Scribd case study cerebrovascular accident

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Werner on stroke case studies: According to a study just published in value health jan-feb Neuro Case Study Stroke , Head injury, seizures. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The flow of neural signals through the basal ganglia is strongly directional. The striatum is the primary recipient of input from other brain areas, most notably the cerebral cortex. The internal segment of the globus pallidus GPe , together with the reticular part of the substantia nigra SNr , give rise to the primary output, most notably to the thalamus.

The striatum projects to the pallidum both directly and indirectly via the subthalamic nucleus, which also receives cortical input. The substantia nigra consists of two parts, one of which functions similarly to the pallidum, the other of which sends a modulatory dopaminergic input to the striatum and other structures.

The adjoining figure shows some of the most important connections between components. On the largest scale, the basal ganglia form a loop that begins and ends in the cortex. Two of these links are excitatory, and two inhibitory, so the net effect of the whole sequence is excitatory: the cortex excites itself via the direct pathway.

Three of these links are inhibitory and two excitatory, so the net effect of the sequence is inhibitory: the cortex inhibits itself via the indirect pathway. The total effect of basal ganglia upon the cortex is believed to result from a complex interplay between these two pathways. Striatum The striatum is the largest component of the basal ganglia.

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The term "striatum" comes from the observation that this structure has a striped appearance when sliced in certain directions, arising from numerous large and small bundles of nerve fibers white matter that traverse it. Early anatomists, examining the human brain, perceived the striatum as two distinct masses of gray matter separated by a large tract of white matter called the internal capsule.

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They named these two masses the "caudate nucleus" and "putamen". More recent anatomists have concluded, on the basis of microscopic and neurochemical studies, that it is more appropriate to consider these masses as two separated parts of a single entity, the "striatum", in the same way that a city may be separated into two parts by a river. Numerous functional differences between the caudate and putamen have been identified, but these are taken to be consequences of the fact that each sector of the striatum is preferentially connected to specific parts of the cerebral cortex.

The internal organization of the striatum is extraordinarily complex. These are GABAergic cells meaning that they inhibit their targets with small cell bodies and dendrites densely covered with dendritic spines, which receive synaptic input primarily from the cortex and thalamus. Medium spiny neurons can be divided into subtypes in a number of ways, on the basis of neurochemistry and connectivity.

There are also several other types of interneurons making up smaller fractions of the neural population. Numerous studies have shown that the connections between cortex and striatum are generally topographic; that is, each part of the cortex sends stronger input to some parts of the striatum than to others. The nature of the topography has been difficult to understand, however—perhaps in part because the striatum is organized in three dimensions whereas the cortex, as a layered structure, is organized in two. This dimensional discrepancy entails a great deal of distortion and discontinuity in mapping one structure to the other.

Pallidum The pallidum consists of a large structure called the globus pallidus "pale globe" together with a smaller ventral extension called the ventral pallidum. The globus pallidus appears as a single neural mass, but can be divided into two functionally distinct parts, called the internal sometimes "medial" and external sometimes "lateral" segments, abbreviated GPi and GPe. The two segments participate in distinct neural circuits. The external segment, or GPe, receives input mainly from the striatum, and projects to the subthalamic nucleus.

The internal segment, or GPi, receives signals from the striatum via two pathways, called "direct" and "indirect". The direct pathway consists of direct projections from the striatum to the GPi.

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These pathways have opposite net effects: striatal activity inhibits the GPi via the direct pathway because striatal outputs are GABAergic, but has a net excitatory effect on the GPi via the indirect pathway because this three-link pathway consists of two inhibitory links plus one excitatory link. Pallidal neurons operate using a "disinhibition" principle. These neurons fire at steady high rates in the absence of input, and signals from the striatum cause them to "pause".

Because pallidal neurons themselves have inhibitory effects on their targets, the net effect of striatal input to the pallidum is a reduction of the tonic inhibition exerted by pallidal cells on their targets. Subthalamic nucleus Function The greatest source of insight into the functions of the basal ganglia has come from the study of two neurological disorders, Parkinson's disease and Huntington's disease.

For both of these disorders, the nature of the neural damage is well understood and can be correlated with the resulting symptoms. Parkinson's disease involves major loss of dopaminergic cells in the substantia nigra; Huntington's disease involves massive loss of medium spiny neurons in the striatum.

The symptoms of the two diseases are virtually opposite: Parkinson's disease is characterized by gradual loss of the ability to initiate movement, while Huntington's disease is characterized by an inability to prevent parts of the body from moving unintentionally.


