Case 3 / NBSS Bunga Diela

STROKE 130110120114

CASE REVIEWaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaillllllll
Mrs. Soetinah, 42 y.o
Chief Complain
Unconsciouss and cannot move her left extremities

History of Illness General Examination Laboratory Examination

- Headache - Soporous (GCS: E2 M4 V3) - Electrolyte normal (Na 135mg%, K 3,9mg%)
- Cannot move her left arm and - BP 190/100 mmHg - Random BG 80mg%
leg properly - HR 80x/min - Ureum 40mg%
- Speech became slurred - R 28x/min - Creatinine 0.9mg%
- Vomit twice - Afebris
- Looked drowsy - Cor: Left border 2cm LMCS
- BP 180/100 mmHg - Pulmonal, abdomen, extremities normal

History of Past Illness Neurological examination: Additional Examination

- Diagnosed as hypertension patient - Meningeal sign: (+) Brudzinki 1 & II - EKG:
- BP 170/90 mmHg - Cranial Nerve: Sinus rhytm with left ventricular
- No routine medical check (+) Dool’s eye movement bilateral hypertrophy
- No medication Bilateral small pupil, still reactive to light - CT scan:
- No history of Diabetes Mellitus, Left Nasolabialfold more flattened and less Hyperdensity on the right basal
Cardiac disease, stroke, and transient reaction to stimuli ganglia and right of lateral ventricles
ischemic attack - Motor function:
- Family history (dad die at 60) : Left arm and leg: Less reaction to pain
infarction stroke stimuli (motor strength = 2)
- Physiologic reflex: Left side: Î
- Pathologic reflex: Left side: (+)

Diagnosis Management Prognosis

Haemorrhagic stroke with Intraventricularhaemorrhage in Treatment: Manitol 20% Quo ad Vitam : ad Bonam
right cerebral hemispere Rehab: Passive medical rehabilitation Quo ad Functionam :dubia ad Bonam
Control stroke sequalae and BP regularly

TIMELINE ddaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa
PAST 14 days hospitalized FUTURE

10yr ago Having dinner 15min later Called family Day 8

doctor hospitalization

- Diagnosed hypertension - Headache - Vomit 2x

- Drowsy BP 180/100 - Given - No complication Doctor suggest to
with BP 170/90 - Can’t move her
Manitol 20% - Motor strength control stroke
left arm and leg sequalae and BP
- Start passive improve : can lift
- Speech slurred Referred to medical regularly
arm and leg against
hospital rehabilitation
gravitation
- No routine med check up
- No history of DM, cardiac
disease, stroke, and TIA Haven General exam,
Neurologic exam, Lab exam,
Additional exam
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CONCEPT MAPPING ddaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaalllllllllllllllllllllll

Chronic hypertension Î BP

Cor: Left border 2cm LMCS

Lypohyalinosis Weaken Auto Regulation |
vessels wall
Weaken vessels Left ventricular hypertrophy
Blood Brain Barrier&
Blood CSF Barrier Spontaneous rupture of blood vessel

Hemorrhage in basal nuclei Hyperdensity at

Brain Vascularization
(Putaminal Hemorrhage) right basal ganglia

Stroke
Central Hemorrhage Stroke
(Intracranical Hemorrhage)
Extravasation of Blood Endothelial Injury

Activating Penetrating Compress adjacent Attract

chemoreceptor area brain ventricle structure inc. arteries inflammatory cell

Vomit Î ICP Widening Ischemic in Inflammatory Cytokine

subarachnoid space certain area protease
Anatomy and Attract inflame
Herniation of matory cell
Physiology of CSF
temporal lobe Inflammation | ATP Anaerobic
Attract inflame
metabolism Î
Anatomy and matory cell
Compress Meningitis Headache
Physiology of
brain stem Lactic acid
Brain Stem
accumulation
Anatomy and
Embryology, Anatomy, ARAS disturbance Histology of
Histology, and Physiology Meninges Clumping nuclear
of Cerebral Hemisphere chromatin
Unconsciousness Consciousness
Cranial Nerve
Nuclear damage
Ascending tract
CN V

Ascending tract
Loss of sensation
Effect adjacent At right Neuron & glial
structure basal ganglia cell death
Left CN VII paralysis

Motor paralysis Descending tract

Descending tract
Abnormal reflex
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GENERAL CONCEPT OF NERVOUS SYSTEM

The nervous system is composed of specialized cells:
- Afferent nerve fibers : to receive sensory stimuli.
- Efferent nerve fibers : to transmit stimuli to effector organs, whether muscular or glandular.

The nervous system is divided into two main parts:

- The central nervous system (CNS) : consists of the brain and spinal cord
= are the main centers where correlation and integration of nervous information occur.
= are covered with a system of membranes (meninges) and are suspended in the cerebrospinal fluid and
further protected by the bones of the skull and the vertebral column.
= composed of large numbers of neurons (excitable nerve cells) and their processes (long axons and short
dendrites), which are supported by neuroglia (specialized tissue).
= are organized into gray matter (consists of nerve cells / cell body embedded in neuroglia) and white matter
(consists of nerve fibers / myelinated axons embedded in neuroglia)

- The peripheral nervous system (PNS) : consists of the cranial and spinal nerves and their associated ganglia.
= consist of bundles of nerve fibers or axons, conduct information to and from the central nervous system.

***Autonomic Nervous System***

= The part of the nervous system (distributed both through CNS and PNS) concerned with the innervation of
involuntary structures, such as the heart, smooth muscle, and glands within the body.
= Divided into two parts (with afferent and efferent nerve fibers in both parts) :
- The sympathetic : to prepare the body for an emergency.
- The parasympathetic : to conserve and restore energy

1. Major Divisions of the Central Nervous System

CEREBRUM
FOREBRAIN DIENCEPHALON
BRAIN MIDBRAIN MEDULA OBLONGATA
HINDBRAIN PONS
CEREBELLUM
CNS
CERVICAL SEGMENT
THORACIC SEGMENT
SPINAL CORD LUMBAR SEGMENT
SACRAL SEGMENT
COCCYGEAL SEGMENT

A. Brain
- Lies in the cranial cavity and is continuous with the spinal cord through the foramen magnum.
- It is surrounded by three meninges : the dura mater, the arachnoid mater, and the pia mater.
- The cerebrospinal fluid surrounds the brain in the subarachnoid space.

B. Spinal Cord
- Situated within the vertebral canal of the vertebral column. Begins superiorly at the foramen magnum in the
skull, and terminates inferiorly in the lumbar region.
- Surrounded by three meninges: the dura mater, the arachnoid mater, and the pia mater.
- Further protection is provided by the cerebrospinal fluid, which surrounds the spinal cord in the
subarachnoid space.
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- Are attached 31 pairs of spinal nerves by the anterior or motor roots and the posterior or sensory roots.
Each posterior nerve root possesses a posterior root ganglion, the cells of which give rise to peripheral
and central nerve fibers.
- Composed of an inner core of gray matter (an H-shaped pillar with anterior and posterior gray horns
united by a thin gray commissure), which is surrounded by an outer covering of white matter (which is
divided into anterior, lateral, and posterior white horns).

2. Major Divisions of the Peripheral Nervous System (GENERAL CONCEPT OF PNS)

CRANIAL NERVES (and their ganglia) : 12 pairs that exit the skull through the foramina

I. Olfactory (A) VII. Facial (A/E)

II. Optic (A) VIII. Vestibulocochlear (A)
III. Oculomotor (A/E) IX. Cochlear (A/E)
IV. Trochlear (E) X. Vagus (A)
V. Trigeminal (A/E) XI. Accessory (E)
VI. Abducent (E) XII. Hypoglossal (E)
PNS
SPINAL NERVES (and their ganglia) : 31 pairs that exit the vertebral column through
the intervertebral foramina
CERVICAL (8)
THORACIC (12)
LUMBAR (5)
SACRAL (5)
COCCYGEAL (1) based on origin

SENSORY (AFFERENT) based on function

PNS SOMATIC
MOTOR (EFFERENT) AUTONOMIC SYMPHATETIC
PARASYMPHATETIC
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Roots (1):
- The anterior root : consists of bundles of efferent nerve fibers / motor fibers carrying nerve impulses away from
the central nervous system (at anterior gray horn of the spinal cord) to go to skeletal muscles (by neuromuscular
junction).
- The posterior root : consists of bundles of afferent nerve fibers / sensory fibers carrying nerve impulses (such as
sensations of touch, pain, temperature, and vibration) to the central nervous system (at posterior gray horn).

