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Ставропольский государственный медицинский университет

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Лучевая диагностика

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Книги по МРТ КТ на английском языке / Neurosurgery Fundamentals Agarval 1 ed 2019

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4.3 Cerebrum

Fig. 4.10 Brain surface anatomy, view of medial surface of right hemisphere. 1. Frontal pole of frontal lobe. 2. Medial frontal gyrus. 3. Cingulate sulcus. 4. Sulcus of corpus callosum. 5. Cingulate gyrus. 6. Paracentral lobule. 7. Precuneus. 8. Subparietal sulcus. 9. Parietooccipital sulcus. 10. Cuneus. 11. Calcarine fissure. 12. Occipital pole of occipital lobe. 13–16. Corpus callosum (cut surface). 13. Rostrum. 14. Genu. 15. Body. 16. Splenium. 17. Lamina terminalis (cut surface). 18. Anterior commissure (cut surface). 19. Septum pellucidum. 20. Fornix. 21. Tela choroidea of third ventricle.

22. Choroid plexus of third ventricle (cut edge). 23. Transverse cerebral fissure.

24. Thalamus. 25. Interthalamic adhesion (cut surface). 26. Interventricular foramen of Monro. 27. Hypothalamus. 28. Suprapineal recess and pineal body (cut surface).

29. Vermis of cerebellum (cut surface). 30. Cerebellar hemisphere. 31. Choroid plexus of fourth ventricle. 32. Medulla oblongata (cut surface). 33. Fourth ventricle.

34. Pons (cut surface). 35. Tectal lamina (cut surface) and mesencephalic aqueduct of

Sylvius. 36. Mamillary body. 37. Oculomotor nerve. 38. Infundibular recess.

39. Temporal lobe lateral occipitotemporal gyrus. 40. Rhinal fissure. 41. Hypophysis

(cut surface) with adenohypophysis (anterior lobe) and neurohypophysis (posterior lobe) of pituitary gland. 42. Optic chiasm (cut surface). 43. Optic nerve. 44. Olfactory bulb and tract. (Reproduced from Von Frick H, Leonhardt H, Starck D, Human Anatomy,

Neuroanatomy

Fig. 4.11 Subcortical structures of the brain.

a, Thalamus. b, head of the caudate nucleus. c, internal globus pallidus. d, external globus pallidus. e, putamen. f, claustrum. Rectangle shows internal capsule: anterior limb (yellow), genu (blue), posterior limb (red), sublenticular part (gray), retrolenticular part (green).

(Illustration by Joao T Alves Belo, MD.)

•	Genu:		or horns, into the frontal, occipital, and
	◦	Corticobulbar fibers.	temporal lobes. Their point of meeting is
•	◦	Corticoreticulobulbar fibers.	known as atrium or trigone. The lateral
•	Posterior limb:		ventricles are connected to the 3rd ventri-
	◦	Corticospinal fibers.	cle through the interventricular foramen
	◦	Corticorubral fibers.	or foramen of Monro (one for each lateral
	◦	Corticothalamic fibers.	ventricle).
•	◦	Thalamocortical fibers.	The 3rd ventricle is located between
•	Sublenticular segment:		the medial surface of both thalami and is
	◦	Auditory radiations.	connected to the 4th ventricle through the
	◦	Corticopontine fibers.	cerebral aqueduct, also known as the Syl-
•	◦	Optic radiations.	vian aqueduct. From the 4th ventricle, CSF
•	Retrolenticular segment:		leaves the ventricular system and enters
	◦	Optic radiations.	the subarachnoid space through three
	◦	Corticotectal fibers.	foramina—two Lateral (foramen of Lus-
	◦	Corticonigral fibers.	chka) and one Medial (foramen Magendie)
	◦	Corticotegmental fibers.	( Fig. 4.12).

Ventricles of the Brain

The ventricles of the brain are cavities containing the cerebrospinal fluid (CSF) covered by ependymal cells. There are four ventricles (two lateral, 3rd and 4th ventricles).

The lateral ventricles surround the caudate nucleus and the thalamus in each hemisphere. They present three extensions,

4.4 Brainstem

4.4.1 Surface Anatomy

The brainstem contains all major motor and sensory pathways traveling to and from the brain, cerebellum, and spinal cord. Furthermore, cranial nerves (CNs) II–XII also originate from nuclei within the brainstem. Topographically, it is

4.4 Brainstem

Fig. 4.12 Overview of the ventricular system and important neighboring structures. Left lateral view. The ventricular system is an expanded and convoluted tube that is the upper extension of the central spinal canal into the brain. (Reproduced from Schuenke, Schulte, and Schumacher, Atlas of Anatomy, 2nd edition, ©2014, Thieme Publishers,

New York. Illustration by Markus Voll.)

divided into three segments from superior to inferior: midbrain, pons, and medulla ( Fig. 4.13, Fig. 4.14, and Fig. 4.15).

