Neuroanatomy: Draw It to Know It

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NEUROANATOMY

Draw It to Know It

ADAM FISCH, MD
Washington University in St. Louis
School of Medicine
Department of Neurology
St. Louis, MO

1
2009
1
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Library of Congress Cataloging-in-Publication Data

Fisch, Adam.
Neuroanatomy : draw it to know it / Adam Fisch.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-19-536994-6
1. Neuroanatomy—Graphic methods. I. Title.
QM451.F57 2009
611 .8—dc22
2008047543

9 8 7 6 5 4 3 2 1

Printed in the United States of America

on acid-free paper
This book is dedicated in loving memory
to my younger brother, David,
whose humility and enthusiasm for
learning remain a source of inspiration.
This page intentionally left blank
 FOREWORD

N
EUROANATOMY IS A nightmare for neuroimaging, the actual practice of neurology,
most medical students. The complex array of whether it is done by a neurologist or a
nuclei, ganglia, tracts, lobes, Brodmann areas non-neurologist involves localizing the problem. The
and cortical layers seem to the uninitiated as the nervous system is just too complicated to skip this
height of useless trivia. My own memory of my step. Without an organized approach based on a
neuroanatomy class in medical school is vivid. Our reasonable understanding of functional
professor, a Ph.D. neuroanatomist, ordered each neuroanatomy, clinical neurology becomes
member of the class to buy a set of colored pencils; the incomprehensible.
kind you had in third grade. Each color was coded for In his wonderful book, Neuroanatomy: Draw
particular structures (red for the caudate, green for It to Know It, neurologist Adam Fisch applies my old
the putamen, yellow for the claustrum and burnt neuroanatomy professor’s colored pencil idea in a
sienna for the globus pallidus). At our senior play, manner that actually works, and it’s fun! Over the
which poked fun at our professors, a beleaguered course of 39 chapters, most of the clinically important
medical student was asked to name the components of neuroanatomically important subjects are covered,
the basal ganglia. Without knowing what the ranging through the overall organization of the
structures even were or did, he responded “red, green, nervous system, the coverings of the brain, the
yellow, and burnt sienna.” Almost forty years later, this peripheral nervous system, the spinal cord, the
remains a class joke. Except for the handful of us who brainstem, the cerebellum and the cerebral cortex.
went into neurology, neurosurgery and psychiatry, the It is clear that the book was written by an experienced
basal ganglia to the rest of my class is just a fading joke neurologist, as the topics are organized in a fashion
from the distant past. that illuminates the principle of anatomical-
And yet, no one can practice even rudimentary pathophysiological correlation, which is the
neurology without some basic understanding of the tool with which neurologists approach clinical
neuroanatomy. Non-neurologists in particular, many problems.
of whom see large numbers of patients with This book should be of great interest to all
neurological complaints, have no hope of sorting out neurologists, neurosurgeons, neurology residents and
common problems such as headache, dizziness, students of neurology. Others who see patients with
tiredness, fatigue, sleep disorders, numbness and neurological complaints, such as internists,
tingling and pain, without a reasonable grasp of how emergency physicians and obstetrician-gynecologists
the nervous system is organized. Despite all of the should also review their neuroanatomy if they wish to
marvelous advances in neuroscience, genetics and provide excellent care to their patients. As any

VII
 experienced teacher knows, one only really knows a information learned in this manner is likely to stick.
subject when one can teach it oneself. By drawing the Adam Fisch has done us all a great service by
anatomy, the reader of this book literally teaches the rekindling the enjoyment in learning the relevant,
subject to himself. By making it clinically relevant, the elegant anatomy of the nervous system.

Martin A. Samuels, MD, DSc(hon), FAAN, MACP

Chairman, Department of Neurology
Brigham and Women’s Hospital
Professor of Neurology
Harvard Medical School
Boston, MA

