A MEDICOLEGAL VIEW OF HEAD

TRAUMA COMPLICATIONS
Thesis
Submitted for full fulfillment of M.D. Degree in
Forensic Medicine and Clinical Toxicology
By
Ahmed Ibrahim Mohammed Ewis
Forensic medicine Society - Beni Suef Government- Ministry of Justice
M.Sc.in forensic medicine and clinical toxicology

Under supervision of

Prof. Mervate Hamdy Abd El Salam

Professor of Forensic Medicine and Clinical Toxicology
Faculty of Medicine - Cairo University

Prof. Abla Abd El Rahman Ali

Assistant Professor of Forensic Medicine and Clinical Toxicology
Faculty of Medicine - Cairo University

Prof. Amany Salah Mohammed

Assistant Professor of Forensic Medicine and Clinical Toxicology
Faculty of Medicine - Cairo University

Dr. Mohammed Adly Mohammed

Lecturer of Forensic Medicine and Clinical Toxicology
Faculty of Medicine - Cairo University

Faculty of Medicine
Cairo University
2012
 Acknowledgment
First of all thanks to Allah
With the deepest feeling of gratitude , I would like to express my
appreciation to Prof.Dr. Usama Ibrahim El-Barrany. Prof. and Head of
forensic medicine and toxicology department, Faculty of medicine, Cairo
University, for his continuous support and encouragement.

I am deeply indebted to Prof. Dr.Mervate Hamdy Abd El-

Salam. Prof. of forensic and toxicology for her unlimited help,
meticulous supervision and sincere supervision during the preparation of
this work which are above all commentaries.

My sincere thanks and gratitude to Prof.Dr.Abla Abd El-

Rahman Ali. Prof. of forensic and toxicology for her great support,
valuable suggestions and encouragement.
I would like to express my deepest gratitude to Prof. Dr.Amany
Salah Mohammed. Prof.of forensic and toxicology, for her grateful
effort, help guidance, valuable assistance and guidance throughout this
work.

I would like to present my sincere thanks to Dr. Mohammed Adly

Mohammed. Lecturer of forensic and toxicology, for his great support
and encouragement.
I am deeply indebted to Prof. Dr. Dina Shokry. Prof. of forensic
and toxicology, for her kind care, close supervision and her worthy
remarks are beyond my words of thanks.
My abundant thanks and gratitude to Prof. Dr. Aly Gamal El-Din
Abd El- Aal. Prof. of forensic and toxicology, for his kind care, for his
continuous support and encouragement.
I would like to present my great thanks to Faculty of Medicine-
Cairo university (Kasr El Aini hospital), Faculty of Medicine of Beni
Suef University, General hospital of Beni Suef, Psychiatry hospital of
Beni Suef, Al Eman center of radiology at Beni Suef and hospital of
Ophthalmology of Beni Suef.

I am deeply indebted to all my professors and colleagues in the

forensic and toxicology department, Faculty of medicine, Cairo
university, for their constructive guidance, effective help and enthusiastic
cooperation.
 Table of Contents

Topic Page
List of Abbreviations I

List of Tables II

List of Figures III-IV

List of Charts V

Abstract VI

Introduction and Aim of the work (1-2)

Review of literature:

- Chapter I: Anatomy of Head (3-15)

- Chapter II: Anatomy of Cranial Nerves. (16-22)

- Chapter III: Pathology of Head Injury (23-40)

- Chapter IV: Complications of Head Trauma (41-56)

Subjects and Methods (57- 72)

Results and figures of investigations (73-114)

Discussion (115- 122)

Summary, Conclusions and Recommendations (123- 133)

References (134- 152)

