? Answer is C. Slide 13: Trigeminal (V) contd We have one more sensory nucleus for CN V. The last one is mesencephalic nucleus. I think this picture is misleading its supposed to be in the midbrain. Mesencephalic nucleus receives proprioceptive sensation from the muscles of mastication and also temporomandibular joint. This one receives information about the jaw position. Contains the cell bodies of the primary sensory neurons for the proprioception. This is the only example where the primary afferents have cell bodies in the CNS (central nervous system).

And so the other ones, the cell bodies for the primary sensory neurons for fine touch, pain, and temperature were all in the trigeminal ganglion. But for this one, primary sensory neurons for proprioception their cell bodies are in the mesencephalic nucleus. From the mesencephalic nucleus the neurons send projections to the motor nucleus of CN V. And this is involved in jaw jerk reflex. I think I will talk about the jaw jerk reflex at the end of the CN V lecture. Slide 14: Trigeminal (V) contd So that was the GSA component of CN V. General somatic afferent. So all we talked about was about the sensory information. All the pathways we talked about and the distribution of nerves and so on its all about the sensory information. So now we are going on to the second function of the trigeminal nerve. SVE, also called branchiomotor. The motor function. So the CN V nerves for SVE originate from the trigeminal motor nucleus at the pons level here. Slide 15: Trigeminal (V) contd And this is the ventral view of the brain stem here and this is the trigeminal motor nucleus. Efferent fibers emerge at motor root of trigeminal and joins V3 of trigeminal nerve. V1 and V2 and V3, V1 and V2 carries only the sensory fibers. V3 is the only one that carries both sensory and motor fibers. Innervates the muscles derived from the first branchial arch. So you should be able to mention which branchial arch, the muscles from which branchial arch gets innervation from which nerve. So the muscles from the first branchial arch gets innervation from the trigeminal nerve, CN V. And specifically CN V controls muscles of mastication and some others. But you need to know it innervates the muscles of mastication. Masseter, temporalis, lateral pterygoid, medial pterygoid. Probably you guys know better than me the musculature of the face. And thats it for the SVE component. Comes out through V3 and innervates the muscles of mastication. Slide 16: Trigeminal (V) contd And this slide is just a summary of the different connections involving CN V. So the one for the proprioception info its cell bodies are in the mesencephalic nucleus. And then from the mesencephalic nucleus and its hard to see in this color but its information goes to the motor nucleus which I will talk about in a little bit. Fine touch information goes through the main nucleus and ascends through the two different tracts. If its coming from the inside of the mouth, dorsal trigeminal tract, otherwise, medial lemniscus. The information of the pain and temperature, the fibers follow the spinal trigeminal tract and end up at the spinal nucleus. And then the 2nd order sensory neurons send fibers to the spinothalamic tract. And this one is motor. Slide 17: Trigeminal (V) contd Heres jaw jerk reflex. This involves CN V. Stretching the muscles that close the jaw (masseter or temporalis) by downward tap on the chin, like this, causes them to contract. So this is an example of the stretch reflex that I talked about when I was talking about the knee jerk reflex in the spinal pathways lecture. Knee jerk reflex, jaw jerk reflex, both of them are stretch reflex. The kind of reflex you get when you cause the stretching of a muscle slightly. Then in response it will contract. And its also a monosynaptic reflex. If you