VIII FOREWORD
 PREFACE

M
Y NEUROANATOMY MENTOR , the late body, imagine cognitive sensory deficits, and
Dr. William DeMyer, often remarked, “if rigorously draw and re-draw the structures and
you can’t draw it, you don’t know it.” His pathways of the nervous system until they become
teaching method was straightforward: to learn the second nature.
structures and fiber pathways of the nervous system, The text is comprehensive but pearls of
draw and re-draw them, and when you think you neuroanatomy are highlighted for those who are
know them well, draw them some more. This book short on time. Anatomic and radiographic images
tries to emulate his approach. It is written in an accompany the figures to clarify what the drawings
instructive rather than a didactic manner so that we cannot. Synonymous terms are listed to mitigate
use the material to learn it. confusion; inter-textual discrepancies are brought
The analogy is simple: if you want to become a to attention; and historical and current contexts
table expert, put one together. Invariably, you will for the anatomical structures are discussed. In
screw the legs on backwards and hammer on the top short, this book provides the tools you need to learn
upside down first, but how else will you learn about neuroanatomy in a practical and complete way so
the washers and wing-nuts, bolts and fillets that fasten that you can use it at the bedside.
one together? How else will you understand what I apologize to readers who are unable to perform
makes a table strong or learn its weak points and the exercises in this book due to physical impairments. If
ways to improve upon one? Reading about tables will you have trouble imagining them, please write to me
never teach you: you have to put one together, and I will gladly try to find alternative exercises
yourself. for you.
With this book, we will trace nerve pathways down Neuroanatomy is hardly simple but it should
our limbs, demonstrate eye movements and vestibular always be fun, so let’s enjoy this trip through
directionality with our hands, palpate sensory the nervous system and every trip back
distributions and muscle patterns across our face and through it.

IX
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 ACKNOWLEDGMENTS

T
O TRY TO ACKNOWLEDGE all of the people Mohammed Al-Lozi, Joseph Black, Kelly Brown,
I ought to would be impossible and William DeMyer, Adriana Escandon, Stephen
self-defeating so I will only mention a few. Duntley, Mark Jacquin, David Holtzman, William
The foremost is Susan Pioli who, along with my Landau, Abdullah Nassief, Robert Pascuzzi, Beth
uncle, Bruce, championed this book from the start. Ward, Thomas Woolsey, and Allyson
Without her enthusiasm for this project, it never Zazulia.
would have been done. I’d also like to thank my editor, I’d also like to thank Denny Fiske, Paul Lysy, and
Craig Panner, and his editorial assistant, David Michael Schwartz for their help generating the muscle
D’Addona, as well as the book’s production manager, testing photographs, and Tammie Benzinger and
Jennifer Bossert; they, along with many others at Robert Cargile in the Department of Neuroradiology
Oxford University Press, steered this book to at Washington University in St. Louis for their help
completion with remarkable vision. creating the diffusion tensor images.
I am grateful to the faculty and staff in the I owe special thanks to my family for all of their
Departments of Anatomy and Neurology at Indiana encouragement during this process.
University and Washington University in St. Louis and Most of all, though, I owe my wife, Kate, all of my
to Robert J. Schwartzman of Drexel University School love and gratitude for allowing the cat and me to
of Medicine for all they taught me about devote our mornings, nights, and weekends to writing
neuroanatomy and clinical neurology during my and illustrating this book. We look forward to being a
neurology training. Special thanks are owed to part of your life, again.

XI
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 CONTENTS

2 Chapter 1, Organization of the Nervous System

4 Chapter 2, Orientational Terminology
6 Chapter 3, Meninges and Ventricular System
24 Chapter 4, Nerve Roots and Rami
28 Chapter 5, Brachial Plexus
36 Chapter 6, Median Nerve
44 Chapter 7, Ulnar Nerve
54 Chapter 8, Radial Nerve
62 Chapter 9, Lumbosacral Plexus
68 Chapter 10, Sciatic Nerve
76 Chapter 11, Femoral Nerve
78 Chapter 12, Cervical Plexus
82 Chapter 13, Sensory Maps of the Body
86 Chapter 14, Peripheral Autonomic Nervous System
102 Chapter 15, Structure of the Spinal Cord and Spinal Canal
108 Chapter 16, Spinal Cord
122 Chapter 17, Reflex Loops and Muscle Tone
130 Chapter 18, Brainstem
168 Chapter 19, Cranial and Spinal Nerve Overview
186 Chapter 20, Somatomotor Cranial Nerves
206 Chapter 21, Pharyngeal Arch Cranial Nerves
234 Chapter 22, Vestibular System
246 Chapter 23, Skull Base

XIII
 260 Chapter 24, Cerebellum
272 Chapter 25, Surfaces of the Brain
294 Chapter 26, White Matter Pathways
310 Chapter 27, Basal Ganglia
327 Chapter 28, Arterial Supply to the Central Nervous System
344 Chapter 29, Thalamus
350 Chapter 30, Hypothalamus
363 Chapter 31, Limbic System
382 Chapter 32, Olfactory System
388 Chapter 33, Visual Pathways
402 Chapter 34, Eye Movements
424 Chapter 35, Central Auditory Pathways
430 Chapter 36, Language
436 Chapter 37, Memory
438 Chapter 38, Apraxia
440 Chapter 39, Sleep Neurocircuitry
448 References
453 Index