Arabic Summary )5-0(

 List of abbreviations

CSF Cerebrospinal fluid LOC Loss of consciousness duration

CN I Olfactory nerve SIADH Syndrome of inappropriate antidiuretic hormone
CN II Optic nerve CSW Cerebral salt wasting
CN III Oculomotor nerve DI Diabetes insipidus
CN IV Trochlear nerve AH Anterior hypopituitarism
CN V Trigeminal nerve PAI Primary adrenal insufficiency
CN VI Abducent nerve GRH Gonadotropin-releasing hormone
CN VII Facial nerve LH Luteinizing hormone
CN VIII Vestibulocochlear nerve FSH Follicular stimulating hormone
CN X Vagus nerve ANS Autonomic nervous system
CN XI Spinal accessory nerve PTM Post-traumatic meningitis
CN XII Hypoglossal nerve UMNL Upper motor neurone lesion
TBI Traumatic Brain Injury LMNL Lower motor neurone lesion
MVCs Motor Vehicle Collisions ENG Electronystagmography
SDH Subdural haematoma MRA Magnetic resonance Angiography
ICP Intracranial pressure IQ Intelligence quotient
ASDH Acute subdural hematoma Hge. Haemorrhages
SAH Subarachnoid haemorrhage Fig. Figure
ICH Intracerebral haemorrhage Isol. Isolated
IVH Intraventricular haemorrhage PCS Post-concussion syndrome
DAI Diffuse axonal injury ICU Intensive care unit
aPTT activated partial thromboplastin Freq. Frequency
time
PT Prothrombin time M Motor complication
CBC Complete blood count Cn Cranial nerves affection
ABG Arterial blood gases E Epilepsy
IV Intravenous C Cognitive complications
CT Computerized tomography S Sensory complications
MRI Magnetic resonance image Au Autonomic disturbance
CBF Cerebral blood flow HBO Hyperbaric oxygen
PTE Posttraumatic epilepsy SIADH Syndrome of inappropriate antidiuretic hormone
PTA Post-traumatic amnesia CSW Cerebral salt wasting
GCS Glasgow Coma Scale DI Diabetes insipidus
PVS Permanent Vegetative State AH Anterior hypopituitarism
VS Vegetative State PAI Primary adrenal insufficiency
PTSD Post-traumatic stress disorder GRH Gonadotropin-releasing hormone
CRF Corticotropin-releasing factor LH Luteinizing hormone
HPA Hypothalamic-pituitary-adrenal FSH Follicular stimulating hormone
axis
Isol. Isolated Cn Cranial nerves affection
PCS Post-concussion syndrome E Epilepsy
ICU Intensive care unit C Cognitive complications
Freq. Frequency S Sensory complications
M Motor complication Au Autonomic disturbance

I
 List of tables

No of Topic of table page

table
1 Glasgow Coma Scale 37
2 Levels of TBI severity 42
3 TBI severity using PTA alone 42
4 Head trauma types within different age groups (years) 87
5 Severity of head trauma regarding to consciousness level (GCS) and death incidence within 89
different age groups (years)
6 Head trauma regarding to open or closed within different age groups (years) 91
7 Head trauma types within gender 93
8 Head trauma severity regarding to conscious level (GCS) and death incidence within gender 95
9 Head trauma types regarding to open or closed within gender 97
10 Head trauma sequelae within gender 99
11 Head trauma severity regarding to conscious level (GCS) and death incidence within different 101
types of head trauma
12 Sequelae of head trauma within different age groups (years) 103
13 Sequelae head trauma within types of head trauma 105
14 Head trauma severity regarding to conscious level (GCS) and death incidence within different 107
sequelae of head trauma
15 Head trauma regarding to open or closed with sequelae of head trauma 109

II
 List of figures

No of Topic of figure page

figure

1 Layers of head (cross section) 49

2 Anterior view of skull 49
3 Lateral view of skull 50
4 Skull base (external view) 50
5 Skull base (internal view) 51
6 Anatomy of meninges 51
7 Anatomy of the brain (external view) 52
8 Brain stem (anteroinferior view) 52
9 Longitudinal section of brain 53
10 Longitudinal section of brain (ventricules) 53
11 Anatomy of cranial nerve nuclei 54
12 Plain x- ray (anteroposterior view) shows depressed
fracture with radiating fractures, at onset of trauma.

