The Nervous System

Neurology

• Neurology is the study of the

nervous system, its related
diseases and conditions and
their treatment
 Nervous System – Functions

The nervous systems performs basically 3 functions:

1. Receive sensory input from internal & external environments.
2. Integrate the input.
3. Respond to stimuli.
Receptors are parts of the nervous system that sense changes in the
environment.
Sensory input can be pressure, taste, sound, light, hormone levels,
blood pH, etc.
 The Nerve Cells

There are 2 main types of nerve

cells found in the human body –
• Neuron.
• Neuroglia.
 The Neuron

The neuron is the

functional unit of the
nervous system and is
variable in size and
shape.
Parts of a neuron:
Axon
Cell body
Dendrite
 Myelination

• Myelination is the presence of a

myelin sheath that protects the
axon and speeds the
transmission of impulses.
 Types of Neuroglia

- Another type of nerve

- Found Brain & blood capillaries
- Also known as Blood brain barrier
- Types
- Astrocytes
- Oligodendrocytes
- Microglial cell
- Ependymal cell
 Types of Neurons

3 different types of Neurons –

Sensory neurons: Have long dendrites & short axons and carry
messages from the sensory receptors to the central
nervous system (afferent nerves).
Motor neurons: Have a long axon and short dendrites and transmit
messages from the central nervous system to the
muscles or glands (efferent nerves).
Interneurons: Found only in the central nervous system where
they connect neuron to neuron.
 Synapse

• Synapse is the junction between neurons.

• Messages travel within the neuron as an electrical potential and
requires the actions of neurotransmitters to cross the synaptic cleft.
• Neurotransmitters are stored in small synaptic vesicles clustered at
the tip of the axon and are released into the synaptic cleft on the
arrival of an action potential.
• Released neurotransmitters diffuse across the cleft and bind to the
receptors of the other cell’s membrane causing ion channels to open,
thus promoting transmission of impulses.
 Synapse

• Some neurotransmitters in the body –

• Serotonin,
• acetylcholine,
• norepinephrine,
• dopamine,
• gabapentin, etc.
 Nervous system

Peripheral NS

Central NS

Motor Nerves Sensory Nerves

Brain Spinal Cord Somatic NS Autonomic NS

Cranial Nerve Spinal Nerve Sympathetic NS

Parasympathetic
NS
Nervous System
 Central Nervous System
• Responsible for processing and storing sensory and motor
information and for controlling consciousness.
 The Central Nervous System

• Brain and the spinal cord are surrounded by connective tissue membranes
called the meninges as well as the CSF.
 The Meninges

The meninges is made of 3

layers:
• Dura mater
• Arachnoid membrane
• Pia mater
 Cerebrospinal Fluid

• CSF flows in and around the organs of

the CNS – from the blood through the
ventricles of the brain, the central canal
of the spinal cord, the subarachnoid
space, and back into the blood.
• It acts as a shock absorber.
• It also contains proteins, glucose, urea,
salts, and some white blood cells and
provides nutrition to the CNS.
 The Brain Ventricles
• The brain ventricles are hollow spaces in the
brain that contain the CSF and provides
support to the brain tissue. There are 4
ventricles.
 The Brain

The brain is divided into 4 major

parts –
Cerebrum
Cerebellum
Diencephalon
Brain stem
 The Cerebrum

• The cerebrum is the uppermost part of the brain. It is divided into right and left
hemispheres by the corpus callosum.

Corpus Callosum

• It controls consciousness, memory, sensation, emotions, and voluntary motions.

 The Cerebrum

• The surface of the

cerebrum is called cerebral
cortex made of
convolutions or elevations
known as gyri which are
separated by grooves
known as sulci.
4 lobes of the cortex
• Occipital
• Temporal
• Parietal
• Frontal
 The Cerebellum

• The cerebellum is a part of the

hind brain and is attached to the
brain stem.
• It has an essential role in
maintaining muscle tone and
coordinating normal movement,
posture, and balance.
 Diencephalon

• The diencephalon is located

between the cerebrum and the
midbrain. It consists of the
thalamus and the hypothalamus.
• The thalamus receives all sensory
stimuli except smell and relays
them to the cerebral cortex.
• The hypothalamus is a small
region located just below the
thalamus.
The Brain Structure
 The Brain Stem

