NEUROANATOMY

1. Central nervous System

Brain
1. Forebrain

Cerebrum

: Telencephalon : cortex (gray matter)

: sub-cortex (white

matter)
: basal ganglia
(gray matter)
Diencephalon : thalamus hypothalamus
2. Midbrain
: Brainstem : Midbrain (Mesencephalon)
Pons (Meten)
MO(Myelen)
3. Hindbrain
: Cerebellum
Spinal Cord
1.
2.
3.
4.
5.

Cervical segments
Thoracic segments
Lumbar segments
Sacral segments
Coccygeal segments

Substansia alba (white matter): ascending and descending

Substansia nigra (gray matter)
2. Peripheral Nervous System
Cranial nerves and their ganglia 12 pairs that exit the skull through the foramina
Spinal nerves and their ganglia 31 pairs that exit the vertebral column through
intervertebral foramina
Relationship of spinal cord segments of vertebral numbers
Vertebrae

Spinal Segment

Cervical vertebrae

Add 1

Upper thoracic vertebrae

Add 2

Lower thoracic vertebrae (7-9)

10th thoracic vertebrae

Add 3
L1-L2 cord segments

11th thoracic vertebra

L3-4 cord segments

12th thoracic vertebra

L5 cord segment

1st lumbar vertebra

Sacral and coccygeal segments

1. Sensory only : Olfactory, Optic, Vestibulochochlear

2. Motoric only : Occulomotor, Trochlear, Abducen, Accessory, Hypoglossal
3. Sensory + Motoric : Trigeminal
Facial
Glossopharyngeal (Taste: posterior 1/3 of tongue
sensory : tonsil, pharynx, middle ear )
Vagus (Sensory and motoric: heart, lung, trachea,
bronchi, larynx, external ear, GI tract)
4. Parasympathetis :
I.
Occulomotor (pupil constriction and accommodation )
II.
Facial ( lacrimal grand, mucosal gland of nose and palate, submandibular
sublingual gland)
III.
Glosspharyngeal (parotid gland)
IV.
Vagus (afferent from baroreceptor, parasympathetic to and from thorax
and abdomen)
CSF production : CSF is secreted (at the rate of 400-500mL daily)
composition : clear and colorless liquid
Glucose (about one half of that blood 50-85/100ml)
Protein (15-30mg/100ml) cells 1-3cells
Parts of the brain
Forebrain- Cerebrum
- Diencephalon
Midbrain
Hindbrain - Pons
- Medulla
Oblongata
- Cerebellum
Spinal cord

Ventricular system
Lateral Ventricle
3rd ventricles
Cerebral aqueduct
4th ventricles

Central canal

CSF absorption

The main site of CSF absorption into the venous system is through the arachnoid
granulations especially those that protrude into the superior sagittal sinus.
Hydrocephalus
1. Obstructive Hydrocephalus : Overproduction of CSF, obstruction of CSF flow, or
interference with CSF absorption results in excess fluid in the cerebral ventricles
and enlargement of head. The excess CSF dilates the ventricles, thin the cerebral
cortex, and separates the bones of calvaria in infants. Although an obstruction
can occur any place, the blockage usually occurs in the cebral aqueduct or an
interventricular foramen. Aqueduct stenosis may be cause by a nearby tumors in
the midbrain or by cellular debris following intraventricular hemorrhage or

bacterial and fungal infections of CNS. In infants, the internal pressure results in
expansion of the brain and calvaria because the sutures and fontanella are still
open.
2. Communicating hydrocephalus : the flow of CSF through the ventricles and
into subarachnoid space is not impaired, however, movement of CSF from this
space into venous system is partly or
NEUROANATOMY
Broadman area :
1.
2.
3.
4.
5.