13 Plain x-ray (anteroposterior view) shows

comminuted depressed fractures at left temporal and
parietal bone with numerous skull fracture radiating
from it, at onset of trauma.
14 Plain x-ray (anteroposterior view) shows inlet of
firearm shots at occipital bone with distribution of
shots allover brain, at onset of trauma.

15 Plain x ray shows two firearm bullets inside skull, at

onset of trauma.

16 CT scan with 3 dimensions reveals depressed

fractures of skull vertex with extension of fissure
fractures into parietals bilaterally, at onset of trauma.

17 CT scan with 3 dimensions reveal depressed fracture

with bone loss at left parietal with brain contusion, at
onset of trauma.

18 CT scan reveals depressed fracture of right frontal

bone, at onset of trauma.

19 CT scan (A, B) reveal depressed comminuted

fracture of right parietal bone with right parietal lobe
contusion and laceration, at onset of trauma.

20 CT scan reveals huge extradural hge. at left

temproparietal area with right shift of midline, at
onset of trauma.

21 MRI shows huge extradural hge at left temproparietal

III
 area compressing left lateral ventricle, at onset of
trauma.
22 CT scan (A,B) show tunnel fracture (tangential single
bullet) of left temporal and parietal bones, loss of
bones,comminuted depressed fractures with
extradural haemorrhage and left temporal and
parietal lobes contusions, at onset of trauma.

23 MRI shows subgaleal calcified haematoma, after 6

months of trauma.

24 MRI reveals prominent ventricular system, after 6

months of trauma.

25 CT scan reveals bilateral parietal large extradural

haemorrhage. at right,.at left side, after 6 months of
trauma.

26 CT scan reveals bilateral frontoparietal subdural

hygroma, after 6 months of trauma.

27 MRI shows left high parietal encephalomalacia, left

parietal fracture, after 6 months of trauma.

28 MRI reveals right parietal large area of

encephalomalacia with depressed fracture of right
parietal bone, after 6 months of trauma .
29 CT scan reveals site of trephine operation at right
parietal bone with depressed fracture with right
extradural hge.with mild shift of middle line to
opposite side, after 6 months of trauma.
30 CT scan reveals comminuted depressed fracture of
frontal bone with right frontal encephalomalcia, after
6 months of trauma.

IV
 List of charts

No of chart Topic of chart Page

1 Head Trauma within Age Groups 69
2 Head Trauma within the Gender 70
3 Types of Head Trauma 71
4 Sites of Head Trauma 72
5 Causative Agents of Head Trauma 73
6 Open or Closed Head Trauma 74
7 Head Trauma Severity regarding to Consciousness Level (GCS) and Death 75
incidence
8 Skull Fractures at Onset of Head Trauma 76
9 Intracranial Haemorrhages at Onset of Head Trauma 77
10 Intracerebral Findings at Onset of Head Trauma 78
11 Follow-up of Scalp findings 79
12 Follow-up of skull findings 80
13 Follow-up of Intracranial Haemorrhages 81
14 Follow-up of Intracerebral findings 82
15 Head Trauma Sequelae 83
16 Deaths due to Head Trauma 84
17 Permanent Infirmity types of Head Trauma 85
18 Death Causes resulting from Head Trauma 86
19 Types Head Trauma within Age Groups (years) 88
20 Severity of Head Trauma regarding to Consciousness level (GCS) and Death 90
incidence within Age Groups (years)
21 Open or Closed Head trauma within Age Groups (years) 92
22 Head trauma Types within the Gender 94
23 Head trauma Severity regarding to Conscious Level (GCS) and Death Incidence 96
within the Gender
24 Open or Closed Head Trauma within the gender 98
25 Head trauma Sequelae within the Gender 100
26 Head trauma Severity regarding to Conscious level (GCS) and Death incidence 102
within Types of Head Trauma
27 Sequelae of Head Trauma within Age Groups (years) 104
28 Head Trauma Sequelae within Types of Head Trauma 106
29 Head Trauma Severity regarding to Conscious level (GCS) and Death incidence 108
within Sequelae of Head Trauma
30 Open or Closed Head Trauma with Sequelae of Head Trauma 110

V
 Key words
Forensic Medicine- Homicidal trauma-Traumatic brain injury-
Pathological complications Clinical complications

Abstract
Purpose: assessment of different types of head trauma with correlation with age,
sex, causative agents, prognosis, severity of trauma, pathological and clinical
complications.