Midbrain

The midbrain is limited superiorly by an imaginary line between the mammillary body and the pineal gland; limited inferiorly by the pontomesencephalic sulcus which separates it from the pons. The anterior surface is denoted by two columns of white matter called cerebral peduncles. The peduncles are separated by the interpeduncular fossa where CN III (oculomotor nerve) exits, to reach the orbit. The posterior surface of the midbrain or tectum has four spherical structures, known as colliculi:

two superior (connected to the lateral geniculate nucleus of the thalamus) related to vision, and two inferior (connected to the medial geniculate nucleus of the thalamus) related to the auditory pathway. Immediately below the inferior colliculi and on each side of the midline, CN IV (trochlear nerve) exits the brainstem.

The trochlear nerve is the only CN that exits the brainstem via its posterior surface. Moreover, it is the only CN that decussates, resulting in contralateral motor innervation ( Fig. 4.16 andFig. 4.17).

Neuroanatomy

Fig. 4.13 Ventral view of brainstem. 1. Corpus callosum in depths of anterior interhemispheric or longitudinal cerebral fissure. 2. Olfactory bulb. 3. Olfactory tract. 4. Olfactory trigone. 5. Medial olfactory stria. 6. Lateral olfactory stria. 7. Anterior perforated substance. 8. Diagonal band of Broca. 9. Optic tract. 10. Cut surface of left temporal lobe. 11. Infundibulum with hypophyseal stalk. 12. Mamillary body. 13. Interpeduncular fossa with interpeduncular perforated substance. 14. Ventral part of cerebral peduncle.

15. Pons. 16. Basilar sulcus. 17. Middle cerebellar peduncle. 18. Pyramid (medulla oblongata). 19. Olive. 20. Ventrolateral sulcus. 21. Ventral root of first cervical nerve.

22. Ventral median fissure. 23. Spinal roots of accessory nerve. 24. Decussation of pyramids. 25. Accessory nerve and cranial roots. 26. Hypoglossal nerve. 27. Glossopharyngeal and vagus nerve. 28. Facial nerve with nervus intermedius and vestibulocochlear nerve. 29. Abducens nerve. 30. Motor and sensory roots of trigeminal nerve. 31. Trochlear nerve. 32. Oculomotor nerve. 33. Optic chiasm. (Reproduced from Von Frick H, Leonhardt H, Starck D, Human Anatomy, ©2016, Thieme Publishers, New York.)

4.4 Brainstem

Fig. 4.14 Lateral view of the brainstem. 1. Medial geniculate body. 2. Lateral geniculate body. 3. Optic tract. 4. Hypophysis. 5. Infundibulum. 6. Mamillary body. 7, 8. Cerebral peduncle. 7. Ventral part (crus cerebri). 8. Dorsal part (mesencephalic tegmentum).

9. Trigeminal nerve. 10. Pons. 11. Abducens nerve. 12. Pyramid (medulla oblongata). 13. Olive. 14. Hypoglossal nerve. 15. Ventrolateral sulcus. 16. Ventral root of the first cervical nerve. 17. Spinal roots of accessory nerve. 18. Dorsal root of first cervical nerve (retracted). 19. Dorsolateral sulcus (medulla oblongata). 20. Cranial roots of accessory and vagus nerve. 21. Tenia of fourth ventricle. 22. Glossopharyngeal and vagus nerves. 23. Facial nerve with nervus intermedius and vestibulocochlear nerve. 24. Middle cerebellar peduncle. 25. Inferior cerebellar peduncle. 26. Superior cerebellar peduncle. 27. Trochlear nerve. 28. Inferior colliculus and brachium of inferior colliculus. 29. Superior colliculus. 30. Pulvinar. (Reproduced from Von Frick H, Leonhardt H, Starck D, Human Anatomy, ©2016, Thieme Publishers, New York.)

Neuroanatomy

Fig. 4.15 Dorsal view of brainstem with cerebellum removed. 1. Caudate nucleus. 2. Lamina affixa. 3. Terminal stria and superior thalamostriate vein in terminal sulcus.

4. Tenia choroidea. 5. Pulvinar. 6. Habenular trigone. 7. Pineal body. 8–11. Mesencephalon. 8. Brachium of superior colliculus. 9. Brachium of inferior colliculus. 10, 11.