• The brain stem is the region

between the diencephalon and
the spinal cord. It consists of
midbrain, pons, and medulla
oblongata.
• The midbrain is the upper part of
the brain stem connecting to the
diencephalon.
• The pons lies between the
midbrain and the medulla.
 Brain Stem

• The medulla oblongata is the

lowest part of the brain and
continues as the spinal cord.
• The brain stem serves as the
pathway for conduction of
impulses between the brain and
the spinal cord. It controls the
vital functions such as
respirations, blood pressure,
and heart rate.
 The Spinal Cord
• The spinal cord runs along the dorsal side of the body and links the
brain to the rest of the body.
• The spinal cord is contained in the vertebral column.
• The gray matter of the spinal cord consists of cell bodies and
dendrites. The white matter consists of bundles of interneuronal
axons.
• The spinal cord is involved in reflexes that do not immediately involve
the brain.
• The spinal nerves connect to the limbs and lower parts of the body.
The Spinal Cord
 The Peripheral Nervous System
• Peripheral nervous system
consists of the cranial
nerves and the spinal
nerves.
• The peripheral nervous
system is responsible for
transmitting the sensory
and motor information.
 The Peripheral Nervous System

These nerves connect the brain and the spinal cord to the rest of the
body.
The peripheral nervous system is made of :
Somatic Nervous system
• 12 cranial nerves
• 31 Pairs of spinal nerves
Autonomic Nervous System
• Sympathetic NS
• Parasympathetic NS
 Cranial Nerves

• The cranial nerves carry impulses to and from the brain.

 The Cranial Nerves

• Olfactory – Receives sensory input for smell.

• Optic – Receives sensory input for vision.
• Occulomotor – Moves the eye, raises eyelids, changes pupil size, and
focuses the lens.
• Trochlear – Moves the eye.
• Trigeminal – Receives sensory input from the skin around the eyes,
forehead, scalp, face, mouth, and lips. Also moves mastication muscles.
• Abducens – Moves the eye.
• Facial – Receives sensory input for taste and ear pain, innervates salivary
glands and tear glands.
 The Cranial Nerves

• Vestibulocochlear – Receives sensory input for hearing and

equilibrium.
• Glossopharyngeal – Moves throat muscle.
• Vagus – Receives sensory input from throat, chest, and abdomen.
Relays impulses to the heart and other visceral organs.
• Accessory – Moves the neck and upper back.
• Hypoglossal – Moves the tongue.
 Tricks to remember Cranial Nerves

# Cranial Nerve Name CN Slogan CN Sensory, Motor & Both CN

1 Olfactory One Some
2 Optic Of Say
3 Occulomotor Our Marry
4 Trochlear Trained Money
5 Trigeminal Teacher But
6 Abducens Ask My
7 Facial For Brother
8 Vestibulocochlear Very Says
9 Glossopharyngeal Good Big
10 Vagus Vada Business
11 Accessory And Makes
12 Hypoglossal Halwa Money
Cranial Nerve
 Plexus

A plexus is a large network of nerves in the peripheral nervous system.

A plexus is a group of nerves that combine with each other. There are five main
plexi formed by the spinal nerves:

There are 31 pairs of spinal nerves including:

8 cervical spinal nerves on each side of the spine called C1 through C8

12 thoracic spinal nerves in each side of the body called T1 through T12
5 lumbar spinal nerves on each side called L1 through L5
5 sacral spinal nerves in each side called S1 through S5
1 coccygeal nerve on each side, Co1
Brachial plexus Lumbar plexus
Sacral plexus Spinal Nerves
 Autonomic nervous system

• Autonomic nervous system provides involuntary control over the

smooth muscles, cardiac muscles, glandular activity and secretion,
etc.
Autonomic nervous system is further divided as –
The sympathetic nervous system.
The parasympathetic nervous system.
 Autonomic nervous system

• The sympathetic nervous system is involved in fight and flight

response and regulates body functions by increasing the heart rate,
constricting blood vessels, and raising blood pressure.
• The parasympathetic nervous system is involved in relaxation and
regulates the body functions by slowing heart rate, increasing
peristalsis, increasing glandular secretions, and relaxing the
sphincter muscles.
• Both the systems innervate the same organs and act in opposition
to maintain homeostasis.
The Peripheral nervous system
 Sympathetic Nervous – Fight/Flight

• Increased Heart Rate.