Methodology: This study was done on 100 cases who were referred to forensic
department of Beni Suef of males and females, age (4 up 65), dead (26) and
living (74) with investigation of dead cases with plain x-ray, CT scan and autopsy
procedure and follow up living cases for 6 months with history taking ,
neuropsychiatry assessment, plain x-ray, CT scan, MRI, MRI angiograph, eye
examinations, hearing tests, EEG, IQ tests.

Results: This study declared some important findings such as predominance of

head trauma frequency between age group 25- less than50 years (61%) where it
was more severe and decreasing in frequency and severity with age extremities,
predominance of head injury in males where male cases represented 84% and
female cases represented 16%. Deaths at day of head trauma represented 88% of
death cases which decreases with time interval.There was a great correlation
between severity of head trauma and prolonged sequelae. Clinical sequelae of head
trauma were 39% ended with permanent infirmity, 35% completely recovered and
26% died. Pure cranial nerve sequelae represented 7%.

Conclusion: According to the present study, Age group 25-less than 50 years was
the predominant group for exposure to head trauma. Glasgow coma scale was a
good prognostic factor. Deaths due to head trauma occurs mainly at day of trauma.

VI
 Introduction and aim of the study

Introduction
Head injury is the most common cause of death and acquired disability
among children and adults in developed countries and, even when adequate
treatment is provided, traumatic head injury commonly causes neuronal loss (Bone
et al., 1991).
The underlying pathophysiology highlights the importance not only of the primary
injury, but also of the secondary processes occurring after injury, which may lead
to cerebral hypoxia and ischemia (Baker et al., 2004).Secondary brain injury is the
leading cause of in-hospital deaths after traumatic brain injury (Bochicchio et al.,
2005).
Moreover, the outcome of head injury varies from center to center depending
on the availability of modern neurosurgical and neuroradiological facilities and
qualified expertise (Bahloul et al., 2004).
Survivors are susceptible to irreversible neurological damage that represents
an important socioeconomic problem.Head injury is the most frequent cause of
mortality and morbidity in any age.Finally, prognosis may be influenced by the
presence of extracranial pathology (Campbell et al., 2004).

The Glasgow Coma scale at the time of admission is the single most
important predictor of outcome. Pre-hospital hypothermia, intra-cranial
hypertension, hypoxia, associated injuries and delayed transportation lead to
secondary insults to already injured brain.Preventing secondary brain insults will
remain the goal of management for the foreseeable future.Primary severe head
injury can be prevented by strict public laws, observation of safety measures and
mass education about the consequences of severe head injury and of course an
efficient medical transfer system.Aconcept of centers of excellence and an
educational programmes. Advance Brain Life Support has been proposed to
decrease the mortality and morbidity (Tarek et al., 2004).

Traumatic brain injury can cause not only focal deficits of motor activity or
language, but also a variety of potentially disabling psychiatric symptoms and
syndromes. These include mood and anxiety disorders; personality disturbances;
aggression; and, occasionally, psychosis. Treatment is complicated by cognitive
deficits, lack of motivation, and lack of awareness of deficits. Controlled treatment
trials for head injury are lacking. Pharmacological treatment may include a wide
range of medications, such as antidepressants, antipsychotics, mood stabilizers, and
stimulants. Family and individual counseling is particularly important in helping

1
 Introduction and aim of the study

the patient and the family reconcile themselves to the reality of the behavioral
changes in the patient post-TBI (Kim et al., 2007).