SPINAL → P. root of SN → SPINAL P. rami of spinal nerve (smaller) EMERGED back side of body
CORD ← A. root of SN ← NERVE A. rami of spinal nerve (larger) PLEXUS front side and limbs

Contains motor and sensory fibers; located at level of intervertebral foramina emerged of rami from some levels

- In the upper cervical region, the spinal nerve roots are short and run almost horizontally.
- In the lower level of the first lumbar vertebra, the roots of the lumbar and sacral nerves form cauda equina
(a long vertical leash of nerves around the filum terminale).

Vertebrae Spinal Segment

Cervical vertebrae Add 1
Upper thoracic vertebrae Add 2
Lower thoracic vertebrae (7–9) Add 3
10th thoracic vertebra L1-2 cord segments
11th thoracic vertebra L3-4 cord segments
12th thoracic vertebra L5 cord segment
1st lumbar vertebra Sacral and coccygeal cord segments
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Ganglia (2)
Are the ovoid structures containing many of neuronal cell bodies and glial cells supported by connective tissues.
It serves as relay stations to transmit nerve impulses, one nerve enters and another exits from each ganglion.
The direction of the nerve impulse determines whether the ganglion will be a sensory or an autonomic ganglion.

a. Sensory Ganglia: fusiform swellings on posterior root of each spinal nerve and cranial nerves V, VII, VIII, IX, X.
- Sensory ganglia receive afferent impulses that go to the CNS
- Each ganglion is surrounded by a layer of connective tissue, continuous with the epineurium and perineurium
of the peripheral nerve.
- Neurons are UNIPOLAR, possessing cell bodies that tend to be separated by nerve fibers bundles, which allow
the nerve impulse passes directly from the peripheral axon to the central axon when reaching the T junction.
- A single nonmyelinated process leaves cell body and, after a convoluted course, bifurcates at a T junction into:
*Peripheral branches, where the former axon terminates in a series of dendrites.
*Central branches, where the latter axon enters the central nervous system.
- Each nerve cell body is COMPLETELY surrounded by capsular cells or satellite cells (flattened sheet-like
extensions of small glial cells derived from neural crest cells), which is create the microenvironments of the
nerve cell body, allowing the production of membrane action potentials and regulating metabolic exchange.

b. Autonomic ganglia (sympathetic and parasympathetic ganglia): fusiform swellings on along the course of
efferent nerve fibers of the autonomic nervous system, at a distance from the brain and spinal cord.
- Effect the activity of smooth muscle, the secretion of some glands, modulate cardiac rhythm and other
involuntary activities by which the body maintains a constant internal environment (homeostasis).
- Found in the sympathetic trunks, in prevertebral autonomic plexuses (e.g., in the cardiac, celiac, and
mesenteric plexuses), and as ganglia in or close to viscera.
- Each ganglion is surrounded by a layer of connective tissue, continuous with the epineurium and perineurium
of the peripheral nerve.
- Neurons are MULTIPOLAR, possessing cell bodies that are irregular in shape.
- The dendrites of the neurons make synaptic connections with the myelinated axons of preganglionic neurons.
- The axons of the neurons are small diameter (C fibers) and unmyelinated nerve fibers, and pass to viscera,
blood vessels, and sweat glands.
- Each nerve cell body is INCOMPLETELY surrounded by capsular cells or satellite cells (a layer of flattened cells),
which is similar in structure to Schwann cells.
- Autonomic nerves comprise an autonomic nervous system with two parts (symphatetic and parasymphatetic):
* Preganglionic sympathetic division : in the thoracic and lumbar segments of the spinal cord
* Preganglionic parasympathetic division : in the medulla & midbrain, and in the sacral segment of spinal cord.
** Postganglionic symphatetic division : in small ganglia along the vertebral column.
** Postganglionic parasymphatetic division : in very small ganglia located near or within the effector organs.
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Plexuses (3)
- A network of nerves composed of nerve fiber bundles, as result from joining some of peripheral nerve branches
that allows individual nerve fibers to pass from one peripheral nerve to another, thus permits a redistribution of
the nerve fibers within the different peripheral nerves.
- At the root of the limbs, the anterior rami of the spinal nerves form complicated plexuses:
* The cervical and brachial plexuses are at the root of the upper limbs.
* The lumbar and sacral plexuses are at the root of the lower limbs.
- Cutaneous nerves form fine plexuses before they reach their terminal sensory endings.
- The autonomic nervous system forms numerous nerve plexuses that consist of preganglionic and postganglionic
nerve fibers and ganglia.
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Embryology of Cerebral Hemisphere

3rd week
Continue to elevate and Begin in cervical region
Slipper-shaped plate of thickened Elevation of the
approach to each other
ectoderm (neural plate) lateral edges
Proceeds in cephalic and
fuse caudal directions

neural folds
neural tubes Open ends of the neural tube
Prosencephalon (forebrain)
4thweek
Dilations Cranial and caudal neuropores
Mesencephalon (midbrain) (primary
brain
vesicles)
Rhombencephalon (hindbrain)

Cervical flexure (at junction of the

hindbrain and the spinal cord)
flexures
Cephalic flexure (in midbrain region)

5thweek

 Cerebral hemisphere as bilateral evaginations of the lateral wall of the prosencephalon

 With further expansion, the hemispheres cover the lateral aspect of the diencephalon,
mesencephalon, and cephalic portion of the metencephalon

7thweek

 Continuous growth of the cerebral hemispheres in anterior, dorsal, and inferior

directions results in the formation of frontal, temporal, and occipital lobes.
 Area between the frontal and temporal lobes becomes depressed and is known as the
insula

9thweek

 During the final part of fetal life, the surface of the cerebral hemispheres grows so
rapidly that a great many convolutions (gyri) separated by fissures and sulci appear on
its surface
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Anatomy of Cerebral Hemisphere

Main Sulci
 The central sulcus is of great importance because :
 the gyrus that lies anterior to it contains the motor cells
 posterior to it lies the general sensory cortex that receives sensory information from the opposite side of the body
 The lateral sulcus is a deep cleft found mainly on the inferior and lateral surfaces of the cerebral hemisphere.
 Consists of a short stem that arises on the inferior surface and on reaching lateral surface
 Stem divides into three rami: the anterior horizontal ramus, the anterior ascending ramus, the posterior ramus.
 An area of cortex called the insula lies at the bottom of the deep lateral sulcus and cannot be seen from the surface unless the lips
of the sulcus are separated
 The parieto-occipital sulcus begins on the superior medial margin of the hemisphere about 2 inches (5 cm) anterior to the occipital pole,
passes downward and anteriorly on the medial surface to meet the calcarine sulcus
 The calcarine sulcus is found on the medial surface of the hemisphere. It commences under the posterior end of the corpus callosum
and arches upward and backward to reach the occipital pole, where it stops.