Tectum. 10. Superior colliculus. 11. Inferior colliculus. 12. Superior medullary velum. 13. Trochlear nerve. 14. Superior cerebellar peduncle. 15. Middle cerebellar peduncle. 16. Inferior cerebellar peduncle, 17. Stria medullares (fourth ventricle) and lateral recess of fourth ventricle. 18. Median eminence. 19. Facial colliculus. 20. Tenia of fourth ventricle. 21. Trigone of hypoglossal nerve. 22. Trigone of vagus nerve (ala cinerea). 23. Obex. 24. Dorsal intermediate sulcus. 25. Dorsolateral sulcus. 26. Dorsal median sulcus. 27. Lateral funiculus. 28. Fasciculus gracilis. 29. Fasciculus cuneatus.

30. Tuberculum gracile. 31. Tuberculum cuneatum. 32. Vestibular area. 33. Median sulcus. 34. Sulcus limitans. 35. Cerebral peduncle. 36. Lateral geniculate body. 37. Medial geniculate body. (Reproduced from Von Frick H, Leonhardt H, Starck D, Human Anatomy, ©2016, Thieme Publishers, New York.)

4.4 Brainstem

	Optic nerve	Perioculomotor
	(CN II)	safe entry zones
Corticospinal
tract
Oculomotor
nerve (CN III)
a	Interpeduncular		Interpeduncular
a	fossa		safe entry zone
Medial			Substantia
lemniscus			nigra

Corticospinal	Corticospinal
tract	tract
b	Oculomotor nerves (CN III)
b

Fig. 4.16 Ventral surface, safe entry zones, and internal structures of the midbrain.

(a) The corticospinal tract is situated in the middle three-fifths of the crus cerebri. The anterior mesencephalic (perioculomotor) safe entry zone is directed through the

frontopontine fibers and between the exit point of the oculomotor nucleus and the medial edge of the corticospinal tract. Alternatively, a second ventral safe entry zone, the interpeduncular safe entry zone, is located medial to the exit point of the oculomotor nerves (CN III) and directed through the interpeduncular fossa. (b) The removal of the frontopontine fibers exposes the medial lemniscus and substantia nigra. (Reproduced from Spetzler R, Kalani M, Nakaji P et al, Color Atlas of Brainstem Surgery, 1st edition,

Neuroanatomy

		Medial geniculate
		body
		Pineal
	Optic tract	gland
		Superior
	Cerebral	colliculus
	Cerebral	Lateral
	peduncle	Lateral
	peduncle	mesencephalic
		mesencephalic
		sulcus
		Inferior
	Oculomotor nerve	colliculus
	Oculomotor nerve
	(CN III)	Trochlear nerve
	Pontomesencephalic	Trochlear nerve
	Pontomesencephalic	(CN IV)
	sulcus	(CN IV)
	sulcus

Fig. 4.17 Cadaveric dissection showing the lateral surface of the midbrain. The lateral mesencephalic sulcus extends from the pontomesencephalic sulcus inferiorly to the medial geniculate body superiorly, and it forms the border between the cerebral peduncle and the tectum of the midbrain. The tectum contains the superior and inferior colliculi. (Reproduced from Spetzler R, Kalani M, Nakaji P et al, Color Atlas of Brainstem

Pons

The pons is separated from the midbrain superiorly by the pontomesencephalic sulcus, and inferiorly from the medulla by the pontomedullary sulcus. From the pontomedullary sulcus and on each side of the midline, the CNs VI (abducens), VII (facial), and VIII (vestibulocochlear) exit the brainstem. CN VI exits right above the pyramids of the medulla, CN VII above the olivary nucleus, and the CN VIII from the outermost portion of the pontomedullary sulcus, a region known also as the pontocerebellar angle. The anterior surface of the pons has an impression over its midline known as the basilar sulcus. Laterally, the anterior surface is limited on each side by CN V (trigeminal nerve). The posterior surface of the pons will be described along with the posterior surface of the upper medulla, as both form the rhomboid fossa.