remember the knee jerk reflex was also a monosynaptic reflex. Afferents innervate the muscle thats involved in closing the jaw. Red is the afferent. This is considered the, position of the jaw, where the jaw is a little bit down or closed, its considered proprioception. So this involves the mesencephalic nucleus. Not the main sensory nucleus or spinal trigeminal nucleus. But it involves mesencephalic nucleus. So information will go to the mesencephalic nucleus. Mesencephalic nucleus actually has the cell bodies of the primary sensory neurons that are collecting this info. Then mesencephalic nucleus will send out another branch of the nerve fibers to the motor nucleus. And then from the motor nucleus, it will synapse with the motor neurons. The motor neurons innervate the muscles and cause the contraction of the muscles to close the jaw. This is monosynaptic because there is only one synapse here. So at the mesencephalic nucleus this is not a synapse because it is one neuron having two branches of axons. So the only synapse here is between the axon coming from the mesencephalic nucleus and the motor neuron at the motor nucleus. Practice question [on podcast] Which of the following four statements is false about the jaw jerk reflex is any? A. The cell bodies of the primary sensory neurons are in the trigeminal ganglion. True or false? False B. It involves a neuronal projection from the mesencephalic nucleus to the trigeminal motor nucleus C. It is a monosynaptic reflex D. It is triggered by stretching of the masseter and/or temporalis muscles E. All of the above statements are true Which of the following four statements is false about the jaw jerk reflex is any? A. The cell bodies of the primary sensory neurons are in the trigeminal ganglion. True or false? False. Its in the mesencephalic nucleus. B. It involves a neuronal projection from the mesencephalic nucleus to the trigeminal motor nucleus which is true C. It is a monosynaptic reflex, true D. It is triggered by stretching of the masseter and/or temporalis muscles, which is also true. E. All of the above statements are true Answer is A That is it for the first hour of todays lecture. I have ten minutes. Im going to be borrowing some time from Dr. Saint-Jeannets lecture at the end. Powerpoint: Jeong Neuroanatomy Lecture 1-16-14b.pptx Slide 1: Facial (VII) So lets just get started with the facial nerve a little bit today. The facial nerve is a big nerve, it has four different functional modalities. GSA, SVA, GVE, and SVE. So it has both sensory and motor functions. Its attached to the pontomedullary junction of the brainstem.

Slide 2: Facial (VII) contd So lets look at each functional modality one by one. General somatic afferent, so again somatic sensation like touch, pain, temperature. Things like that. But from a very restricted area. From outer ear only. Skin of the auditory canal and outer surface of tympanic membrane. So its the GSA from only a very small area. Cell bodies of the primary sensory neurons are in the geniculate ganglion. This is just in case you are wondering where the geniculate ganglion it is here at the back of your head. Projects to the main sensory nucleus and spinal nucleus of the trigeminal nerve. So for the GSA component, facial nerve, you will see some other examples, but facial nerve do not have its own sensory nuclei. It will go to the sensory nuclei that we just talked about for the trigeminal nerve. So the information goes to the main sensory nucleus of the trigeminal nerve, spinal nucleus of the trigeminal nerve. Slide 3: Facial (VII) contd The 2nd functional modality in CN VII is special visceral afferent taste. Taste from the anterior two thirds of the tongue and soft palate. So in this picture [went back to slide 2 of 1-16-14b] you are seeing the lateral side of the face with all the internal structures shown. You see these green areas indicates the areas where you get the taste info from CN VII. So there are three cranial nerves that carry taste information. And the CN VII is one of them. Anterior two thirds of the tongue and the soft palate towards the back of the oral cavity. [back to slide 3 of 1-16-14b]. Cell bodies of the primary sensory neurons in geniculate ganglion [back to slide 2 of 1-16-14b]. So the same as the GSA, the cell bodies of the primary sensory neurons are here in the geniculate ganglion [back to slide 3 of 1-16-14b]. And project fibers to the nucleus solitarius in medulla. So its here. You will see all the taste information from all three nerves go to nucleus solitarius. Nucleus solitarius is the major visceral sensory nucleus of brainstem and you will see there are many different cranial nerves that send information to the nucleus solitarius. Slide 4: Facial (VII) contd General visceral efferent, visceral, this means autonomic nervous system. GVE component of CN VII forms preganglionic parasympathetic nerves. And they originate from superior salivatory nucleus in pons. Which is about here in the pons. The superior salivatory nucleus, you expect from the name that it will control salivation. Slide 5: Facial (VII) contd So GVE of CN VII they originate from the superior salivatory nucleus and then they terminate at the pterygopalatine or submandibular ganglion. So if you remember I mentioned briefly during the spinal pathway lectures, that for the autonomic nervous system there is one more synapse between the nucleus and the target tissue. So they synapse at the pterygopalatine or submandibular ganglion. And from here the post ganglionic neurons innervate the lacrimal gland, so that means CN VII controls tear production. And then the small glands of nasal and oral cavities. And the submandibular ganglion the post ganglionic neurons innervate submandibular and sublingual salivary gland. So CN VII controls tear production and salivation. And these are if you wonder where they are.