Area
Area
Area
Area
Area

4 : Primary motor cortex

6 : Premotor
44,45 : Broca
17 : visual
22 :

Lobes and its function

1. Frontal lobe : fungsi motoric, memori dan kognitif, bahasa, fleksibilitas
kognitif
a. Presentral: Hemiplegia / monoplegia tergantung pada luasnya
daerah yg terkena
b. Posterior Inferior (Broca) : Aphasia motorik
c. Gaze palsy : gerak kepala dan mata ke arah contralateral
d. Prefrontal : primitive refles, gait apraxia, sindroma prefrontal (ggn
kepribadian)
e. Urine Incontinence
2. Parietal lobe : somatosensory perception
a. Post centralis : cortical sensory dysfunction (contralateral)
b. Dominant hemisphere : Aphasia wernickle, agosia, akalkulia, agrafia
c. Non dominant : apraxia
3. Temporal lobe : language function and auditory perception involved in long
term memory and emotion (hypocampus and amygdala)
a. Anterograde / retrograde amnesia
b. De javu, jamais vu
c. Hallucination
4. Occipital lobe : visual perception, and processing
a. Hemianopsia, prosopagnosia
Descending tract are motor.
1. Lateral corticospinal and Anterior corticospinal : Primary motor area lies in
front of central gyrus (area 4), premotor area lies in (area 6) corona
radiate posterior limb of internal capsule midbrain pons distal to
MEDULLA OBLONGATA (90% decussation as lateral corticospinal tract,
uncrossed : anterior corticospinal tract, crossed within spinal cord)
Ascending tracts are sensory :
1. lateral spinothalamic tract : Painful and thermal sensation
2. Anterior spinothalamic tract : Light (crude) touch and pressure

First order neuron synapse at substansia gelantinosa second order

neuron cross to opposite side and ascend (Pain and thermal fibers enter
lateral spinothalamic tract
Light touch and pressure fibers enter
anterior spinothalamic tract) tract ascend through the medulla oblongata,
pons, midbrain as Spinal lemniscus Second neuron ends in ventral
posterolateral nucleus of Thalamus third order neuron arise from
thalamus and pass through capsula internal sensory cortex of cerebrum
(postcentral gyrus)
3. Dorsal column: Discriminative (ability to localize accurately the area of the
body touched and also to be aware that two points are touched
simultaneously), pressure, position and movement.
First order neuron enter the dorsal column of same side and ascend to
medulla oblongata ends in gracile nucleus and cuneate nucleus of
medulla oblongata Second neuron cross in medulla and ascend as
medial lemniscus.
4. Spinocerebellar tracts :
Type of paralysis
Hemiplegia : is a paralysis of one side of the body and includes the upper limb,
one side of the trunk, and the lower limb
Monoplegia : is a paralysis of one limb only
Diplegia : is a paralysis of two corresponding limbs (arms or legs)
Paraplegia : is a paralysis of the two lower limbs
Quadriplegia : is a paralysis of all four limbs

Superior extremities : C5-T1

Inferior extremities : L2- S2
1. above C9 : Tetraparesis

Extremities superior and inferior : UMN

2. C5-T1 : Tetraparesis
UMN

Superior extremities : LMN

3. T2-L1 : Paraparesis

UMN

4. L2- S2 : Paraparese

LMN

Inferior Extremities :

Limb weakness : Limb weakness results from damage to the motor system at
any level from the motor cortex to muscle
Tone

Fasciculation
Atrophy /
wasting
Reflexes

UMN
Hypertonicity
(after a few
days to weeks
of spinal
shock)
Passive
movements
produce a
clasp knife
CLONUS +
Absent
Absent

LMN
Hypotonicity

Present
Present (within 2-3 weeks)

1.Tendon : exaggerated
Depressed / absent
2.Superficial : depressed / absent(abdominal, rarely
affected cresmateric)
3.Plantar response : Extensor
Flexor

Pathophysiology of atherosclerosis
Platelets circulating in blood containing thromboxane A2, a substance that
promotes their aggregation, while vascular endothelium secrets prostacyclin,an
aggregation inhibitor that balance this effect. These products are synthesized
after conversion of arachidonic acid into intermediate endoperoxides by
cyclooygenase enzymes.
If endothelial continuity is interrupted by trauma, atherosclerosis, etc, subsurface
collagen is exposed to blood and stimulates adhesion of platelets to vessels wall.
Platelet then discharge thromboxane A2, causing aggregation of adjacent
platelets.
As more platelets aggregate, fibrin network develops and stabilizes mass into
white thrombus, which then retracts into vascular wall. In some cases,
endothelium may later heal over without narrowing of lumen.
If thrombus develops later, red blood cells become enmeshed in platelet-fibrin
aggregate to form red thrombus, which may grow and block vessel lumen.