Lobes of cerebral hemisphere

Superolateral Surface of the Hemisphere
 The frontal lobe occupies the area anterior to the central sulcus
and superior to the lateral sulcus.
o The precentral sulcus runs parallel to the central sulcus, and the precentralgyrus lies between them
 The parietal lobe occupies the area posterior to the central sulcus and superior to
the lateral sulcus; it extends posteriorly as far as the parieto-occipital sulcus.
o The postcentral sulcus runs parallel to the central sulcus, and the
postcentralgyrus lies between them.
 The temporal lobe occupies the area inferior to the lateral sulcus.
o The superior and middle temporal sulci run parallel to the posterior ramus
of the lateral sulcus and divide the temporal lobe into the superior,
middle,and inferior temporal gyri
 The occipital lobe occupies the small area behind the parieto-occipital sulcus
Medial and Inferior Surfaces of the Hemisphere
 The corpus callosum, which is the largest commissure of the brain
 The cingulate gyrus
 The paracentral lobule
 The precuneus
 The cuneus
 The collateral sulcus.
 Anterior to the lingual gyrus is the parahippocampalgyrus
 The medial occipitotemporalgyrus
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Internal Structure of the Cerebral Hemispheres

 Lateral Ventricle
 Basal Nuclei
The corpus striatum is situated lateral to the thalamus. It is almost completely divided by a band of nerve fibers, the internal
capsule,into the caudate nucleus and the lentiform nucleus.
o The caudate nucleus,large C-shaped mass of gray matter that is closely related to the lateral ventricle, lies lateral to the thalamus.
o The lateral surface of the nucleus is related to the internal capsule, which separates it from the lentiform nucleus
o The lentiform nucleus is a wedge-shaped mass of gray matter whose broad convex base is directed laterally and its blade medially
o The claustrum, in turn, separates the external capsule from the subcortical white matter of the insula
The amygdaloid nucleus is situated in the temporal lobe close to the uncus, considered as a part of limbic system
The claustrum is a thin sheet of gray matter that is separated from the lateral surface of the lentiform nucleus by the external capsule
White matter of cerebral hemisphere
 Commisure fibers
Connect corresponding regions of the two hemispheres: the corpus callosum, the anterior commissure, the posterior commissure, the
fornix, and the habenular commissure
 Association fibers
Connect various cortical regions within the same hemisphere and may be divided into short and long groups.
 The short association fibers lie beneath the cortex and connect adjacent gyri
 The long association fibers are collected into named bundles that can be dissected in a formalin-hardened brain.
 Projection Fibers
Afferent and efferent nerve fibers passing to and from the brainstem to the entire cerebral cortex must travel between large nuclear
masses of gray matter within the cerebral hemisphere. At the upper part of the brainstem, these fibers form a compact band known as
the internal capsule,which is flanked medially by the caudate nucleus and the thalamus and laterally by the lentiform nucleus
 Septum pellucidum
is a thin vertical sheet of nervous tissue consisting of white and gray matter covered on either side by ependyma. It stretches between
the fornix and the corpus callosum. It is essentially a double membrane with a closed, slitlike cavity between the membranes
 The telachoroidea
is a two-layered fold of pia mater. It is situated between the fornix superiorly and the roof of the third ventricle and the upper surfaces
of the two thalami inferiorly.

Histology of Cerebral Hemisphere

Nerve cells of Cerebral cortex
1. Pyramidal cells (giant pyramidal cells : betz cells)
2. Stellate cells (granule cells) : small size, polygonal in shape, short axon,
terminates on nearby neurons
3. Fusiform cells : long axis vertical to the surface and are considerated
mainly in the deepest cortical layers. Inferior dendrite branches within
the same cellular layer, while the superficial layer dendrite ascends
toward the surface of the cortex and branches in the superficial layers.
4. Horizontal cells of Cajar : small, fusiform, horizontally oriented cells in
the most superfiscial layers of the cortex
5. Cells of Martinotti : small, multipolar cells that are present throughout
the levels of the cortex, where it ends in more superfiscial layer
Nerve fibers of Cerebral Cortex
1. The radial fibers. Run at right angles to the cortical surface.
2. The tangential fibers. Run parallel to the cortical surface.
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Layers of cerebral cortex

1. Molecular layer (plexiform layer) consist of tangentially oriented nerve fibers.
2. External granular layer. Contains large numbers of small pyramidal cells and stellate cells.
3. External pyramidal layer. Composed of pyramidal cells, whose cell body size increases from the superficial to the deeper borders of layer.
4. Internal granular layer. Composed of closely packed stellate cells. There is a high concentration of horizontally arranged fibers known
collectively as the external band of Baillarger.
5. Ganglionic layer (internal pyramidal layer). Contains very large and medium-size pyramidal cells. Scattered among the pyramidal cells are
stellate cells and cells of Martinotti.
6. Multiform layer (layer of polymorphic cells). Majority of the cells are fusiform, many of the cells are modified pyramidal cells, whose cell
bodies are triangular or ovoid.

Physiology of Cerebral Hemisphere

A. Frontal Lobe
Area
Precentral Area
primary motor area (Brodmann
area 4)
premotor area/ secondary motor
(Brodmann area 6 and parts of
areas 8, 44, and 45)
Supplementary motor area
Frontal eye field(Broadmann
areas 6, 8, and 9)
Motor Speech areas of Broca
(Brodmann areas 44 and 45).
Prefrontal cortex (Brodmann
areas 9, 10, 11, and 12)
Location
Posterior region
Anterior region
In the medial frontal gyrus on the medial
surface of hemisphere and anterior to the
paracentral lobule
Extends forward from the fascial area of
precentralgyrus into middle frontal gyrus
between anterior and ascending rami and
ascending the ascending and posterior rami of
the lateral fissure
Includes the greater parts of the superior,
middle, and inferior frontal gyri; the orbital
gyri; most of the medial frontal gyrus; and
the anterior half of the cingulate gyrus
Function
produces isolated movements on the opposite side of the body as
well as contraction of muscle groups concerned with the performance
of a specific movement., carry out the individual movements of
different parts of the body
produces muscular movements similar to those obtained by
stimulation of the primary motor area; however, stronger stimulation
is necessary to produce the same degree of movement, store
programs of motor activity assembled as the result of past experience
Conjugate movements of eyes, esp toward opposite side
Brings about the formation of words by its connections with
the adjacent primary motor areas
concerned with the makeup of the individual's personality
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B. Parietal Lobe
Area Location Function
Primary Somesthetic Area/Primary somatic Postcentralgyrus receive projection fibers from the ventral posterior lateral
sensory cortex S1 (Broadmann areas 1, 2, 3) and ventral posterior medial nuclei of the thalamus
Secondary somesthetic area/secondary somatic Superior lip of the posterior limb Neurons respond particularly to transient cutaneous stimuli,
sensory cortex S2 of the lateral fissure continue from primary somesthetic area
Somesthetic association area (Broadmann 5 Posterior of primary Receive and integrate different sensory modalities, recognize
and 7) somatosensory area things without seeing

C. Occipital Lobe
Area Location Function
Primary visual area (Brodmann area 17) Walls of the posterior part of the Receive visual impulse
calcarine sulcus
Secondary visual area/ visual association Surrounds the primary visual area Relate the visual information received by the primary visual
(Broadmann area 18 and 19) on the medial and lateral surfaces area to past visual experiences, enabling the individual to
recognize and appreciate what he or she is seeing
Occipital eye fields to be reflex and associated movements of eye when it is
following an object
D. Temporal Lobe
Area Location Function
Primary auditory area (Brodmann area 41 Inferior wall of lateral sulcus Reception of sound
and 42)
Secondary auditory area/ auditory association Posterior to the primary auditory Receives impulses from the primary auditory area and from
(Brodmann area 22) area in the lateral sulcus and in the thalamus
the superior temporal gyrus
Sensory speech area of Wernicke (Brodmann Left dominant hemisphere mainly permits the understanding of the written and spoken
area 22, 39, 40) in the superior temporal gyrus language and enables a person to read a sentence,
understand it, and say it out loud

E. Other Cortical Area

Area
Primary gustatory area
(Brodmann area 43)
Secondary olfactory area
(Brodmann area 28)
Vestibular area
Insula
Location Function
Lower end of the postcentralgyrus in the superior wall of the Taste area
lateral sulcus and in the adjoining area of the insula.
Smell area
Near the part of the postcentralgyrus/ opposite the auditory Sensations of the face
area in the superior temporal gyrus
Buried within the lateral sulcus and forms its floor Planning or coordinating the articulatory
movements necessary for speech

CEREBELLUM
ANATOMY
 The cerebellum is situated in the posterior cranial fossa and is covered superiorly by the tentorium cerebella
(duramater, separates the cerebrum with cerebellum)
 It is the largest part of the hindbrain and lies posterior to the fourth ventricle, the pons, and the medulla
oblongata.
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 The cerebellum is ovoid in shape and constricted in its median part. It consists of two cerebellar hemispheres
joined by a narrow median vermis. The cerebellum is connected to the posterior aspect of the brainstem by
three symmetrical bundles of nerve fibers called the superior, middle, and inferior cerebellar peduncles.