Aim of the study

The study was designed to evaluate the complications of isolated traumatic

head injury referred to forensic department of Beni suef for dead cases through
Plain x-ray, CT, autopsy and living cases through complete neuropsychiatry
evaluation and investigations with Plain x-ray, CT, MRI, MRI angiography,
fundoscopy, vision acuity test, hearing tests, electroencephalography, IQ tests, to
define simple predictive factors which can be used in routine practice as an
indicator of poor prognosis and diagnosis of final sequelae after 6 months.

2
 Review of literature: Head Anatomy

Chapter I

Head Anatomy
1-Scalp

The scalp is the anatomical area bordered by the face anteriorly and the neck
to the sides and posteriorly.
Layers of scalp: (Figure 1) (Gray, 2005)
It is usually described as having five layers, which can be remembered with the
mnemonic "SCALP":
S: The skin on the head from which head hair grows. It is richly supplied with
blood vessels.
C: Connective tissue, a thin layer of fat and fibrous tissue lies beneath the skin.
A: The aponeurosis called epicranial aponeurosis (or galea aponeurotica) is the
next layer. It is a tough layer of dense fibrous tissue which runs from the frontalis
muscle anteriorly to the occipitalis posteriorly.
L: The loose areolar connective tissue layer provides an easy plane of separation
between the upper three layers and the pericranium. In scalping the scalp is torn off
through this layer. It also provides a plane of access in craniofacial surgery and
neurosurgery. This layer is sometimes referred to as the "Danger Zone" because of
the ease by which infectious agents can spread through it to emissary veins which
then drain into the cranium (Knight et al., 1996).
P: The pericranium is the periosteum of the skull bones and provides nutrition to
the bone and the capacity for repair. It may be lifted from the bone to allow
removal of bone windows (craniotomy). The clinically important layer is the
aponeurosis. Scalp lacerations through this layer mean that the "anchoring" of the
superficial layers is lost and gaping of the wound occurs; this requires suturing
(American Association of Anatomists, 2009).

2-Skull bones

The head is positioned upon the superior portion of the vertebral column,
attaching the skull upon C-1. The skeletal section of the head and neck forms the
superior segment of the axial skeleton and comprises skull, hyoid bone, auditory
ossicles, and cervical spine. The skull can be further subdivided into: (Figures 2, 3,
4 and 5)

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 Review of literature: Head Anatomy

(a) Cranium (8 bones: frontal, 2-parietal, occipital, 2-temporal, sphenoid and

ethmoid), and
(b) Facial bones (14 bones: 2-zygomatic, 2-maxillary, 2-palentine, 2-nasal, 2-
lacrimal, volmer, 2-inferior conchae, mandible), and
(c)Skull base: The skull base forms the floor of the cranial cavity and separates the
brain from other facial structures (Gray, 2005).

1- Anterior cranial fossa:

The anterior limit of the anterior skull base is the posterior wall of the
frontal sinus. The anterior clinoid processes and the planum sphenoidale, which
forms the roof of the sigmoid sinus, mark the posterior limit .
The frontal bone forms the lateral boundaries. The frontal bone houses the
supraorbital foramina, which, along with the frontal sinuses, form 2 important
surgical landmarks during approaches involving the anterior skull base (Gray,
2005).

2- Middle cranial fossa:

The greater wing of the sphenoid helps form the anterior limit of the middle
skull base. The posterior limit is the clivus .
The greater wing of the sphenoid forms the lateral limit as it extends laterally and
upward from the sphenoid body to meet the squamous portion of the temporal bone
and the anteroinferior portion of the parietal bone. The greater wing of the
sphenoid forms the anterior floor of the fossa. The anterior aspect of the petrous
temporal bone forms the posterior floor of the middle cranial fossa (Gray, 2005)

3-Posterior cranial fossa:

The posterior skull base consists of primarily the occipital bone, with
contributions from the sphenoid and temporal bones.The basal portion of the
occipital bone (the basiocciput) and the basisphenoid form the anterior portion the
posterior skull base. These 2 regions combine to form the midline clivus (Gray,
2005).