Either platelet-fibrin aggregates or more fully formed clots break off, with
embolization into distal arterial branches

STROKE
1. Gejala dan tanda klinis yang berlansung Selma 24jam atau lebih akibat
gangguan fungsi otak fokal (atau global) yang terjadi tiba-tiba dan
berlangsung progressif atau menetap atau berakhir dengan kematian
tanpa penyebab yang lain selain gagguan cerebrovascular.
2. Stadium :
i.
Transient Ischemic Attack (TIA) : Serangan neurologic deficit yang
bersifat temporary akibat ggn peredaran darah otak secara
mendadak, menghilang engan cepat (<24 jam) tanpa gejala sisa.
ii.
Reversible Ischemic Neurologic deficit (RIND) : TIA, >24jam
iii.
Stroke in evolution : Stroke yang sedang berlangsung dan bersifat
proggresif dan dapat berakhir dengan completed stroke
iv.
Completed stroke : Stroke Hemorrhagic atau stroke non
hemorrhagic
3. Stroke Ischemic : kurangnya aliran darah ke otak sehingga mengganggu
kebutuhan darah dan O2 di jaringan otak, dengan tanda neurologic deficit
4. Klasifikasi of stroke ischemic berdasarkan Tria of Org 10172 in Acute
Stroke Treatment (TOAST) :
I.
Large-artery atherosclerosis (thrombus / emboli)
II.
Cardioembolism
III.
Small vessel occlusion (lacunar)
IV.
Stroke of other determined etiology
V.
Stroke of undetermined etiology
5. SI : thrombosis, emboli, pengurangan perfusi sistemik umum
6. Thrombosis : obstruksi aliran darah yg terjadi pada proses oklusi pada satu
pem darah atau lebih
7. Emboli: pembentukan material dari tempat lain dlm sistem vascular dan
tersangkut dlm pem darah tertentu sehingga memblokade aliran darah
8. Pengurangan perfusi : kegagalan pompa jantung atau proses perdarahan
atau hipovolemik
9. Anterior cerebral arteries, middle cerebral arteries, and posterior cerebral
arteries.
10.The anterior and middle cerebral arteries carry the anterior circulation and
arise from supraclinoid internal carotid arteries.
11.Anterior cerebral arteries (ACA): Medial portion of frontal and parietal
lobes and Anterior portion of basal ganglia and anterior internal
capsule.
12.Middle cerebral arteries (MCA) : Lateral portion of frontal and parietal,
Anterior and Lateral portions of temporal lobes, and gives rise to
perforating branches to the globus pallidus, putamen, and internal
capsule. MCA is the dominant vascular supply to the hemisphere.
13.Posterior cerebral arteries (PCA) : arise from basilar artery and carry the
posterior circulation. PCA give rise to perforating branches that supply

thalami and brainstem and cortical branches to the posterior and

medial temporal lobe and occipital lobe.
14.The cerebral hemisphere are supplied by :
I.
Inferiorly : PICA, from vertebral artery
II.
Superiorly : Superior cerebellar artery
III.
Anterolaterally : AICA, from basilar artery
15.Core : degeneration of neuron infarct
CBF <10ml/100g
16.Penumbra : a metabolically active region, peripheral to ischemic area,
where blood flow is reduced zone of dereased or marginal perfusion (CBF
< 25ml/100g of tissue /min). Tissue in the penumbra can remain viable for
several hours because of marginal perfusion.
17.Lacunar stroke : results from occlusion of the penetrating branches of the
MCA,the lenticulostriate arteries, or the penetrating branches of the circle
willis, vertebral artery, opr basilar artery. The great majority of lacunar
strokes are related to HTN.
18.Emboli stroke : Valvular thrombi (MS, endocarditis, or the use of prosthetic
valve) Mural thrombi : MI, AF, dilated cardiomyopathy, CHF
19.FAST of ASA : Face drooping, Arm weakness, Speech difficulty, Time to call
911
20.SI : SBP : >220mmHg
DBP : >120mmHg Lower 15%
rtPA patient :
target : <185mmHg
<110mmhg <180mmhg
<105mmHg
21. Middle cerebral artery stroke :