The cerebellum is divided into three main lobes:

 The anterior lobe may be seen on the superior surface of the cerebellum and is separated from the
middle lobe by a wide V-shaped fissure called the primary fissure.
 The middle lobe (sometimes called the posterior lobe), which is the largest part of the cerebellum, is
situated between the primary and uvulonodular fissures.
 The flocculonodular lobe is situated posterior to the uvulonodular fissure.
 A deep horizontal fissure that is found along the margin of the cerebellum separates the superior from the
inferior surfaces; it is of no morphologic or functional significance.
 The cerebellum also divided in sagital subdivision: consist of
Vermis in the middle of cerebellum divided it into right and left hemisphere.

HISTOLOGY
The cerebellum is composed of an outer covering of gray matter called the cortex and inner white matter.
Embedded in the white matter of each hemisphere are three masses of gray matter forming the intracerebellar
nuclei.
Cerebellar Cortex
The cerebellar cortex can be regarded as a large sheet with folds lying in the coronal or transverse plane (folium).
The gray matter of the cortex throughout its extent has a uniform structure. It may be divided into three layers:
(1) an external layer, the molecular layer;
The molecular layer contains two types of neurons: the outer stellate cell and the inner basket cell. Neuroglial
cells are found between these structures.
(2) a middle layer, the Purkinje cell layer;
The Purkinje cells are large Golgi type I neurons. They are flask shaped and are arranged in a single layer in a plane
transverse to the folium, the dendrites of these cells are seen to pass into the molecular layer, where they undergo
profuse branching. The primary and secondary branches are smooth, and subsequent branches are covered by
short, thick dendritic spines. It has been shown that the spines form synaptic contacts with the parallel fibers
derived from the granule cell axons.
At the base of the Purkinje cell, the axon arises and passes through the granular layer to enter the white matter.
On entering the white matter, the axon acquires a myelin sheath, and it terminates by synapsing with cells of one
of the intracerebellar nuclei. Collateral branches of the Purkinje axon make synaptic contacts with the dendrites of
basket and stellate cells of the granular layer in the same area or in distant folia. A few of the Purkinje cell axons
pass directly to end in the vestibular nuclei of the brainstem.
(3) an internal layer, the granular layer.
The granular layer is packed with small cells with densely staining nuclei and scanty cytoplasm called granular cell.
Each cell gives rise to four or five dendrites, which make clawlike endings. The axon of each granule cell passes into
the molecular layer. These fibers, known as parallel fibers, run at right angles to the dendritic processes of the
Purkinje cells. Most of the parallel fibers make synaptic contacts with the spinous processes of the dendrites of the
Purkinje cells. Neuroglial cells are found throughout this layer. Scattered throughout the granular layer are Golgi
cells. Their dendrites ramify in the molecular layer, and their axons terminate by splitting up into branches that
synapse with the dendrites of the granular cells.
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Intracerebellar Nuclei
Four masses of gray matter are embedded in the white matter of the cerebellum on each side of the midline. From
lateral to medial, these nuclei are
(1) The dentate nucleus is the largest of the cerebellar nuclei. It has the shape of a crumpled bag with the
opening facing medially. The interior of the bag is filled with white matter made up of efferent fibers that
leave the nucleus through the opening to form a large part of the superior cerebellar peduncle.
(2) The emboliform nucleus is ovoid and is situated medial to the dentate nucleus, partially covering its hilus.
(3) The globose nucleus consists of one or more rounded cell groups that lie medial to the emboliform
nucleus.
(4) The fastigial nucleus lies near the midline in the vermis and close to the roof of the fourth ventricle; it is
larger than the globose nucleus.
The intracerebellar nuclei are composed of large, multipolar neurons with simple branching dendrites. The axons
form the cerebellar outflow in the superior and inferior cerebellar peduncles.
White Matter
The white matter is made up of three groups of fibers:
(1) The intrinsic fibers do not leave the cerebellum but connect different regions of the organ.
(2) The afferent fibers(greater part) They enter the cerebellar cortex mainly through the inferior and middle
cerebellar peduncles.
(3) The efferent fibers. The great majority of the Purkinje cell axons pass to and synapse with the
intracerebellarnuclei. The axons of the neurons then leave the cerebellum. A few Purkinje cell axons in the
flocculonodular lobe and in parts of the vermis bypass the cerebellar nuclei and leave the cerebellum
without synapsing.
Fibers from the dentate, emboliform, and globose nuclei leave the cerebellum through the superior cerebellar
peduncle. Fibers from the fastigial nucleus leave through the inferior cerebellar peduncle.
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Cerebellar Peduncles
The cerebellum is linked to other
parts of the central nervous system by
numerous efferent and afferent fibers
that are grouped together on each
side into three large bundles, or
peduncles. The superior cerebellar
peduncles connect the cerebellum to
the midbrain, the middle cerebellar
peduncles connect the cerebellum to
the pons, and the inferior cerebellar
peduncles connect the cerebellum to
the medulla oblongata.

PHYSIOLOGY
The cerebellum plays a very important role in the control of posture and voluntary movements. Also as a
coordinator of precise movements by continually comparing the output of the motor area of the cerebral cortex
with the proprioceptive information received from the site of muscle action; it is then able to bring about the
necessary adjustments by influencing the activity of the lower motor neurons. This is accomplished by controlling
the timing and sequence of firing of the alpha and gamma motor neurons. It is also believed that the cerebellum
can send back information to the motor cerebral cortex to inhibit the agonist muscles and stimulate the antagonist
muscles, thus limiting the extent of voluntary movement. Each cerebellar hemisphere controls muscular
movements on the same side of the body. Important in balancing, cognitive, and language.
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Anatomy and Physiology of Brain Stem

- Brainstem is part of brain between spinal cord and
diencephalon
- It is made up of medulla oblongata, pons, and midbrain
occupies the posterior cranial fossa of the skull

Medulla Oblongata

- Continuous with the superior part of the spinal cord and forms the inferior part of the brain stem
- Begins at the foramen magnum and extends to the inferior border of the pons
- Medulla’s white matter contains all sensory (ascending) tracts and motor (descending) tracts that extend between the spinal cord and
other parts of the brain.
- Some of the white matter forms bulges on the anterior aspect of the medulla. These protrusions, called the pyramids, are formed by the
large corticospinal tracts that pass from the cerebrum to the spinal cord. Just superior to the junction of the medulla with the spinal
cord, 90% of the axons in the left pyramid cross to the right side, and 90% of the axons in the right pyramid cross to the left side.
This crossing is called the decussation of pyramids
- Just lateral to each pyramid is an oval-shaped swelling called an olive).
- Within the olive is the inferior olivary nucleus, which receives input from the cerebral cortex, red nucleus of the midbrain, and spinal
cord. Neurons of the inferior olivary nucleus extend their axons into the cerebellum, where they regulate the activity of cerebellar
neurons. By influencing cerebellar neuron activity, the inferior olivary nucleus provides instructions that the cerebellum uses to make
adjustments to muscle activity as you learn new motor skills.
- The medulla also contains several nuclei. Some of these nuclei control vital body functions.
o The cardiovascular center regulates the rate and force of the heartbeat and the diameter of blood vessels
o The medullary rhythmicity area of the respiratory center adjusts the basic rhythm of breathing normal breathing rhythm
o The vomiting center of the medulla causes vomiting
o The deglutition center of the medulla promotes swallowing
o Sneezing involves spasmodic contraction of breathing muscles
o Coughing involves a long drawn and deep inhalation
o Hiccupping is caused by spasmodic contractions of the diaphragm
- Nuclei associated with sensations of touch, pressure, vibration, and conscious proprioception are located in the posterior part of the
medulla. These nuclei are the right and left gracile nucleus and cuneate nucleus.
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- Ascending sensory axons of the gracile fasciculus and the cuneate fasciculus, which are two tracts in the posterior columns of the spinal
cord, form synapses in these nuclei. Postsynaptic neurons then relay the sensory information to the thalamus on the opposite side of the
brain. The axons ascend to the thalamus in a band of white matter called the medial lemniscus, which extends through the medulla,
pons, and midbrain. The tracts of the posterior columns and the axons of the medial leminiscus are collectively known as the posterior
column–medial lemniscus pathway.
- The medulla also contains nuclei that are components of sensory pathways: gustation (taste), audition (hearing), and equilibrium (balance).
o The gustatory nucleus of the medulla is part of the gustatory pathway from the tongue to the brain; it receives gustatory input from
the taste buds of the tongue
o The cochlear nuclei of the medulla are part of the auditory pathway from the inner ear to the brain; they receive auditory input
from the cochlea of the inner ear
o The vestibular nuclei of the medulla and pons are components of the equilibrium pathway from the inner ear to the brain; they
receive sensory information associated with equilibrium from proprioceptors in the vestibular apparatus of the inner ear.
- Finally, the medulla contains nuclei associated with five pairs of cranial nerves: vestibulocochlear (VIII) nerves, glossopharyngeal (IX)
nerves, vagus (X) nerves, accessory (XI) nerves (cranial portion), and hypoglossal (XII) nerves.
Pons
- Lies directly superior to the medulla and anterior to the cerebellum
- The pons is a bridge that connects different parts of the brain with one
another. These connections are provided by bundles of axons.
- Like the medulla, the pons consists of nuclei, sensory tracts, and motor
tracts.
o Signals for voluntary movements from motor areas of the cerebral cortex
are relayed through several pontine nuclei into the cerebellum.
o Along with the medulla, the pons contains vestibular nuclei that are
components of the equilibrium pathway from the inner ear to the brain.
o Other nuclei in the pons are the pneumotaxic area and the apneustic
area of the respiratory center. Together with the medullary rhythmicity
area, the pneumotaxic and apneustic areas help control breathing.
- The pons also contains nuclei associated with the following four pairs of
cranial nerves: trigeminal (V) nerves, abducens (VI) nerves, facial (VII) nerves,
and vestibulocochlear (VIII) nerves.