XIV CON TEN TS

N E U R O A N AT O M Y

Draw It to Know It
 CHAPTER 1

Organization of the Nervous System

T
HROUGHOUT THIS BOOK , we will learn the dorsal nerve root off the posterior spinal cord, which
anatomy of the nervous system in detail, but carries sensory fibers, and attach a dorsal root
first, in this chapter, let’s march briskly through ganglion onto it; sensory cell bodies lie within the
the nervous system to form a broad perspective on it. dorsal root ganglion. Now, draw the ventral nerve root
Draw a coronal section through the brain. From from the anterior surface of the spinal cord; it carries
outside to inside, label the meninges, cortex, motor fibers. Show the nerve roots form a mixed
subcortical white matter, basal ganglia, thalamus, spinal nerve, and indicate it exits the spinal canal
and ventricular system. In general, the meninges through a neural foramen.
protect and vascularize the nervous system; the cortex Mixed spinal nerves often intertwine into
is the gray matter, highly cellular outer layer of the plexuses, which complicate the localization of
brain; the subcortical white matter carries impulses peripheral nerve injuries. Within the upper extremity,
within the brain and ushers them to and from remote show there are two different plexuses: the cervical and
nervous system regions; the basal ganglia are involved brachial plexuses. Then, below them, indicate the
in motor and behavioral functions; the thalamus thoracic nerves remain unmixed. Next, show the
receives and modifies sensory impulses, which it lumbosacral roots form the lumbosacral plexus, and
projects throughout the brain; and the ventricular specifically indicate the lower lumbosacral roots
system assists the meninges in their task of form the cauda equina before they exit the spinal
nourishing and supporting the rest of the canal.
nervous system. At the tip of a representative thoracic peripheral
Below the brain, draw the brainstem; it is a nerve, draw a neuromuscular junction synapse and
funnel-shaped structure with a bulbous out-pouching attach muscle fibers to it. Muscles and neuromuscle
in the middle. From superior to inferior, show the junctions are commonly affected parts of the
brainstem comprises the midbrain, pons, and medulla. peripheral nervous system as are the sensory receptors
The brainstem is requisite for human life; it contains that exist at the tips of peripheral nerves.
neuronal pools essential for survival and is the major Lastly, include the peripheral autonomic nervous
thoroughfare for fibers passing between the brain and system, which we represent here with one of the two
spinal cord. sympathetic paravertebral chains that flank the spinal
On the lateral aspects of the brainstem, draw the cord. Prevertebral sympathetic ganglia and
leafy hemispheres of the cerebellum. The cerebellum is parasympathetic ganglia also constitute the peripheral
pivotal in motor coordination skills as well as autonomic nervous system. The peripheral
non-motor behavioral functions, such as learning. autonomic nervous system most notably
Next, draw the long, thin spinal cord with its executes cardiopulmonary and gastrointestinal
cervical and lumbosacral enlargements.Draw the functions.

2
 Paravertebral Spinal Dorsal root
chain cord ganglion
Meninges
Peripheral nerve
Cortex
Cervical Ventral
Subcortical root Cervical
white matter
& brachial
Basal plexuses
Ventricular
motor
system Thor-
nuclei
Thalamus acic Thoracic Neuro-
spinal nerve muscular
junction Muscle
Midbrain
Lumbosacral fibers
Cere- Pons &
bellum Coccygeal Lumbosacral
plexus
Medulla