• Increased blood pressure.
• Pupil dilation.
• Decreased urination.
• Increased sweating.
• Bronchial dilation.
• Decreased salivation.
 Parasympathetic – Energy Sparing

• Decreased heart rate.

• Decreased blood pressure.
• Pupil constriction.
• Increased urination.
• Decreased sweating.
• Bronchial constriction.
• Increased salivation.
 The Peripheral nervous system

• Nerve is a cordlike bundle of nerve cells that transmits impulses.

• Ganglia is a group of nerve cell bodies located outside the CNS.
CIRCLE OF WILLIS
 Vocabulary

• Acetylcholine Neurotransmitter chemical released at the ends of

some nerve cells.
• Afferent nerves Nerves that carry impulses toward the brain and
spinal cord; sensory nerves.
• Arachnoid Middle layer of the three membranes Membrane
that surround the brain and spinal cord.
• Astrocyte A type of neuroglial cell; connective, supporting cell
of the nervous system. astrocytes transport water
and salts between capillaries and nerve cells.
 Vocabulary

• Autonomic Nerves that control involuntary body nervous

functions; automatically carry impulses system from
the brain and spinal cord to muscles, glands, and
internal organs.
• Axon Microscopic fiber that carries the nerve impulse
along a nerve cell.
• Blood brain Blood vessels that selectively let certain barrier
substances enter the brain tissue and keep other
substances out.
• Brain stem Lower portion of the brain that connects the
cerebrum with the spinal cord. The pons and
medulla are part of it.
 Vocabulary

• Cauda equina A collection of spinal nerves below the end of the

spinal cord at the level the second lumbar vertebrae.
• Cell body Part of a nerve cell that contains the nucleus.
• Cerebellum Posterior part of the brain. It is responsible for
coordinating voluntary muscle movements and
maintaining balance.
• Cerebral cortex Outer region of the cerebrum.
• Cerebrospinal Liquid that circulates throughout the brain and the
spinal fluid CSF cord.
 Vocabulary

• Cerebrum Largest part of the brain; responsible for voluntary

muscular activity, vision, speech, taste, hearing,
thought, memory, and many other functions.
• Convolution Elevated portion of the cortex; gyrus.
• Dendrite Microscopic branching fiber of a Nerve Cell that is
the first part to receive the nerve impulse.
• Dura mater Outermost layer of the meninges surrounding the
brain and spinal cord.
 Vocabulary

• Efferent nerves Nerves that carry impulses away from the brain and
spinal cord to the muscles, glands, and organs; motor
nerves.
• Fissure Depression or groove in the surface of the cerebral
cortex.
• Gyrus Elevation in the surface of cerebral cortex; convolution.
• Hypothalamus Portion of the brain beneath the thalamus; controls
sleep, appetite, body temperature, and secretions from
the pituitary gland.
•
 Vocabulary

• Medulla Part of the brain just above the spinal cord; controls
breathing, heartbeat, and the size of the blood
vessels. Nerve fibers cross over here.
• Meninges Three protective membranes that surround the
brain and spinal cord.
• Microglial cell One type of neuroglial cell.
• Motor nerves Nerves that carry messages away from the brain,
spinal cord to muscles and groin.
 Vocabulary

• Myelin sheath Fatty tissue that surrounds and protects the axon of
nerve cell.
• Nerve Macroscopic structure consisting of axons and dendrites
in bundles.
• Neuroglia Cells in the nervous system that do not carry
impulses but are supportive and connective in function.
e.g. astrocytes, microglial cells, & oligodendroglia. There
are about 100 billion neuroglial cells.
• neuron A nerve cell; carries impulses throughout the body.
 Vocabulary

• Neurotransmitter Chemical messenger, released at the end of a

nerve cell, that stimulates or inhibits another
cell. the second cell affected may be another
nerve cell, a muscle cell, or a gland cell. e. g.
acetylcholine, epinephrine, and dopamine.
• Oligodendroglia A neuroglial cell that produces myelin, which
is a fatty tissue that forms a sheath covering
the axons.
 Vocabulary

