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4/3/17 1 Neuroanatomy Review for the Speech-Language Pathologist: From One Neuron to Another Andrea Hayes, M.S., CCC-SLP, BCS-S April 8, 2017 Disclosures I have no financial disclosures to discuss I have no non-financial disclosures to discuss It has been decided that the new median salary medical Speech- Language Pathologists will be $3,141,592,653 for all that we are required to know and a separate bonus for every Qme we hear from our paQents “but there’s nothing wrong with my speech so why do I need Speech Therapy?” OR from one of our dear nurses that “they swallow fine, they aren’t coughing”

Transcript of Neuroanatomy Review for the SLP Handouts - · PDF fileNeuroanatomy Review for the ... •...

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Neuroanatomy Review for the Speech-Language

Pathologist: From One Neuron to Another

AndreaHayes,M.S.,CCC-SLP,BCS-SApril8,2017

Disclosures

•  Ihavenofinancialdisclosurestodiscuss

•  Ihavenonon-financialdisclosurestodiscuss

•  IthasbeendecidedthatthenewmediansalarymedicalSpeech-LanguagePathologistswillbe$3,141,592,653forallthatwearerequiredtoknowandaseparatebonusforeveryQmewehearfromourpaQents“butthere’snothingwrongwithmyspeechsowhydoIneedSpeechTherapy?”ORfromoneofourdearnursesthat“theyswallowfine,theyaren’tcoughing”

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Course Outline

•  EmbryologyandNeuralDevelopment

•  NeuralProtecQon

•  Neuroanatomy

•  VascularSupplytotheBrain

•  CranialNerves!

Early Mitosis

•  Zygote•  Blastocyst•  Bilaminargermdisc•  Trilaminargermdisc

•  ectoderm• mesoderm•  endoderm

Neurulation

•  Flatneuralplateformed•  Crest,folds,andgroove•  Neuraltube•  Primaryvesiclesform

•  Prosencephalon• Mesencephalon•  Rhombencephalon

h`ps://embryology.med.unsw.edu.au/embryology/index.php/Human_Embryo_Development_Movie

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Congenital Anomalies

•  Anencephaly

•  Spinabifida

•  Microcephaly

•  Agenesisofthecorpuscallosum

•  Cleelipandpalate

Cephalic Structures •  Prosencephalon

•  Diencephalon•  Thalamus•  Hypothalamus

•  Telencephalon•  Hemispheres

•  Mesencephalon•  Midbrain

•  Rhombencephalon•  Metencephalon

•  Pons•  Cerebellum

•  Myelencephalon•  Medullaoblongata

Neural Migration •  Neurons

•  Unipolar,bipolar,mulQpolar•  Pyramidal•  Purkinje

•  Neuroglia•  OligodendrocytesandSchwanncells• Microglia•  Ependymalcells•  Astrocytes

•  Synapses

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Central Nervous System • Cerebrum•  SpinalCord

Peripheral Nervous System

•  SpinalNerves(31pairs)• CranialNerves(12pairs)

Motor Pathway…..

Sensory Pathway…

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Defying Gravity….

• Brainweighsabout1400gramsinair• Ventricles,boneandmeningesprotectusfrombumpsandgravity

• Cerebrospinalfluidgivesbuoyancytothebrainsoitweightsonly50gramsintheskull

Ventricular System

https://www.youtube.com/watch?v=SDMO4vYkqdg

•  InterconnecQngchambersinthebrain•  Choroidplexus___________________•  LateralVentricles_________________•  ForamenofMunro________________•  3rdVentricle____________________•  AqueductofSylvius_______________•  4thVentricle_____________________

Hydrocephalus •  Enlargementoftheventricles•  Dueto:

•  ExcessproducQonofCSF•  Blockagewithinsystem•  FailureofCSFtore-absorb

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Bony Protection

•  Skull•  Cranialbones•  Facialbones

•  Spinalcolumn•  Cervical•  Thoracic•  Lumbar•  Sacral•  Coccygeal

Skull

Skull • Foramenovale____• Stylomastoidforamen____• InternalacousQcmeatus____• Jugularforamen___________• Hypoglossalcanal_____• Foramenmagnum_____

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Spinal Column •  Cervical

•  C1______________________•  C2______________________•  C3•  C4•  C5•  C6•  C7

•  Thoracic•  Lumbar•  Sacral•  Coccygeal

Meningeal Protection: “PAD” the Brain!