Medulla

The medulla is the most caudal brainstem segment, limited superiorly by the

pontomedullary sulcus and inferiorly by an imaginary plane running below the motor decussation and above the roots of the first cervical nerves. The anterior surface has a vertically oriented fissure on its midline known as the anterior median fissure, representing the medial limit of the pyramids. The lateral limit of the pyramids is the anterolateral sulcus. The anterior median fissure and anterolateral sulcus continue inferiorly to the spinal cord, except for the anterior median fissure on the lower third of the medulla where the motor decussation takes place and momentarily efface it. On the superior portion of the anterolateral sulcus, CN XII (hypoglossal nerve) exits the brainstem anterior to the olives, on each side. The lateral surface of the medulla its limited anteriorly by the anterolateral sulcus and posteriorly by the posterolateral sulcus. From superior to inferior, the CNs IX, X, and XI exit the brainstem via the posterolateral sulcus. The posterior surface of the medulla is divided into a superior and an inferior segment. The inferior segment

4.4 Brainstem

has on its midline the posterior median fissure separating the gracile fasciculi on either side. These fasciculi are laterally limited by the posterior intermedius sulci which separate the gracile and cuneate fasciculi. The latter are limited laterally by the posterolateral sulcus ( Fig. 4.18 andFig. 4.19).

Rhomboid Fossa

The superior segment of the posterior surface of the medulla, forms with the posterior surface of the pons the so-called rhomboid fossa or floor of the 4th ventricle. For didactic purposes, the pontomedullary sulcus is employed as a reference to

Glossopharyngeal
nerve (CN IX)		Pyramid
Vagus nerve
(CN X)		Olive
		Olive
Hypoglossal nerve		Anterior
(CN XII)		median
(CN XII)		fissure
		fissure
		Accessory
		nerve (CN XI)
		Pyramidal
		decussation

Supraolivary fossette

Olive

Preolivary sulcus

Glossopharyngeal

nerve (CN IX)

Vagus nerve (CN X)

Postolivary

sulcus

Hypoglossal nerve (CN XII)

Accessory nerve (CN XI)

Fig. 4.18 (a) The medulla contains the glossopharyngeal (CN IX), vagus (CN X), accessory (CN XI), and hypoglossal (CN XII) nerves. The medulla is divided in the midline by the anterior median fissure. The corticospinal tract runs within the pyramid. (b) Lateral view of the medulla. The preolivary sulcus is located between the pyramid and olive, and the postolivary sulcus is located behind the olive. The hypoglossal nerve exits from the preolivary sulcus, and the accessory nerve exits from the postolivary sulcus. The depression rostral to the olive, the supraolivary fossette, is just below the junction of the facial nerve (CN VII) and the vestibulocochlear nerve (CN VIII) with the brainstem. The glossopharyngeal, vagus, and accessory nerves exit the medulla just dorsal to the postolivary sulcus, which is located between the olive and the inferior cerebellar peduncle. (Reproduced from Spetzler R, Kalani M, Nakaji P et al, Color Atlas of Brainstem Surgery, 1st edition,

Neuroanatomy

Obvvex	Cuneate
Gracile	tubercle
tubercles	Lateral
	medullary
	safe entry
	zone
Posterior median
sulcus and safe
entry zone

Posterior lateral
sulcus and safe	Posterior
entry zone	intermediate
	sulcus and
	safe entry
	zone

Fig. 4.19 The surface anatomy and safe entry zones of the dorsal medulla. There are three dorsal medullary sulci, which have been used to gain entry to the dorsal medulla and have been described as safe entry zones. These include the posterior median sulcus below the obex in the midline, the posterior intermediate sulcus between the gracile tubercle and the cuneate tubercle, and the posterior lateral sulcus along the lateral margin of the cuneate tubercle. An additional safe entry zone, the lateral medullary (inferior cerebellar peduncle) safe entry zone, has been proposed. (Reproduced from Spetzler R, Kalani M, Nakaji P et al, Color Atlas of Brainstem Surgery, 1st edition,

divide the rhomboid fossa into an inferior or medullary triangle and a superior or pontine triangle.

Inferior or Medullary Triangle

The medullary triangle is limited laterally by the inferior cerebellar peduncles ( Fig. 4.20). Three important structures occupying this area from medial to lateral include:

•Hypoglossal trigone, related to the nucleus of the CN XII.

•Vagal trigone, related to the motor nucleus of the CN X. On the inferolateral aspect of the trigone is the area postrema which controls vomiting.

•Vestibular trigone, related to the vestibular and dorsal cochlear nuclei.

Superior or Pontine Triangle

At each side of the midline and just above an imaginary plane from the pontomedullary sulcus, the facial colliculi are located ( Fig. 4.20). The abducens nucleus and the fibers of the CN VII make an indentation in the white matter as they loop around this nucleus.

In the superolateral segment, the motor nucleus of the trigeminal nerve makes an impression. Lateral to the trigeminal impression lies the locus coeruleus which is the main source of noradrenaline in the central nervous system (CNS).3

Alesionoftheponsattheleveloftheabdu- censnucleusmaycauseMillard-Glubersyn- drome characterized by CNs VI and VII palsies and contralateral body hemiplegia.

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