Midbrain
- The midbrain extends from the pons to the diencephalon
- The aqueduct of the midbrain (cerebral aqueduct) passes
through the midbrain, connecting the third ventricle above with
the fourth ventricle
- Like the medulla and the pons, the midbrain contains both
nuclei and tracts.
- The anterior part of the midbrain contains paired bundles of
axons known as the cerebral peduncles. The cerebral peduncles
consist of axons of the corticospinal, corticopontine, and
corticobulbar tracts, which conduct nerve impulses from motor
areas in the cerebral cortex to the spinal cord, pons, and
medulla, respectively.
- The posterior part of the midbrain, called the tectum, contains
four rounded elevations
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- The two superior elevations, nuclei known as the superior colliculi,

serve as reflex centers for certain visual activities. Through neural
circuits from the retina of the eye to the superior colliculi to the
extrinsic eye muscles, visual stimuli elicit eye movements for tracking
moving images (such as a moving car) and scanning stationary
images (as you are doing to read this sentence). The superior
colliculi are also responsible for reflexes that govern movements of
the head, eyes, and trunk in response to visual stimuli.
- The two inferior elevations, the inferior colliculi, are part of the
auditory pathway, relaying impulses from the receptors for hearing
in the inner ear to the brain. These two nuclei are also reflex
centers for the startle reflex, sudden movements of the head, eyes,
and trunk that occur when you are surprised by a loud noise
- The midbrain contains several other nuclei:
o Left and right substantianigra, which large and darkly pigmented
o Left and right red nuclei, which look reddish due to their rich
blood supply and an iron-containing pigment in neuronal cell bodies
- Still other nuclei in the midbrain are associated with two pairs of cranial nerves: oculomotor (III) nerves and trochlear (IV) nerves

Brain Vascularization, Circle of Willis, and Cerebral Blood Flow

A. Arteries of the Brain
- Supplied by the two internal carotid and the two vertebral arteries.
- The four arteries lie within the subarachnoid space
Internal Carotid Artery
Common carotid artery
A localized dilatation: carotid sinus

Internal carotid artery Passing through carotid canal of temporal bone

Ophthalmic cerebral Posterior communicating Choroidal artery Horizontally through cavernosus sinus
artery artery
Emerges on medial side of the anterior clinoid
Anterior cerebral arteries Middle cerebral arteries by perforating the dura mater

Turn posteriorly to the region of medial end of Piercing arachnoid mater to enter
lateral cerebral sulcus subarachnoid space

Branches:
- Ophthalmic artery: enters through optic canal below and lateral to the optic nerve
- Posterior communicating artery: Runs posteriorly above occulomotor nerve to join the
posterior cerebral artery
- Choroidal artery: Passes Pass posteriorly close to optic tract, enters the inferior horn of the
lateral ventricle, ends in the choroid plexus
- Anterior cerebral artery:smallest branch of ICA, runs forward & medially superior to optic nerve
and enters longitudional fissure of cerebrum
- Middle cerebral artery: largest branch of ICA, runs laterally in lateral cerebral sulcus
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Vertebral Artery
Passing through foramina of Enter skull through
Sub arachnoid space
the upper six cervical vertebrae foramen magnum
Subclavian artery
Medulla oblongata

Vertebral artery
Join with vessel
Branches of Cranial portion Basilar artery of opposite side

Meningeal Anterior Medullary Pontine Anterior-inferior Posterior

branches spinal artery arteries arteries cerebellar artery cerebral artery

Posterior Posterior-inferior Labyrinthine Superior

spinal artery cerebral artery artery cerebellar artery

Branches of cranial portion:

- Meningeal branches: small; supply bone and dura in posterior cranial fossa
- Posterior spinal artery: descends on posterior surface of spinal cord
close to posterior root of spinal nerve
- Anterior spinal artery: is formed from a contributory branch from
each vertebral artery near its termination
- Posterior inferior cerebellar artery: largest branch of vertebral artery,
passes on an irregular course between the medulla & the cerebellum
- Medullary arteries: very small branches that are distributed to the
medulla oblongata
Branches of basilar artery:
- Pontine arteries: small vessel, enters pons
- Labyrinthine artery: long, narrow artery; supplies internal ear
- Anterior inferior cerebellar artery: supplies anterior and inferior cerebellum
- Superior cerebellar artery: supplies superior cerebellum, pons, pineal gland,
and superior medullary velum
- Posterior cerebellar artery: joined by posterior communicating branch of ICA
Cortical branch: supply inferolateral and medial surface of temporal lobe and lateral and medial surface of occipital lobe
Central branch: supply part of thalamus, lentiform nucleus, midbrain, pineal, and medial geniculate bodies
Choroidal branch: enters inferior horn of lateral ventricle; supplies choroid plexus and choroid plexus of 3rd ventricle

B. Circle of Willis
- Lies in interpeduncular fossa at the base of the brain
- Formed by the anastomosis between two internal carotid arteries
and two vertebral arteries
- Contains a posterior communicating artery and an anterior
communicating artery on each side
- Function: allow blood that enters by either internal carotid or
vertebral arteries to be distributed to any part of cerebral
hemisphere
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C. Veins of the Brain

- No muscular tissue in their very thin walls, no valves
- Emerge from the brain and lie in the subarachnoid space
- Pierce the arachnoid mater and the meningeal layer of the dura
- Drain into the cranial venous sinuses
External Cerebral Veins
Superior cerebral veins:pass upward over the lateral surface of the
cerebral hemisphere
Superficial middle cerebral vein:drains the lateral surface of the
cerebral hemisphere; runs inferiorly in the lateral sulcus
Deep Middle cerebral vein: drains the insula; joined by the anterior
cerebral and striate veins to form the
basal vein
InternalCerebral Veins
- Union of the thalamostriate vein and the choroid vein at the interventricular foramen

D. Cerebral Blood Flow

Normal Rate of Cerebral Blood Flow
- Adult person: + 50-65ml/100g brain tissue/minute
- For entire brain: 750-900ml/minute or 15% or resting cariac output
Regulation of Cerebral Blood Flow
3 metabolic factors potent in controlling blood flow:
Carbon Dioxide concentration
Hydrogen ion concentration
Oxygen concentration
Cerebral Blood Flow with Carbon Dioxide and Hydrogen Ion
Vasodilation of
Carbon Dioxide + Carbonic Acid Hydrogen ions cerebral vessels
Water in body fluid
(Î cerebral blood flow)