•  Pia

•  Arachnoid

•  Dura

Pia Mater = Tender Mother

•  TissuepaperlikecoveringoftheCNS•  Fibersanchorthearachnoidtothepiasothereisnomovement• Conformstothesulciandgyri• OnlyonecelllayerthickbutiseffecQvebarriertoinfecQon

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Arachnoid = Spider’s Web

• Givesappearanceofacobweb• Highlyvascularized•  Subarachnoidspace

•  CSFcirculatesthroughthespace•  ArachnoidvillihelpdrainCSF

Dura Mater = Tough Mother

•  Epiduralspace________________•  Subduralspace________________•  Falxcerebri___________________•  Tentoriumcerebelli_____________

I the

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Vascular Supply!

•  CaroQdsystem •  Vertebrobasilarsystem

Carotid System

•  InternalcaroQds• ACA__________________• MCA__________________

•  ExternalcaroQds

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Vertebrobasilar System

• Vertebralarteries• PICA__________________________

• Basilarartery• PCA____________________• Anteriorinferiorcerebellararteries•  Superiorcerebellararteries

Circle of Willis • ConnectcaroQdandvertebralsystems• AComm__________________________• PComm__________________________•  Safetynetfordisruptedbloodsupplyifthelesionisbelowthecircle

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Cerebrum

•  Hemispheres•  Centralsulcus

• Motor•  Sensory

•  Longitudinalfissure•  Corpuscallosum

Corpus Callosum •  Rostrum•  Genu•  Body•  Splenium

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Frontal Lobe • Precentralgyrus=__________• Damage….

• motorimpairmentstocontralateralside•  cogniQveimpairments• non-fluentaphasiawithorwithoutacquiredapraxiaofspeech,transcorQcalmotoraphasia,Broca’saphasia

•  **spasQcdysarthriaifbothhemispheresaffected• dysphagia• unilateraluppermotorneurondysarthria

•  lowerfacialparesisoncontralateralsideofdamage•  lingualparesisoncontralateralsideofdamage

Temporal Lobe

• Primaryauditorycortex• Damage…

• fluentaphasia•  transcorQcalsensoryaphasiaorWernicke’saphasia

• memory•  recogniQon• processing

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Parietal Lobe • Postcentralgyrus=_______• Damage…

•  visualneglect•  sensoryimpairments•  conducQonaphasia•  anosognosia• prosopagnosia•  astereognosia•  right/leediscriminaQon•  agraphia•  acalculia

Occipital Lobe

• Primaryvisualcortex• Damage…..

•  corQcalblindness•  a`enQon•  reading•  symbolicrecogniQon

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Cerebellum • CoordinaQon,balance• Damage…

•  ataxia• dysdiadochokinesia• dysmetria•  intenQontremor• disequilibrium• nystagmus• dysphagia•  ataxicdysarthria

Diencephalon

•  Thalamus• Hypothalamus•  Epithalamus/pinealgland• Damage….

•  thalamicpainsyndrome•  sensoryprocessingdisorders• dysphagia

Limbic System • Amygdala• Hippocampus• Cingulategyrus• Damage…

• memory•  encoding/learning•  retrieval•  emoQons•  fear• behavior

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Basal Ganglia •  Caudatenucleus•  Putamen•  Globuspallidus•  Subthalamicnucleus•  SubstanQanigra•  Damage….

•  Chorea•  HyperkineQcdysarthria

•  Athetosis•  Ballismus•  Tremor•  Bradykinesia

•  HypokineQcdysarthria

Brainstem • Midbrain(CNIII,IV)• Pons(CNV,VI,VII,VIII)• Medullaoblongata(CNIX,X,XII)• Damage

•  sight,smell,hearing,taste• disequilibrium• nausea•  coma• dysphagia• flacciddysarthria

Mnemonics

•  SomeSayMarryMoney,ButMyBrotherSaysBigBrainsMa0erMore.• Olivertheop(mis3coctopustrotstriumphantlyaboutfacingaudiencesglossilyvaguelyspinninghippos.