• Parasympathetic Involuntary, autonomic nerves that

help nerves regulate body functions like heart
rate respiration.
• Pia mater Thin, delicate, inner membrane of the
meninges.
• Plexus A large, interlacing network of nerves e.g.
lumbar, and brachial plexuses.
 Vocabulary

• Pons Bridge part of the brain anterior to the cerebellum

and between the medulla and the rest of the
brain.
• Receptor An organ that receives a nervous stimulation and
passes it on to nerves within the body. The skin,
ears, eyes, and taste buds are receptors.
• Sensory nerves Nerves that carry messages to the brain and spinal
cord from a receptor.
 Vocabulary

• Stimulus A change in the internal or external environment

that can evoke a response.
• Sulcus Depression in the surface of the cerebral cortex.
• Sympathetic Autonomic nerves that influence body nerves
functions involuntarily in times of stress.
• Synapse The space through which a nervous impulse is
transmitted from one neuron to another or from a
neuron to another such as a muscle or gland cell.
 Vocabulary

• Thalamus Main relay center of the brain. it conducts impulses

between the spinal cord and the cerebrum;
incoming sensory messages are relayed through the
thalamus to appropriate centers in the cerebrum.
• Ventricles Reservoirs in the interior of the brain that are filled
with cerebrospinal fluid.
 Detailed Examination

• A detailed history is obtained by questioning the patient about

headaches, weakness, sensory changes, gait or balance, and LOC.
• Mental status is assessed using the Mini-Mental Status Exam. This
tool is used to screen for brain lesions, psychiatric conditions,
dementia, etc
• All the cranial nerves are tested.
 Clinical examination

• Mental functions:
• Appearance and behavior
• Emotional state
• Delusions, hallucinations
• Orientation
• Consciousness
• Memory
• General intelligence
 Gait

• Spastic: Walks with narrow base, drags feet.

• Cerebellar ataxia: Walks with wide base, appears drunken.
• Festinant: e.g. Parkinson disease, short and rapid steps with
bent forward.
• Waddling: Gait of duck bent backwards, wide base and
swaying. High stepping gait.
 Involuntary movements

• Myoclonus: Rapid, irregular and jerky movements of groups of

muscles.
• Tremor: Regular or irregular distal movements with oscillatory nature.
• Coarse/ Intention/Senile/ Hysterical/Pill-rolling.
• Athetosis: Writhing movement mainly in distal muscles.
• Chorea: Involuntary dance-like movements.
• Sydenham/ Huntington/Senile.
 Involuntary movements

• Dyskinesia.
• Dystonia: Abnormally maintained posture.
• Flexion/ Hemiplegic dystonia.
• Hemiballismus: Involuntary movement affecting mainly arms, in
which arm is flung rapidly from full extension in to abduction and
external or internal rotation
 Involuntary movements

• Torticollis: Jerky, rotational posture of neck.

• Tics: Simple normal movements repeated unnecessarily.
• Myokimia: Twichy, rhythmical movement of periorbital muscles.
• Tetany: Characteric posture of hand in hypocalcemia.
• Carpopedal spasm/Trousseau sign/ Chvostek sign.
 Signs of Meningeal Irritation

Signs of Meningeal Irritation

• Neck stiffness
• Kernig sign
• Brudzinski sign
 Detailed Examination

• Gait is tested for normal

heel-to-toe walking.
• Romberg test is done to
assess the equilibrium.
 Detailed Examination

• Tremors and tics are examined in the limbs.

• Muscle strength is examined in all the major muscle group and is
graded on a scale of 5.
• Sensory system is evaluated by testing for pain, temperature, light
touch, etc.
 Pathology
Diseases & Conditions
Congenital Disorders
• Hydrocephalus: Abnormal accumulation of fluid in the brain.
• Spina bifida: Congenital defect in the spinal column due to imperfect union of vertebral parts.