3-Meninges

The meninges (singular meninx) are the system of membranes which

envelops the central nervous system. The meninges consist of three layers: the dura
mater, the arachnoid mater, and the pia mater. The primary function of the
meninges and of the cerebrospinal fluid is to protect the central nervous system
(Kandel, 2000). (Figure 6)

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 Review of literature: Head Anatomy

1- Dura mater:
The dura mater is a thick, durable membrane, closest to the skull. It consists of
two layers, the periosteal layer, closest to the calvaria and the inner meningeal
layer. It contains larger blood vessels which split into the capillaries in the pia
mater (Spitz et al., 1993).
It is composed of dense fibrous tissue, and its inner surface is covered by
flattened cells like those present on the surfaces of the pia mater and arachnoid.
The dura mater is a sac which envelops the arachnoid and has been modified to
serve several functions. The dura mater surrounds and supports the large venous
channels (dural sinuses) carrying blood from the brain toward the heart (Kandel,
2000).

2- Arachnoid membrane:
The middle element of the meninges is the arachnoid membrane, so named
because of its spider web-like appearance. It provides a cushioning effect for the
central nervous system. The arachnoid mater exists as a thin, transparent
membrane. It is composed of fibrous tissue and, like the pia matter, is covered by
flat cells also thought to be impermeable to fluid (Spitz et al., 1993).
The arachnoid does not follow the convolutions of the surface of the brain and so
looks like a loosely fitting sac. In the region of the brain, particularly, a large
number of fine filaments called arachnoid trabeculae pass from the arachnoid
through the subarachnoid space to blend with the tissue of the pia mater (Kandel,
2000).

3- Pia mater:
The pia or pia mater is a very delicate membrane. It is the meningeal envelope
which firmly adheres to the surface of the brain and spinal cord. As such it follows
all the minor contours of the brain (gyri and sulci) (Zigmond, 1999).
It is a very thin membrane composed of fibrous tissue covered on its outer surface
by a sheet of flat cells thought to be impermeable to fluid. The pia mater is pierced
by blood vessels which travel to the brain and spinal cord, and its capillaries are
responsible for nourishing the brain (Spitz et al., 1993).

Blood supply of meninges:

1- Middle meningeal artery:

The middle meningeal artery (Latin arteria meningea media) is typically the
third branch of the first part (retromandibular part) of the maxillary artery; one of
the two terminal branches of the external carotid artery. After branching off the

5
 Review of literature: Head Anatomy

maxillary artery in the infratemporal fossa, it runs through the foramen spinosum
to supply the dura matter (the outermost meninges) and the calvaria (DeMyer,
1998).
The middle meningeal artery is the largest of the three (paired) arteries which
supply the meninges, the others being the anterior meningeal artery and the
posterior meningeal artery (Walker, 2003).
Clinical relevance:
An injured middle meningeal artery is the cause of an epidural hematoma. A head
injury (e.g., from a road traffic accident or sports injury) is required to rupture the
artery. Emergency treatment requires decompression of the haematoma, usually by
craniotomy. The middle meningeal artery runs in a groove on the inside of the
cranium. This can clearly be seen on a lateral skull X-ray, where it may be
mistaken for a fracture of the skull (Walker, 2003).

2- Posterior meningeal artery:

The posterior meningeal artery is a small vessel branched of the ascending
pharyngeal artery which supply the dura mater (Walker, 2003).It passes through
the mastoid foramen before entering the cranium via the jugular foramen
(Carpenter, 2003).

3- Anterior (meningeal) ethmoidal artery:

It accompanies the nasociliary nerve through the anterior ethmoidal canal,
supplies the anterior and middle ethmoidal cells and frontal sinus, and enters the
cranium (DeMyer, 1998).