Cerebral Blood Flow with Oxygen

- Rate of utilization: 3.5(+0.2) ml of O2/100g of brain tissue/minute

Vasodilation of
Oxygen deficiency | cerebral tissue PO2 Brain function deranged cerebral vessels
(Î cerebral blood flow)

Cerebral Blood Flow with Arterial Pressure Changes (Autoregulation)

- Between Arterial Pressure limits of 60 and 140 mmHg
- Autoregulation: compensatory lowering of cerebral vascular
resistance/ raising of the vascular resistance
Cerebral Blood Flow with Sympathetic Nervous System
- Cerebral circulatory system has strong sympathetic innervation that
passes upward from the superior cervical sympathetic ganglia in
the neck and then into the brain along with the cerebral arteries
- Transection of sympathetic nerve causes change in cerebral blood
flow
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Sympathetic Nervous System Prevent high pressure

Preventing vascular
Arterial pressure rises constrict large and reaching small brain
hemorrhages into the brain
intermediate brain artery blood vessel

Cerebral Microcirculation
- Metabolic rate, number of capillaries and rate of blood flow of gray matter 4x of white matter
- Brain capillaries much less “leaky” than the blood capillaries in almost any tissue of the body Capillaries supported on all sides by
“glial feet”, small projections from surrounding glial cells
- Function of glial feet: against all surfaces of the capillaries and provide physical support to prevent overstretching of the capillaries in
case of high capillary blood pressure

Cranial Nerve
Location of Nerve
Nerve Components Cranial Exit Main Action(s)
Cell Bodies
Olfactory (CN I) Special sensory Olfactory epithelium Foramina in cribriform Smell from nasal mucosa of roof of each nasal cavity and superior
(olfactory cells) plate of ethmoid bone sides of nasal septum and superior concha
Optic (CN II) Special sensory Retina (ganglion cells) Optic canal Vision from retina
Oculomotor (CN Somatic motor Midbrain Motor to superior rectus, inferior rectus, medial rectus, inferior
III) oblique, and levatorpalpebraesuperioris muscles; raises superior
eyelid; turns eyeball superiorly, inferiorly, and medially
Visceral motor
Presynaptic: midbrain Parasympathetic innervation to sphincter of pupil and ciliary
Superior orbital fissure
Postsynaptic: ciliary muscle; constricts pupil and accommodates lens of eye
ganglion
Trochlear (CN IV) Somatic motor Midbrain Motor to superior oblique that assists in turning eye infero-laterally
(or inferiorly when adducted)
Trigeminal (CN V)
Ophthalmic (CN Superior orbital fissure Sensation from cornea, skin of forehead, scalp, eyelids, nose, and
V1) mucosa of nasal cavity and paranasal sinuses
Maxillary (CN V2) Foramen rotundum Sensation from skin of face over maxilla, including upper lip,
General sensory Trigeminal ganglion maxillary teeth, mucosa of nose, maxillary sinuses, and palate
Mandibular (CN V3) Foramen ovale Sensation from skin and over side of head mandible including lower
lip, mandibular teeth, temporomandibular joint, mucosa of mouth
and anterior two thirds of tongue
Branchial motor Pons Motor to muscles of mastication, mylohyoid, anterior belly of
digastric, tensor velipalatini, and tensor tympani
Abducent (CN VI) Somatic motor Pons Superior orbital fissure Motor to lateral rectus that turns eye laterally
Facial (CN VII) Branchial motor Pons Motor to muscles of facial expression and scalp; also supplies
stapedius of middle ear, stylohyoid, and posterior belly of digastric
Special sensory Geniculate ganglion Taste from anterior two thirds of tongue and the palate
Visceral motor Presynaptic: pons Internal acoustic meatus; Parasympathetic innervation to submandibular and sublingual
Postsynaptic: facial canal; stylomastoid salivary glands, lacrimal gland, and glands of nose and palate
pterygopalatine foramen
ganglion;
submandibular
ganglion
Vestibulocochlear
(CN VIII)
Vestibular Special sensory Vestibular ganglion Vestibular sensation from semicircular ducts, utricle, and saccule
Internal acoustic meatus
related to position and movement of head
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Cochlear Special sensory Spiral ganglion Hearing from spiral organ

Glossopharyngeal Branchial motor Medulla Motor to stylopharyngeus to assist with swallowing
(CN IX) Visceral motor Presynaptic: medulla Parasympathetic innervation to parotid gland

Postsynaptic: otic
ganglion
Visceral sensory Superior ganglion
Special sensory Inferior ganglion
General sensory Inferior ganglion
Visceral sensation from parotid gland, carotid body and sinus,
pharynx, and middle ear
Taste from posterior third of tongue
Cutaneous sensation from external ear

Vagus (CN X) Branchial motor Medulla Motor to constrictor muscles of pharynx (except stylopha-ryngeus),
intrinsic muscles of larynx, muscles of palate (except tensor
Jugular foramen velipalatini), and striated muscle in superior two thirds of
esophagus
Visceral motor Presynaptic: medulla Parasympathetic innervation to smooth muscle of trachea, bronchi,
Postsynaptic: neurons digestive tract, and cardiac muscle of heart
in, on, or near viscera
Visceral sensory Superior ganglion Visceral sensation from base of tongue, pharynx, larynx, trachea,
bronchi, heart, esophagus, stomach, and intestine to left colic
flexure
Special sensory Inferior ganglion Taste from epiglottis and palate
General sensory Superior ganglion Sensation from auricle, external acoustic meatus, and dura mater of
posterior cranial fossa
Spinal accessory Somatic motor Spinal cord Motor to sternocleidomastoid and trapezius
(CN XI)
Hypoglossal (CN Somatic motor Medulla Hypoglossal canal Motor to intrinsic and extrinsic muscles of tongue (except
XII) palatoglossus)
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Descending Tract
Motor neurons situated in the anterior gray columns of the spinal cord send axons to innervate skeletal muscle through the anterior roots of
the spinal nerves – or lower motor neurons (as the final common pathway to the muscles)
This neurons are constantly bombarded by nervous impulses that descend from the medulla, pons, midbrain, and cerebral cortex, as well as
those that enter along sensory fibers from the posterior roots.
The nerve fibers that descend in the white matter from different supraspinal nerve centers are segregated into nerve bundels – descending
tract (or upper motor neurons); influence motor activity
Function Anatomical Organization
3 neurons:
First-order neuron: cerebral cortex
Second-order neuron: anterior gray column
Third-order neuron: lower motor neuron
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GENERAL CONCEPT OF UPPER MOTOR NEURON

Motor neuron merupakan neuron efferent yang mengantarkan impulse dari sistem syaraf pusat ke efektor
sehingga menyebabkan bagian tubuh dapat bergerak.

Motor Neuron dibagi menjadi 3 jenis, yaitu :

1. Upper Motor Neuron : mengantarkan impuls dari nukleus di cerebral cortex ke nukleus di ventral gray horns
pada spinal cord.
2. Peripheral Motor neuron : terletak di peripheral reflex arc, mengantarkan impuls dari interneuron ke otot
skeletal atau otot rangka.
3. Lower Motor Neuron : mengantarkan impuls dari ventral gray horns pada spinal cord ke otot skeletal atau
otot rangka.