Hydrocephalus Meningocele Spina bifida occulta

 Diseases & Conditions

• Alzheimer disease: Brain disorder marked by deterioration of mental capacity (dementia)

beginning in middle age.
• Amyotrophic lateral sclerosis (ALS): Progressive disorder characterized by degeneration
of motor neurons in the spinal cord and brain stem; also called Lou Gehrig disease.
• Huntington chorea: Hereditary nervous disorder due to degenerative changes in the
cerebrum and involving bizarre, abrupt, involuntary, dance-like movements.
• Multiple sclerosis : Destruction of myelin sheath on neurons in the CNS and its
replacement by plaques of sclerotic (hard) tissue. demyelination: Destruction of myelin
on the axons of nerves (seen in multiple sclerosis).
 Diseases & Conditions

Epilepsy: Chronic disorder characterized

by recurrent seizure activity.
• Absence seizure: Minor (petit mal) form
of seizure, consisting of momentary
clouding of consciousness and loss of
contact with the environment.
• Tonic-clonic seizure: Major convulsive
seizure marked by sudden loss of
consciousness, stiffening of muscles,
and twitching and jerking movements.
• Aura: Peculiar sensation appearing
before more definite symptoms.
 Diseases & Conditions
• Myasthenia gravis: Neuromuscular Bell palsy: Paralysis of facial
disorder characterized by relapsing nerve. Patient is not able to close
weakness (-asthenia) of skeletal muscles
(attached to bones). Note ptosis of the the eye on the affected side.
upper eyelids and weakness of facial
muscles.
 Diseases & Conditions

• Palsy: Paralysis (partial or complete loss of motor function).

• Parkinson disease: Degeneration of nerves in the brain,
occurring in later life, leading to tremors, weakness of
muscles, and slowness of movement. Dopamine: A
neurotransmitter which is deficient in Parkinson disease.
• Tourette syndrome: Neurological disorder marked by
involuntary, spasmodic, twitching movements; uncontrollable
vocal sounds; and inappropriate words.
 Diseases & Conditions

Infectious disorders
Meningitis: Inflammation of meninges;
leptomeningitis.
• Neck stiffness
• Kernig sign
• Brudzinski sign.
Shingles: Viral disease affecting peripheral
nerves. Blisters spread in a band like
fashion along the course of peripheral
nerves.
Herpes zoster: Type of herpes virus that
causes shingles.
 Diseases & Conditions

Neoplastic disorders
Brain tumors: Abnormal growth of brain tissue and meninges.
Astrocytoma: Malignant tumor of neuroglial brain cells (astrocytes).
Blast: Immature forms ( as in glioblastoma).
Traumatic disorders
Cerebral concussion: Temporary brain dysfunction (brief loss of
consciousness) after injury, usually clearing within 24 hours.
Cerebral contusion: Bruising of brain tissue as a result of direct trauma to the
head; neurological deficits persist longer than 24 hours
 Diseases & Conditions

Vascular Disorders
Cerebrovascular accident (CVA): Disruption in the normal blood supply to the brain. The
different types are:
Thrombotic
Embolic
Hemorrhagic
TIA: Transient ischemic attack; mini-stroke.

Aneurysm: Abnormal widening of a blood vessel; can lead to hemorrhage in CVA.

 Study section

• Embolus: A mass (clot) of material travels through the bloodstream and suddenly
blocks a vessel.
• Occlusion: Blockage.
• palliative: Relieving symptoms but not curing.
• Thymectomy: Removal of the thymus gland used as a treatment for myasthenia gravis.
• TIA: Transient ischemic attack; mini-stroke.
• Tay-Sachs disease Accumulation of lipids in the brain leading to paralysis and blindness
 Diseases & Conditions

• Paralysis – Loss of motor function due to injury or disease affecting nerve supply.
• Paraplegia – Paralysis of the lower limbs.
• Hemiplegia – Paralysis on one side of the body.
• Quadriplegia – Paralysis of all 4 limbs.
 Diseases & Conditions

• Cluster headache – Several, unilateral, periorbital, or

temporal headaches that lasts from 15 to 180
minutes and occurs several times a day.
• Benign intracranial hypertension – An increase in
intracranial pressure without any evidence of
intracranial lesions, obstructions, or infections.
• Brain death – Complete loss of cerebral and
brainstem activity with no brain wave activity.
• Amnesia – Disturbance in long-term memory.
 Common Diagnostic Tests

• Biopsy of nerve tissue – Used to diagnose

malignant growths.
• CSF analysis – CSF is analyzed for
composition, wbc’s, pH, color, clarity, etc
to diagnose trauma, tumor, and
infections.
• Cerebral angiography- X-rays of the brain
after injecting a radiopaque substance to
visualize arterial and venous circulation in
the brain
• CT of the brain- To determine if the CVA is
caused by blockage or hemorrhage.
 Common Diagnostic Tests