Cauda
equina

Figure 1-1 Overview of nervous system anatomy

Organization of the Nervous System 3

 CHAPTER 2

Orientational Terminology

T
HE NERVOUS SYSTEM has several synonymous with dorsal, inferior with ventral,
orientational planes that even experienced anterior with rostral, and posterior with caudal.
neurologists find challenging. Take the time Next, include a sagittal section of the brainstem at
to learn them now, as this knowledge is requisite a −80◦ angle to the cerebral hemispheres (i.e., almost
to understanding the remainder of the book. If you in perpendicular to it). During early embryogenesis,
try to skip this chapter, you will invariably find both the cerebral hemispheres and brainstem lie along
yourself hopelessly disoriented later. the same orientational plane. However, as human
At the top of the page, draw intersecting forebrains develop, they undergo an 80◦ flexion
horizontal and vertical lines. Along the horizontal that results in the so-called “cephalic flexure” at
line, label left as anterior and right as posterior. Label the junction between the brainstem and the cerebral
the top of the vertical line as superior and the bottom hemispheres. Thus, the plane of the brainstem is
as inferior. The two superior–inferior and anterior– −80◦ to that of the cerebral hemispheres. Let’s explore
posterior orientational axes are consistent throughout how this affects the orientation of the dorsal-ventral
the nervous system; that is, top is always superior and rostral-caudal axes of the brainstem; remember,
and bottom is always inferior, and front is always the superior–inferior and anterior–posterior axes
anterior and behind is always posterior. We are not are unchanged throughout the nervous system. Label
so lucky with the dorsal–ventral and rostral–caudal behind the brainstem as dorsal and in front of it as
orientational axes we will soon introduce because ventral. Then, label the top of the brainstem as rostral
of the rotation of the neuraxis during embryogenesis. and the bottom as caudal. Now, within the brainstem,
Next, let’s draw a sagittal (aka longitudinal) which orientational terms are most similar? Indicate
section through the oblong cerebral hemisphere. The superior is most similar with rostral, inferior with
sagittal plane runs from anterior to posterior and the caudal, anterior with ventral, and posterior with dorsal.
sagittal suture, which runs from the front to the back Next, draw a coronal (i.e., frontal) section through
of the skull, is a good example of this plane of the brain. Coronal relates to the word “crown.” Imagine
orientation. Label the top of the cerebral hemisphere the blooming cerebral hemispheres sit like a crown
as dorsal and the bottom as ventral. To remind on top of the neuraxis. Indicate the top of the brain
yourself that dorsal is on top and ventral is on is dorsal (superior) and the bottom is ventral (inferior).
bottom, remember the dorsal fin of a shark is on its Now, let’s introduce two more
back whereas its underbelly is ventral. Label the planes of orientation: lateral–medial and right–left.
anterior portion of the hemisphere as rostral and the Label the outside edges of the hemispheres as lateral
posterior portion as caudal. Rostral is related to the and the midline as medial. Then, label the left-hand
word “beak” and caudal is related to the word “tail.” side as radiographic right and anatomic left and
Within the cerebral hemispheres, which the right-hand side as radiographic left and anatomic
orientational terms are synonymous? Superior is right. These planes refer to the standardized ways

4
radiographic images and anatomic sections are viewed. the bottom is the back. Label the front of the section
Coronal radiographic sections are viewed head-on as rostral (anterior) and the back as caudal (posterior).
and anatomic sections are viewed from behind. Label the left side of the section as radiographic right
Lastly, draw an axial (aka horizontal) section and anatomic left and the right side as radiographic
through the brain. Although the superior–inferior left and anatomic right. Radiographic axial images
and anterior–posterior axes do not change within are viewed from below (i.e., as if the patient’s feet
the nervous system, they will alter as our perspective are coming out at you) whereas anatomic axial images
changes because we will be drawing three-dimensional are viewed from above (i.e., as if the patient’s head
structures on a two-dimensional page. In axial section, is coming up at you). Label the center of the cerebral
the top of the page is the front of the brain and hemispheres as medial and their periphery as lateral.

Superior

Anterior Posterior

Inferior

SAGITTAL
Dorsal

Rostral Caudal

Rostral Dorsal
Ventral
Ventral Caudal

CORONAL
Dorsal

Radiographic Radiographic
right & left &
anatomic anatomic
left right

Lateral Medial Lateral

Ventral

AXIAL
Rostral (anterior)

Radiographic Radiographic
right & left &
anatomic anatomical
left Right

Lateral Medial Lateral

Caudal (posterior)

Figure 2-1 Orientational planes

 CHAPTER 3

Meninges and Ventricular System

T
HE VENTRICULAR SYSTEM runs through the formed and reabsorbed at a rate of 0.33 mL/min.
center of the nervous system and the choroid Clinicians often withdraw cerebrospinal fluid from the
plexus that lines it produces cerebrospinal nervous system through a procedure called a lumbar
fluid, which suspends and nourishes the brain and puncture, discussed later in the “Structure of the
spinal cord.The meninges cover the nervous system Spinal Cord and Spinal Canal” chapter. Depending on
and are layered in the following manner: the pia mater the purpose of the procedure, the amount of fluid
is the innermost layer; the arachnoid mater overlies it; withdrawn during a lumbar puncture ranges from just
and the dura mater is the thick outer-covering of the a few milliliters to as much as 40 mL; however, in a
nervous system. Fluid enters the subarachnoid space typical lumbar puncture roughly 12 mL of fluid is
and then is reabsorbed into the venous sinuses within withdrawn. What percent of the cerebrospinal fluid in
the dura mater. the nervous system is this? Ten percent. And how
There is approximately 120 mL of cerebrospinal quickly is it replaced? In about half-an-hour (or, more
fluid in the nervous system at any one time, and it is exactly, in 36 min).