Upper Motor neuron:

- First-order neuron and unable to leave CNS
- Responsible for conveying impulses for voluntary motor activity through descending motor pathways that make
up the upper motor neuron
- UMN send fiber to LMN, and that exert direct or indirect supranuclear control over the LMN of the cranial and
spinal nerves.
- UMN control LMN through two different pathways:
* Pyramidal tract (major)
* Extra-pyramidal tract (minor)

a. Pyramidal tract
- This tract is direct and monosynaptic, meaning that the axons of its neurons do not synapse with other cells
until they reach their final destination in the brainstem of spinal cord.
- This direct connection allows messages to be transmitted very rapidly from the CNS to the periphery.
- Pathway:
Motor cortex → Internal capsule → Basis peduncle (midbrain) → Basis pontis (pons) → Pyramids (upper
medulla) → Cross median plane → Form lateral corticospinal tract (lower medulla) → Ventral horn of spinal
cord → Lateral corticospinal tract and Ipsilateral-anterior corticospinal tract
- Pyramidal tract that synapse with cranial nerves located in the brainstem form the corticobulbar tract. This is
the part of the pyramidal tract that carries motor messages that are most important for speech ad swallowing.
To cause a serious speech problem, the lesions of UMN of pyramidal tract must be bilateral. This is called by
pseudo-bulbar palsy

b. Extra-pyramidal tract
- Involved in autonomic motor movements
- Works with autonomic nervous systems
- Component: * Basal ganglia
* Red nucleus
* Substantia nigra
* Reticular formation
* Cerebellum

Manifestation of Syndrome Upper Motor Neuron Syndrome Lower Motor Neuron Syndrome
Type of Paralysis Spastic / Rigid / Kaku Flaccid / Lemas
Athropy Karena jarang digunakan Karena pengurangan volume otot
Physiological Reflex √ X
Superficial Reflex X √
Pathological Reflex Babinski Sign (+) X
Fasciculation X √
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Reflex Arc
An involuntary pathway in response a stimulus

A reflex arc consists of:

- A receptor organ, situated in the skin, muscle, or tendon
- An afferent neuron, its cell body is situated in the posterior
root ganglion
- An effector neuron, is the termination of afferent neuron
- An effector organ, situated in the muscle spindle

Figure A: Multiple branching of afferent fibers entering

the spinal cord and the presence of many internuncial
neurons that synapse with the effector neuron

Figure B: The law of reciprocal innervation

- The flexor and extensor reflexes of the same limb
cannot be made to contract simultaneously.
- The afferent nerve fibers responsible for flexor
reflex muscle action must have branches that
synapse with the extensor motor neurons of the
same limb, causing them to be inhibited.
- A reflex on one side of the body causes opposite
effects on the limb of the other body side, this
crossed extensor reflex may be demonstrated.
- Afferent stimulation of the reflex arc that causes
the ipsilateral limb to flex results in the
contralateral limb being extended.

A monosynaptic reflex arc: a reflex arc involving only one synapse (and occur in very short time).
Criteria: - The afferent fibers has large diameter
- The afferent fibers are rapidly conducting
- The afferent fibers entering the spinal cord frequently branch
- The afferent fibers synapse with many internuncial neurons, which ultimately
synapse with the effector neuron.
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The spinal segmental reflex arc involving motor activity is greatly influenced by higher centers
in the brain, which are mediated through the corticospinal, reticulospinal, tectospinal,
rubrospinal, and vestibulospinal tracts.

Lower motor neuron axons give off collateral branches as they pass through the white matter
to reach the anterior roots of the spinal nerve. These collaterals synapse on neurons described
by Renshaw, which, synapse on the lower motor neurons. These internuncial neurons are
believed to provide feedback on the lower motor neurons, inhibiting their activity.

A: A monosynaptic reflex arc.

B: Multiple neurons synapsing with the lower motor neuron.
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SUMMARY

Cerebral cortex
↓
Thalamus
↓
Brainstem Corticonuclear tract Cranial Nerve
↓
Corticospinal tract Upper
Motor
Neuron

Anterior Lateral
↓ ↓
Tidak menyilang Menyilang di decussition of pyramid
↓ ↓
Postular muscle tone Gray matter of spinal cord
↓
Anterior gray horn
↓
Anterior root
↓
Spinal nerve
Reflex ↓ Lower
Arc Anterior rami Motor
↓ Neuron
Nerve plexus
↓
Neuromuscular junction
↓
Skeletal muscle
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Consciousness= stage of being conscious/aware

Anatomy of Consciousness
Normal consciousness includes the active functioning of two main parts of nervous system:
o Reticular formation -> state of wakefulness
 A net (reticular) that made up of nerve cells and nerve fibers then extends up
through the axis of CNS from spinal cord to the cerebrum
 Consist of deeply placed continuous network of nerve cells and fibers, divide into
3 longitudinal columns:
Median column; consist intermediate-size neurons
Medial column; consist large neurons
Lateral column; consist small neurons
 Inferiorly, continuous with interneurons of gray matter of spinal cord
Superiorly, impulses relayed to cerebral cortex, a substantital projection fibers
leaves reticular formation to enter cerebellum
 Function: control of skeletal muscle, antigravity muscles, respiratory muscles,
muscle of facial expression, control of somatic and visceral sensations, control of
autonomic nervous system, control of the endocrine nervous system, influence on
biologic clocks, reticular activating system
o Cerebral cortex (association cortex) -> state of awareness (state in which individual
can respond to stimuli and interact with the environment)
 Anterior temporal cortex: storage of previous sensory experiences
 Posterior parietal cortex: stereognosis (visual information, touch and pressure integrated into concept of size, form, and texture)
 Prefrontal cortex: associating experience
Stage of Consciousness
o Lethargy: slow speech, diminished voluntary movement
o Stupor: speak if stimulated by painful stimuli, absent voluntary movement, eyes closed, little spontaneous eye movement
o Coma: not speak, respond only reflexly to painful stimuli/not respond at all, eyes closed and do not move
Disorder of Consciousness
o Quantitative changes of consciousness (reduced vigility/alertness):somnolence, sopor, coma
o Qualitative changes of consciousness (disturbed perception, thinking, affectivity, memory and consequent motor disorders): delirium and
obnubilation
 Assessed by using: Glasgow Coma Scale
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Disturbances of Consciousness
- Apperception is perception modified by a person’s own emotions and thoughts.
- Sensorium is the state of cognitive functioning of the special senses
- Associated with brain pathology
1. Disorientation: disturbance of orientation in time, place, or person
2. Clouding of consciousness: incomplete clearmindedness with disturbances in perception and attitudes
3. Stupor: lack of reaction to, and unawareness of, surroundings
4. Delirium: bewildered, restless, confused, disoriented reaction associated with fear and hallucinations
5. Coma: profound unconsciousness
6. Coma vigil: coma in which a patient appears to be awake with eyes open but cannot be aroused (also known as akineticmutism)
7. Twilight state: disturbed consciousness with hallucinations
8. Dreamlike state: often used as a synonym for complex partial seizure or psychomotor epilepsy
9. Somnolence: abnormal drowsiness
10. Confusion: disturbances of consciousness in which reactions to environmental stimuli are inappropriate; manifested by disordered
orientation in relation to time, place, or person
11. Drowsiness: a state of impaired awareness associated with a desire or inclination to sleep
12. Sundowning: syndrome in older persons that usually occurs at night and is characterized by drowsiness, confusion, ataxia, and falling
as the result of being overly sedated with medications; also called sundowner’s syndrome
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STROKE
Definition
Brain dysfunction, sudden and very rapid development of symptoms, focal or global, caused by only
primary cerebrovascular disease which persistence of the neurological deficit for > 24 hours or die.