4-Cerebral cortex

The cerebral cortex is a structure within the brain that plays a key role in
memory, attention, perceptual awareness, thought, language, and consciousness. In
preserved brains, the outermost layer of the cerebrum has a gray color, hence the
name "gray matter" (Zigmond, 1999).
Cortex may be classified on the basis of gross topographical conventions into four
lobes:
Frontal Lobes
Parietal Lobes
Temporal Lobes
Occipital Lobes (Alexandre et al., 2007). (Figure 6)

6
 Review of literature: Head Anatomy

Brain lobes:

1-Frontal lobe:
The frontal lobe has three main areas, known as the precentral cortex,
prefrontal cortex and the orbitofrontal cortex. These three areas are represented in
both the left and the right cerebral hemispheres.The precentral cortex or primary
motor cortex is concened with the planning, initiation and control of physical
movement. The prefrontal cortex in the left hemisphere is involved with verbal
memory while the prefrontal cortex in the right hemisphere is involved in spatial
memory (Gelder et al., 2000).
The frontal lobe contains most of the dopamine-sensitive neurons in the
cerebral cortex. The dopamine system is associated with attention, long-term
memory, planning, and drive. Dopamine tends to limit and select sensory
information arriving from the thalamus to the fore-brain (Blakemore et al., 2005).

2- Parietal lobe:
The parietal lobe is positioned above the occipital lobe and behind the frontal
lobe (Blakemore, 2005). The parietal lobe integrates sensory information from
different modalities, particularly determining spatial sense and navigation. For
example, it comprises somatosensory cortex and the dorsal stream of the visual
system. This enables regions of the parietal cortex to map objects perceived
visually into body coordinate positions (Blakemore, 2005).

3- Temporal Lobe:
The temporal lobe is a region of the cerebral cortex that is located beneath the
Sylvian fissure on both the left and right hemispheres of the brain.The temporal
lobe is involved in auditory processing and is home to the primary auditory cortex.
It is also important for the processing of semantics in both speech and vision. The
temporal lobe contains the hippocampus and plays a key role in the formation of
long-term memory (Blumer et al., 2001).

4- Occipital lobe:
The occipital lobe is the visual processing center of the mammalian brain
containing most of the anatomical region of the visual cortex. The primary visual
cortex is Brodmann area 17, commonly called V1 (visual one). Human V1 is
located on the medial side of the occipital lobe within the calcarine sulcus; the full
extent of V1 often continues onto the posterior pole of the occipital lobe. Visually
driven regions outside V1 are called extrastriate cortex (Blakemore, 2005).

7
 Review of literature: Head Anatomy

5- SUBCORTICAL STRUCTURES

1- Basal ganglia:
The basal ganglia is a group of nuclei in the brain interconnected with the
cerebral cortex, thalamus and brainstem. Mammalian basal ganglia are associated
with a variety of functions: motor control, cognition, emotions, and learning
(Gilies, 2005).

2- Thalamus:
The thalamus is a paired and symmetric part of the brain. It constitutes the
main part of the diencephalon. In the caudal (tail) to rostral (head) sequence of
neuromeres, the diencephalon is located between the mesencephalon (cerebral
peduncule, belonging to the brain stem) and the cerebrum (Gray, 2005).

3- Hypothalamus:
The hypothalamus is located below the thalamus, just above the brain stem. In
the terminology of neuroanatomy, it forms the ventral part of the diencephalon. All
vertebrate brains contain a hypothalamus. In humans, it is roughly the size of an
almond The hypothalamus is responsible for certain metabolic processes and other
activities of the autonomic nervous system. It synthesizes and secretes
neurohormones, often called hypothalamic-releasing hormones, and these in turn
stimulate or inhibit the secretion of pituitary hormones. The hypothalamus controls
body temperature, hunger, thirst, fatigue, and circadian cycles (Gray, 2005).

4- Limbic system:
The limbic system is a set of brain structures includes the hippocampus,
amygdala, anterior thalamic nuclei, and limbic cortex, which support a variety of
functions including emotion, behavior, long term memory, and olfaction (Walker
et al., 2005).