• OnOldOlympus'ToweringTopAFinAndGermanViewedSomeHops

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CN I: Olfactory •  Sensorynerve•  Smell

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CN II: Optic •  Sensorynerve•  Vision

•  Infofromleevisualfieldgoestorightoccipitallobeandviceversa

Sensory:NeuronOrder•  Firstorderneuron

–  PhotonsoflightconvertedtoelectricalsignalsinreQna.Thesephotoreceptorcellsaretherodsandcones.TheyinturnsynapsewiththeopQcnerve

•  Rods•  Cones

•  Secondorderneuron–  OpQcnerveleavesreQnaandjoinstheotheropQcnerveattheopQcchiasmtravelingthentorespecQvethalamicnuclei

•  Thirdorderneuron–  FromlateralgeniculatenucleusinthalamustotheoccipitalcortexforinterpretaQon

•  LeeandrightopQcnervesexitviaopQccanalandjointogetherattheopQcchiasm

•  OpQcchiasm– ½offibersfromeachnervecrossmidlineandexitchiasminoppositeopQctract

– ½offibersstayonthesamesideopQctract

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Visiondeficits•  DamagetoreQnaornerveitself=blindnessinthatsameeye/ipsilateral

•  Lossofperipheralvisionofbotheyes=damagetomedialaspectofchiasm=bitemporalhemianopia

•  DamagetolateralaspectofopQcchiasm=decreasedvisionofoneeye’speripheralvision

•  Damageposteriortochiasm=lossofinputfromcontralateralvisualfieldsofbotheyes

•  DamagetoopQctract=lossofcontralateralvisualfieldsinbotheyes=homomynoushemianopia

CN III: Oculomotor • Motornerve•  EyemovementandpupildilaQon

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CN IV: Trochlear • Motornerve•  Eyemovement

CN V: Trigeminal •  Bothsensoryandmotor•  Somatosensoryinfofromtheface/headandmotorformasQcaQon

•  Origin:Pons•  TerminaQon:

•  Opthalmicbranch•  Maxillarybranch•  Mandibularbranch

CN V: Trigeminal •  Symptoms

•  Facialnumbness•  ReducedfacialsensaQon•  Jawweakness/chewing

•  Test•  Close/openjaw•  Lighttouchtopartsofface

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Sensory:NeuronOrder

•  Firstorderneuron– Fromsensoryreceptorsinface(threebranches)

•  Secondorderneuron– FromsensorynucleiofCNVinponstocontralateralthalamus

•  Thirdorderneuron– FromthalamustoipsilateralpostcentralgyrusforinterpretaQon

Motor:NeuronOrder

•  Firstorderneuron/UMN– Fromprecentralgyrustonucleiinpons

•  Secondorderneuron/LMN– Exitsviaforamenovaletosynapsewithmusclesonipsilateralsideforchewing(masseterandtemporalis)

CN V: Trigeminal •  UMNdamage-min.unlessbilateral•  LMNdamage-wasQng,weakness,jawdeviaQon

•  Trigeminalneuralgia

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CN V: Trigeminal

CN VI: Abducens • Motornerve•  Lateraleyemovement

CN VII: Facial •  Sensoryandmotornerve•  ContralateralinnervaQontolowerface

•  BilateralinnervaQontoupperface

•  Facialexpression•  Origin:Pons•  TerminaQon:

•  5branches

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CN VII: Facial

Sensory:NeuronOrder

•  Firstorderneuron– Fromchemoreceptors/tastebudsonanterior2/3oftongue

•  Secondorderneuron– FromsensorynucleiofVIIIinponsuptothecontralateralthalamus

•  Thirdorderneuron– FromthalamustoipsilateralpostcentralgyrusforinterpretaQon

Motor:NeuronOrder

•  Firstorderneuron/UMN– Fromprecentralgyrusdownthroughtheinternalcapsuletoipsilateralandcontralateralforupperfaceandjustcontralateralforlowerface

•  Secondorderneuron/LMN– FromnucleiinponsexiQngulQmatelythroughthestylomastoidforamentoallmusclesoffacialexpression

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CN VII: Facial •  Symptoms

•  Facialweakness•  Decreasedtastetoanterior2/3oftongue

•  Test•  Smile•  Puckerlips/whistle•  Puffoutcheeks•  Raiseeyebrows/wrinkle

UMN Damage

LMN lesion - Bell’s Palsy • Markedfacialasymmetry•  Atrophyoffacialmuscles•  Eyebrowdroop•  Smoothingofforeheadandnasolabialfolds

•  Droopingofmouthcorner•  Cannotcloseeye•  Poorlipseal

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CN VIII: Auditory •  Sensorynerve•  BilateralinnervaQon•  Hearingandbalance•  Origin:Pons•  TerminaQon:

•  AcousQc•  VesQbular

CN VIII: Auditory •  Symptoms

•  Dizziness•  VerQgo

•  Test•  Tickingwatch

CN IX: Glossopharyngeal •  Sensoryandmotornerve•  BilateralinnervaQon•  Swallowing•  Origin:Medulla•  TerminaQon:

•  Pharynx•  Larynx•  ParoQdgland•  Tongue

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Sensory:NeuronOrder…•  Firstorderneuron:Fromreceptorsinupperpharynxandposterior1/3oftonguetosensorybranchesofIX

•  Secondorderneuron:sensorybranchesofIXinbrainstemuptothalamus

•  Thirdorderneuron:FromthalamusuptopostcentralgyrusforinterpretaQon

•  **Responsiblefortheafferentpartofthegagreflex•  **MotorporQonofthegagismediatedbyVagus/X

Motor:NeuronOrder

•  Firstorderneuron/UMN– FromprecentralgyrusthroughinternalcapsuletoipsilateralandcontralateralIXnucleiinmedulla

•  Secondorderneuron/LMN– FromnucleiofIXinmedullaexiQngoutthroughthejugularforamentoinnervatethestylopharyngeusmuscleandsmoothmuscleglandsofpharynx,larynx,andvisceralofthoraxandabdomen

CN IX: Glossopharyngeal •  Symptoms

•  Dysphagia•  IncreasedsecreQons•  Tasteinposterior1/3oftongue•  PressuretoEustachiantubes

•  Test •  Swallowing

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CN X: Vagus •  Symptoms

•  Velarweakness•  Dysphagia•  Hypernasality•  Dysphonia

•  Test•  Uvula/palate•  Swallowing•  Voice

CN X: Vagus - Wanderer •  Sensoryandmotornerve•  BilateralinnervaQon•  SwallowingandvisceralfuncQons•  Origin:Medulla•  TerminaQon:

•  Pharyngealbranch•  Laryngealbranch

Sensory:NeuronOrder

•  Firstorderneuron:ReceptorswithinQssueofpharynxandlarynxgatherinfoandsynapsewithsensorybranchesofnerve

•  Secondorderneuron:branchesofXfrommedullauptothalamus

•  Thirdorderneuron:ThalamustopostcentralgyrusforinterpretaQon

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Motor:NeuronOrder•  Firstorderneuron/UMN

–  FromprecentralgyrusthroughinternalcapsuletoipsilateralandcontralateralXnucleiinthemedulla

•  Secondorderneuron/LMN–  Exitsviajugularforamenandthendividesintothreemajorbranches

•  Pharyngealbranch(motoraspect/gagreflex,elevaQonofpalate,constricQonofpharynx)

–  Superior,middle,andinferiorconstrictormuscles–  LevatorpalaQnimuscule–  Salpingopharyngeusmuscle–  Palatopharyngeusmuscle–  Palatoglossusoftongue(allothertonguemusclesareXII)

•  Superiorlaryngealnerve–  Externallaryngealnerve–cricothyroid–  Internallaryngealnerve–sensorynerve

•  Recurrentlaryngealnerve–  Rightrecurrentloopsaroundtherightsubclavianarterythenupthroughgroovebetween

esophagusandtracheatoinnervateintrinsicrightvocalfoldmuscles–  Leerecurrentloopsaroundthearchoftheaortaupthroughgroovebetweenesophagus

andtracheatoinnervateintrinsicleevocalfoldmuscles

CN XI: Accessory or Spinal Accessory • Motornerve•  BilateralinnervaQon•  Headmovement/shoulders

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CN XII: Hypoglossal • Motornerve•  ContralateralinnervaQon•  Tongue•  Origin:Medulla•  TerminaQon:Musclesoftongue

Motorneuronorder

•  Firstorderneuron/UMN– Fromprecentralgyrusthroughinternalcapsuletocontralateralmedulla/LMN

•  Secondorderneuron/LMN– Exitsviahypoglossalforamen– Extrinsicmuscles–genioglossus,styloglossus,hyoglossus

–  Intrinsicmuscles–superiorlongitudinal,inferiorlongitudinal,verQcal,transversefibers

CN XII: Hypoglossal •  Symptoms

•  Dysarthria•  Tongueweakness

•  Test•  Protrudetongue•  Lateralizetongue•  Elevatetongue•  Depresstongue•  LingualcircumducQon•  DeviaQon?Atrophy?