• Electroencephalography – Electrical potential of the brain is recorded

to diagnose sleep disorders, epilepsy, tumors, hemorrhages, etc.
 Common Diagnostic Tests

Myelography
X-rays of the spinal
cord, used to diagnose
spinal cord injuries and
vertebral hernias.
MRI – For diagnosis of
tumors and
inflammatory sites.
 Common Diagnostic Tests

Electromyography
Electrical activity in the
muscles is recorded to assess
neuromuscular disorders.
Lumbar puncture
A needle is inserted into the
subarachnoid space to
withdraw CSF. Also called a
spinal tap.
Glasgow coma scale
 Common Diagnostic Tests

• Digital subtraction angiography of

the vertebrobasilar system.
Electroencephalography (EEG)

• Alpha -- awake & resting

• Beta -- mental activity
• Theta -- emotional stress
• Delta -- deep sleep

Intracranial tumor
 Drug Classifications

• Anticholinergics: Used in the treatment of Anticonvulsants: Used in the treatment of

Parkinson disease; inhibits the action of epilepsy and other forms of seizures.
acetylcholine. phenobarbital (Luminal)
benztropine mesylate (Cogentin) carbamazepine (Tegretol)
biperiden (Akineton) lorazepam (Ativan)
phenytoin (Dilantin)
trihexyphenidyl
valproic acid (Depakote)
• Dopaminergic: Used in the treatment of clonazepam (Klonopin)
Parkinson disease; enhances diazepam (Valium)
the action of dopamine. Barbiturates: Act as anticonvulsants as well as
amantadine (Symmetrel) sedatives. Also used to treat insomnia.
phenobarbital (Luminal)
pramipexole (Mirapex)
secobarbital (Seconal)
levodopa (Sinemet)
 Drug Classifications
• Cholinergics: Used to treat myasthenia gravis and Alzheimer
disease. Inhibits the action of cholinesterase that breaks down dd acetylcholine.
donepezil (Aricept)
neostigmine (Prostigmin)
• Sedative: Treatment of insomnia.
estazolam (ProSom)
flurazepam (Dalmane)
phenobarbital (Luminal)
• Stimulant: Stimulates the nervous system and also to control Attention Deficit Disorder
(ADD).
amphetamine (Adderall)
methylphenidate (Ritalin)
 Therapeutic Procedures

• Cerebral aneurysmectomy: Excision of a

cerebral aneurysm.
• Cordotomy: Division of spinal cord tracts.
• Cranioplasty: Surgical reconstruction of the
skull.
• Electrostimulation: Stimulation of the peripheral
nerves by placing an electrode of a stimulating
device. Used to treat chronic pain.
• Diskectomy: Complete or partial removal of the
intervertebral disks
 Therapeutic Procedures
• Craniotomy: Creating an opening into Spinal fusion: Surgical joining of 2 or more vertebrae
the skull.
 Therapeutic Procedure

• Stereotactic surgery: Use of 3-D CT scans to

locate deep-seated brain structures and lesions
and to guide surgery.
• Surgical evacuation of cerebral hemorrhage:
Surgical aspiration of hematoma to relieve
pressure on the brain tissue.
• Surgical excision of brain tumor: Excision of all or
part of benign or malignant neoplasm in the
brain.
• Laminectomy: Excision of all or part of the
posterior arch of the vertebra to relieve pressure
on the spinal nerve root.
 Therapeutic Procedures
• Thalamotomy: Surgical destruction of the Trephination
thalamus to treat epilepsy, involuntary Surgical creation of an opening in the brain to
movements, and chronic pain.
relieve intracranial pressure or expose brain
• Vagotomy: Surgical severing of the vagus nerve tissue.
as a treatment for peptic ulcers.
 Therapeutic Procedures

Vagus nerve stimulation

Intermittent electrical
stimulation of the vagus
nerve by a device like a
pacemaker to reduce the
number of seizures.
Ventricular shunting
Diversion of CSF from the
ventricles of the brain to a
body cavity outside the
cranium as a treatment for
hydrocephalus.
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