Arachnoid granulations Superior sagittal sinus

Emissary
vein
Skull
Dura
Subdural
space
Subarachnoid
space
Pia

Vein Cortex

Artery Dura Arachnoid

Photo 3-1 Intracranial meninges

With permission From Brodal, P. The Central Nervous System: Structure and Function. 3rd ed. New York: Oxford University Press, 2004.

6
 Fat, vessels Vertebral arch

Dorsal root
Dura
Ventral root

Spinal
ganglion

Dorsal
ramus

Ventral
ramus

Vertebral body

Photo 3-2 Intraspinal meninges

With permission From Brodal, P. The Central Nervous System: Structure and Function. 3rd ed. New York: Oxford University Press, 2004.

Photo 3-3 Flow pattern of cerebrospinal fluid & Anatomy of the ventricular system
From Woolsey, T. A., J. Hanaway, and M. H. Gado. The Brain Atlas: A Visual Guide to the Human Central Nervous System. 3rd ed. Hoboken,
NJ: Wiley, 2008. Reproduced with permission of John Wiley & Sons Inc.
 First, we will establish the different cerebrospinal this blood–brain barrier so they are sensitive to toxins
fluid spaces and meningeal layers and then we will and other large molecules. The area postrema,
address the flow pattern of cerebrospinal fluid. Each specifically, is an important chemoreceptor trigger
cerebrospinal fluid space has intracranial and zone. Direct activation of the area postrema produces
intraspinal divisions and we will account for their vomiting, often without the sensation of nausea. We
differences. After we complete this diagram, we will will discuss the area postrema further in the
address the folding and contour of ventricular system, “Brainstem” chapter.
as it will help us understand the shape of many other Now, draw the ventricular extension from the
intracerebral structures. fourth ventricle into the spinal division of the nervous
Draw a coronal diagram of the central system: the central canal, which runs the length of the
nervous system. Start with the intracranial spinal cord. After the second decade of life, the central
division of the ventricular system. In the center of canal progressively narrows and obliterates; by middle
the brain, draw its T-shaped portion. Label the adulthood, it is mostly nonfunctional. When this
lateral arms of the “T” as the lateral ventricles and happens, how is cerebrospinal fluid delivered to the
the caudal extension as the third ventricle. The spinal canal?
hypothalamus, an important central autonomic In midline, draw the foramen of Magendie (aka the
nervous system structure, surrounds the third median aperture) and at both lateral aspects of the
ventricle. fourth ventricle, draw the foramina of Luschka (aka
Next, draw the narrow cerebral aqueduct (aka the the lateral apertures). Note that a good mnemonic for
aqueduct of Sylvius), which extends from the bottom the foramen of Magendie and the foramina of Luschka
of the third ventricle into the diamond-shaped fourth is that the first letter of their names corresponds to the
ventricle, which you should draw, now. The area first letter of their locations: Magendie-midline and
postrema sits at the base of the fourth ventricle. It is Luschka-lateral. Cerebrospinal fluid flows from the
one of the circumventricular organ interfaces between fourth ventricle into the subarachnoid space through
the blood and cerebrospinal fluid. Normally, there is a these foramina and, in this manner, is able to reach the
barrier to the diffusion of large molecules between the spinal cord after the central canal obliterates. We will
blood vessels and the cerebrospinal fluid, the so-called diagram the complete flow pattern of cerebrospinal
blood–brain barrier. Circumventricular organs lack fluid after we draw the meninges.

8 N E U R O A N AT O M Y : Draw It to Know It
 Lateral
ventricle

Interventricular
foramen of Monro 3rd
ventricle

Cerebral
aqueduct

Foramen Foramen
of of Magendie
Luschka
4th ventricle

Central
canal

Figure 3-1 Coronal view of ventricular system

Meninges and Ventricular System 9