Classification (based on etiology)

1. Ischemic Stroke (90%)
→ Occurs when persistent ischemia or a complete interruption of the blood supply to a particular area
of the brain produces irreversible destruction of brain tissue.
The onset come rapidly, focal deficit completely, and may continue to worse over hours or days.
a. Thrombotic:
- Occurs when a thrombus superimposed on the atherosclerotic plaque (that may be located in
extracranial or intracranial arteries)
- Pathomechanisms:
* Atherosclerotic plaque enlarge → stenotic / occlusion (large vessel thrombosis)
* Embolism or plaque fragments → occlusion / artery to artery embolus (small vessel disease)
b. Embolic
- Occurs when there is an occlusion of an artery by an embolus, usually at activity.
- The source of embolus:
* Cardiac conditions: atrial fibrillation, acute myocardial infarction, congestive heart failure
* Transcardial conditions (paradoxical embolus)

2. Hemorrhage Stroke (10%)

→ Occurs as result of a vessel rupture anywhere within the cranial cavity (major RF is hypertension).
The onset is acute, severe headache, unconsciousness, and usually BP elevated at this time.
Most common bleeding locations: basal ganglia, thalamus, lobe of hemisphere, cerebellum, pons.
a. Hypertensive Intracerebral Hemorrhage (ICH):
- Rupture of an arteriosclerotic small artery that has been weakened and bleeds into the
surrounding brain, accumulating and compressing the surrounding brain tissue.
- The major causes are:
* Hypertension resulting Charcot-Bouchard Aneurysm in small blood vessels (< 300 µm in
diameter) which are most often located in the lenticulostriate vessels of the basal ganglia.
* Artery Venous Malformations (AVM) resulting Berry Aneurysm: congenital in nature and result
in a weakness of the blood vessel wall.
* Blood dyscrasia (low platelet)
* Drug (e.g: alcohol, amphetamine, ecstasy)
b. Spontaneous Subarachnoid Hemorrhage (SAH):
- Aneurysm burst in a large of artery on or near the thin and delicate membrane surrounding the
brain, blood spills into the area which is filled by CSF. It is
- Caused by small vessels occlusion, cardiac emboli, atherothromboembolism.
c. Subdural Hemorrhage
Hemorrhage into subdural space, often over cerebral convexity. May see rupture of meningeal
or bridging of vein.
d. Epidural Hemorrhage
Hemorrhage into epidural space, has association with skull fracture in middle meningeal artery.
Case 3 / NBSS Bunga Diela
Stroke 130110120114

Clinical Characteristic
- Feeling weak, even hardly to move (paralysis) in one side.
- Loss of function in extremities.
- Paralysis in facial muscle in one side, tetany.
- In severe condition, hardly to speak.
- Mouth’s line not straight, commonly have problem with swallowing.
- Eyes may be fixed in one direction or lose vision.
- Hearing ability decreased.
- In hemorrhage stroke, commonly nausea and vomiting, headache, seizures.

Risk Factors
a. Modifiable: b. Non-modifiable:
- Cigarette smoking - Cardiac disease - Age
- Alcohol consumption - Hypertension - Sex
- Oral contraceptive use - Diabetes - Race
- Socioeconomic features - Obesity - Family history
- Low exercise - Stress

Diagnostic Tools
- CT SCAN: observe bleeding or mass within brain
- Magnetic Resonance Imaging: observe bleeding or mass within brain more detail than CT SCAN
- Magnetic Resonance Angiogram: MRI test use specifically for viewing the blood vessels non-invasively
- Heart Test: for searching the source of embolism
- Blood Test: for acute situation

Differential Diagnosis
- Head injury
- Brain tumor
- Epilepsy
- Migraine
- Vertigo
- Intracranial infection

Management
Maintain adequate delivery of oxygen, control blood pressure, maintain electrolyte, to minimize
or prevent stroke occurrence and optimize the functional recovery following stroke.
a. Pharmacological intervention:
→ Reduce the risk of ischemic stroke following hemorrhagic stroke
- Antihypertensive medications (e.g: propanolol)
- Anticoagulant medications (e.g: mannitol, heparin)
- To treat spasticity (e.g: dantrolene, tizanidine, baclofen)
- To treat hiccups (e.g: chlorpromazine, baclofen)
b. Non-Pharmacological intervention:
- Surgery: performed for aneurysm or arteriovenous malformation that are bleeding
Case 3 / NBSS Bunga Diela
Stroke 130110120114

Rehabilitation
Improving quality of life for people with stroke
- Managing emotional consequencies
- Exercise program: try to walk at least 50 feet a day to prevent deep vein thrombosis.
- Swallowing training: to prevent aspiration (accidental sucking in of food or fluids into the airway).
- Attention training: to perform specific tasks using repetitive drills in response to certain stimuli.
- Occupational training: improves daily living activities and social participation.
- Speech and sign language therapy: 9 hours a week of therapy for 3 months for recovery.

Prevention
- LIFESTYLE CHANGES:
* Quit Smoking (avoid exposure to second-hand smoke)
* Eat Healthy (diet rich in fruits and vegetables)
* Exercise (min. 30minutes of exercise/day)
* Maintain healthy weight
* Limit alcohol day consumption
- CONTROL DIABETES:
* Fasting blood glucose levels <110mg/dl and HbA1c<7%
- CONTROL BLOOD PRESSURE:
* Normal blood pressure <140/90mmHg

Complication
a. Neurological complication:
- Intracranial problems
- Brain edema
- Vasospasm
- Hydrocephalus
- PNS paralysis
b. Non-Nerological complication:
- Respiratory problems (e.g: lung edema, bronchopneumonia)
- Cardiovascular problems (e.g: increased systemic pressure, and heart abnormality)
- Hyperglycemia
- Depression

Course and Prognosis

- The outlook depends on: * The type of stroke
* How much brain tissue is damaged
* What body functions have been affected
* How quickly the patient get treated
- People who have a stroke due to a blood clot (ischemic stroke) have a better chance of surviving than
those who have a stroke due to bleeding in the brain (hemorrhagic stroke)
- The risk for a second stroke is highest during the weeks or months after the first stroke, and then the
risk begins to decrease.
Case 3 / NBSS Bunga Diela
Stroke 130110120114

PHARMACOLOGICAL PROPERTIES OF MANNITOL

Class of Drugs
Diuretics

Mechanism of Action
Osmotic diuretic. Its hypertonicity causes water to be retained in proximal and henle loop (regions that
are freely permeable to water) and promotes water dieresis. This effect reduces contact time between
fluid and tubular epithelium, thereby reducing Na+ as well as water reabsorption.

Effect
Elevates blood plasma osmolality, resulting in enhanced flow of water from tissues, including the brain
and CSF, into interstitial fluid and plasma. So, cerebral edema, elevated intracranial pressure, and CSF
volume and pressure may be reduced.

Side Effect
- Dizziness - Nausea
- Headache - Vomiting
- Hypotension - Blurred vision
- Convulsions - Urinary retention
- Angina-like chest pains - Electrolyte imbalances

Pharmacokinetic
Distribution : - Onset: IOP reduction 30-60 min; ICP reduction 15 min
- Duration: IOP reduction 4-6 hr; ICP reduction: 3-8 hr
Metabolism : - Liver (very slight)
- Metabolites: glycogen
Elimination : - Half-life: 100 min
- Excretion: 80%

Indications
- Cerebral edema
- Intraocular pressure
- Anuria/oliguria
- Bronchiectasis

Contraindications Cautions
- Hypersensitivity - Do not mix with blood
- Severe pulmonary edema or heart failure - May cause hypovolemia, headache, polydipsia
- Severe dehydration - Pregnancy Category: C
- Active intracranial bleeding - Lactation: use caution

Dosage Regiment (for Cerebral Edema)

Adult
1.5-2 g/kg IV infused over 30-60 minutes
Child
0.25-1 g/kg IV initially; maintenance dose of 0.25-0.5 g/kg IV q4-6hr
Case 3 / NBSS Bunga Diela
Stroke 130110120114

BHP
- Stroke patient, commonly have dysphasia so they cannot communicate and their mental capacity also
decreased. So, they should have medical intervention.
- In the recent past, stroke patient is dread because of medical predicament (severe, incapaciting stroke
with little chance functional recovery). In result, they can’t able to voice her wishes.
- Doctor use medical indication and patient preference as a clinical decision making. But, sometimes
both of it can be unclear which make the ethical conflict arise.
- In the condition where patient’s expressed preferences but physician ignores and overriding it
because physician think they know the best. As a result, patient is overtly/covertly.
- Uncooperative/noncompliant which make the treatment effectiveness may be compromised and
cause the benefit decreased.
- This principal can be conclude that the philosophy of law and medicla ethics commonly overlap. So,
respect for individual human rights/autonomy features strongly in both as in all aspect of medicine,
ethical discourse cannot be had without a sound of understanding of the prognosis of each clinical
option.

PHOP
Prevention, Promotion, Curative (Treatment), and Rehabilitative of STROKE

CRP
- 80-90% are ischemic, 10% are hemorrhagic
- Male:Female = 1.25:1 but reverse after age 80
- Higher rates in Blacks, Hispanics, & Native Americans