Slide 6: Facial (VII) contd The fourth functional modality carried by CN VII, branchiomotor or special visceral efferent. So again, SVE means they innervate the muscles of branchial arch region. Thats SVE. And SVE is the largest component of CN VII. So most of the fibers of CN VII carries SVE information. Originate from the facial motor nucleus. Here in the pons. I know you hate to hear this but for the important nuclei you need to remember where they are like in terms of midbrain, pons, medulla. For example facial motor nucleus is in the pons, trigeminal motor nucleus is also in the pons. Things like that. Nucleus solitartius is in the medulla. You need to remember the locations of the important cranial nerve nuclei. I say you need to remember because I have seen the board exam questions asking the location of the nuclei. Slide 7: Facial (VII) contd So the SVE component of CN VII innervate the muscles derived from the second branchial arch. CN V innervated muscles from the first branchial arch, CN VII innervates muscles from the second branchial arch. And these muscles include the muscles of facial expression and a few others. But important thing is CN VII innervates muscles of facial expression. CN V innervates muscles of mastication. Each facial motor nucleus gives efferents to ipsilateral face. So the projection is ipsilateral. Damage to the facial motor nucleus or CN VII causes weakness of the entire ipsilateral half of the face. So in this case all the fibers coming from the ipsilateral nucleus, in terms of left or right, the consequence of damaging the facial motor nucleus or the consequence of damaging CN VII would be the same. Because the fibers are all coming from the ipsilateral nucleus to the ipsilateral face. CN VII is involved in the corneal blink reflex, which I will talk about in a little bit. And this just shows the distribution of CN VII. It actually covers a large area of the face. And this is for the motor. And in terms of the motor function, CN VII covers a very large area of the face, but for the somatosensory function it was only carrying information for the outer ear. So it has a much bigger motor function than somatosensory function. Slide 8: Facial (VII) contd So now I need to explain facial paralysis. To do that I need to explain the corticobulbar tract first. Its kind of like the corticospinal tract. Corticospinal tract is the descending pathway that gets the information from the cerebral cortex down to the spinal cord to control the movement of muscles in the body. Corticobulbar tract is the nerve fiber tracts from the cerebral cortex to the bulbar, means brain stem, so from cortex to the brainstem, and then to the muscles in the face, head, and neck area. That is the corticobulbar tract. And in the strict sense, corticobulbar could mean only the portion from the cortex to the brain stem. So originates from the cerebral cortex and projects to the motor nuclei. So there are multiple kinds of motor nuclei. Like for example weve seen trigeminal motor nucleus, oculomotor nucleus, and so on. Motor nuclei of cranial nerves in the brainstem. And cortex to the cranial nerve nuclei is connected through the axons of upper motor neurons. So the neurons of the primary motor cortex are called upper motor neuron. They send down the axon fibers, down down down. And then they project to the motor nuclei of the cranial nerves. In general the upper motor neurons project to the motor nuclei bilaterally. Lets say the upper motor neuron at the left cerebral hemisphere will give info to the facial motor nuclei of both left and right side. Usually it is bilateral but there are exceptions. Exceptions

as this one. So lets look at the sentence above that. Corticobulbar tract or the upper motor neuron that would eventually control the upper face, projects bilaterally to both nuclei. This is like what I just stated here. But the upper motor neuron that would control the lower face projects to the contralateral facial motor nucleus. So if you remember the primary motor cortex has a homunculus. So there is a map of the neurons are located in which part of the cortex would control the upper face and lower face. So that is already mapped in the primary motor cortex humonculus. So the upper motor neurons, depending on whether they will respond to the upper or lower face in the humonculus they behave differently. So thats what it means. And once they synapse at the facial motor nucleus, from there, the lower motor neuron, whose cell bodies are in the facial motor nucleus, they all project ipsilaterally. And this portion, from the facial motor nucleus to the target is what we call CN VII. So if a question said you are damaging CN VII you are always damaging the axon of the lower motor neuron, not the upper motor neuron. If you want to say you are damaging the axons of the upper motor neuron, it will say differently. Things like upper motor neuron or corticobulbar tract. But if the question simply says damage to CN VII that always means lower motor neuron. And its true for the other examples we will see later on. Controlling the movement of the muscles like accessory nerve, hypoglossal nerve. What we call CN XII, CN XI, they all correspond to the axons of the lower motor neuron. Ok? Slide 9: Facial (VII) contd So I think I have to do this next time, facial paralysis. Ok.