5- Pituitary gland:
It is composed of two lobes: the adenohypophysis or anterior pituitary and the
neurohypophysis or posterior pituitary. The pituitary gland is functionally linked to
the hypothalamus by the pituitary stalk, whereby hypothalamic releasing factors
are released and, in turn, stimulate the release of pituitary hormones. Although the
pituitary gland is known as the master endocrine gland, both of its lobes are under
the control of the hypothalamus, the master's master (Longscope et al., 2000).

8
 Review of literature: Head Anatomy

6- Midbrain:
The midbrain is divided into three parts. The first is the tectum, which is
"roof" in Latin. The tectum includes the superior and inferior colliculi and is the
dorsal covering of the cerebral aqueduct. The inferior colliculus, involved in the
special sense of hearing sends its inferior brachium to the medial geniculate body
of the diencephalon. Superior to the inferior colliculus, the superior colliculus
marks the rostral midbrain. It is involved in the special sense of vision and sends
its superior brachium to the lateral geniculate body of the diencephalon (Gray,
2005).

7- Brainstem:
The brainstem is the lower part of the brain, adjoining and structurally
continuous with the spinal cord. The brain stem provides the main motor and
sensory innervation to the face and neck via the cranial nerves. Though small, this
is an extremely important part of the brain as the nerve connections of the motor
and sensory systems from the main part of the brain to the rest of the body pass
through the brain stem (Dabbs et al., 2002).
This includes the corticospinal tract (motor), the posterior column-medial
lemniscus pathway (fine touch, vibration sensation and proprioception) and the
spinothalamic tract (pain, temperature, itch and crude touch) (Gray, 2005).
The most medial part of the medulla is the anterior median fissure. Moving
laterally on each side are the pyramids. The pyramids contain the fibers of the
corticospinal tract (also called the pyramidal tract), or the upper motor neuronal
axons as they head inferiorly to synapse on lower motor neuronal cell bodies
within the ventral horn of the spinal cord (Gerard, 2007).

8- Cerebellum:
The cerebellum (Latin for little brain) is a region of the brain that plays an
important role in the integration of sensory perception, coordination and motor
control. In order to coordinate motor control, there are many neural pathways
linking the cerebellum with the cerebral motor cortex (Fine et al., 2002). (Figures
7, 8, 9)

Ventricular system: (Figure 10)

The ventricular system is a set of structures in the brain continuous with the
central canal of the spinal cord. The system comprises four ventricles: right and
left lateral ventricles, third ventricle and fourth ventricle (Purves et al., 2004).

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 Review of literature: Head Anatomy

Cerebrospinal fluid:
Cerebrospinal fluid (CSF), Liquor cerebrospinalis, is a clear bodily fluid that
occupies the subarachnoid space and the ventricular system around and inside the
brain. Essentially, the brain "floats" in it. More specifically, the CSF occupies the
space between the arachnoid mater (the middle layer of the brain cover, meninges)
and the pia mater (the layer of the meninges closest to the brain).It acts as a
"cushion" or buffer for the cortex, providing a basic mechanical and
immunological protection to the brain inside the skull (Gray, 2005).
It is produced in the brain by modified ependymal cells in the choroid plexus and
the remainder is formed around blood vessels and along ventricular walls. It
circulates from the choroid plexus through the interventricular foramina (foramen
of Monro) into the third ventricle, and then through the cerebral aqueduct
(aqueduct of Sylvius) into the fourth ventricle, where it exits through two lateral
apertures (foramina of Luschka) and one median aperture (foramen of Magendie).
It then flows through the cerebellomedullary cistern down the spinal cord and over
the cerebral hemispheres (Gray, 2005).
The CSF contains approximately 0.3% plasma proteins, or 15 to 40 mg/dL,
depending on sampling site. CSF pressure ranges from 80 - 100 mmH2O or 4.4 -
7.3 mmHg in newborns, and <200mmH20 in normal children and adults (Edgley
et al., 2004).

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 Review of literature: Head Anatomy

(Figure 1): Layers of head (cross section) (www.wikipedia.com,

2011).

(Figure 2): Anterior view of skull (Atabaki, 2007).

(Figure 3): Lateral view of skull (Atabaki, 2007).

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