It is noteworthy that although both diseases have cognitive symptoms, especially in their advanced stages, the most salient symptoms relate to the ability to initiate and control movement. Thus, both are classified primarily as movement disorders. A different movement disorder, called hemiballismus, may result from damage restricted to the subthalamic nucleus.

Hemiballismus is characterized by violent and uncontrollable flinging movements of the arms and legs. Role in motivation Although the role of the basal ganglia in motor control is clear, there are also many indications that it is involved in the control of behavior in a more fundamental way, at the level of motivation. In Parkinson's disease, the ability to execute the components of movement is not greatly affected, but motivational factors such as hunger fail to cause movements to be initiated or switched at the proper times.

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The immobility of Parkinsonian patients has sometimes been described as a "paralysis of the will". These patients have occasionally been observed to show a phenomenon called kinesia paradoxica, in which a person who is otherwise immobile responds to an emergency in a coordinated and energetic way, then lapses back into immobility once the emergency has passed.

Thousands of experimental studies combine to demonstrate that the dopaminergic projection from the VTA to the NA plays a central role in the brain's reward system.

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Animals with stimulating electrodes implanted along this pathway will bar-press very energetically if each press is followed by a brief pulse of electrical current. Numerous things that people find rewarding, including addictive drugs, good-tasting food, and sex, have been shown to elicit activation of the VTA dopamine system. Although it is not universally accepted, some theorists have proposed a distinction between "appetitive" behaviors, which are initiated by the basal ganglia, and "consummatory" behaviors, which are not.

For example, an animal with severe basal ganglia damage will not move toward food even if it is place a few inches away, but if the food is placed directly in the mouth, the animal will chew it and swallow it. Comparative anatomy and naming The basal ganglia form one of the basic components of the forebrain, and can be recognized in all species of vertebrates. Even in the lamprey generally considered one of the most primitive of vertebrates , striatal, pallidal, and nigral elements can be identified on the basis of anatomy and histochemistry.

A clear emergent issue in comparative anatomy of the basal ganglia is the development of this system through phylogeny as a convergent cortically re-entrant loop in conjunction with the development and expansion of the cortical mantle. There is controversy, however, regarding the extent to which convergent selective processing occurs versus segregated parallel processing within re-entrant closed loops of the basal ganglia. Regardless, the transformation of the basal ganglia into a cortically re-entrant system in mammalian evolution occurs through a re-direction of pallidal or "paleostriatum primitivum" output from midbrain targets such as the superior colliculus, as occurs in sauropsid brain, to specific regions of the ventral thalamus and from there back to specified regions of the cerebral cortex that form a subset of those cortical regions projecting into the striatum.

The abrupt rostral re-direction of the pathway from the internal segment of the globus pallidus into the ventral thalamus-- via the path of the ansa lenticularis--could be viewed as a footprint of this evolutionary transformation of basal ganglia outflow and targeted influence.

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The evolutionary emergence of cortical re-entrant systems in the brain has been postulated by Gerald Edelman as a critical basis for the emergence of primary consciousness in the theory of Neural Darwinism. In the basal ganglia, however, the great majority of neurons use GABA as neurotransmitter and have inhibitory effects on their targets. The inputs from the cortex and thalamus to the striatum and STN are glutamatergic, but the outputs from the striatum, pallidum, and substantia nigra pars reticulata all use GABA.

Thus, following the initial excitation of the striatum, the internal dynamics of the basal ganglia are dominated by inhibition and disinhibition. Other neurotransmitters have important modulatory effects. The most intensively studied is dopamine, which is used by the projection from the substantia nigra pars compacta to the striatum, and also in the analagous projection from the ventral tegmental area to the nucleus accumbens. Acetylcholine also plays an important role, being used both by several external inputs to the striatum, and by a group of striatal interneurons.

Although cholinergic cells make up only a small fraction of the total population, the striatum has one of the highest acetylcholine concentrations of any brain structure. The first anatomical identification of distinct subcortical structures was published by Thomas Willis in For many years, the term corpus striatum was used to describe a large group of subcortical elements, some of which were later discovered to be functionally unrelated.

For many years, the putamen and the caudate nucleus were not associated with each other. Instead, the putamen was associated with the pallidum in what was called the nucleus lenticularis or nucleus lentiformis. The striatum was named on the basis of the striated striped appearance created by radiating dense bundles of striato-pallido-nigral axons, described by anatomist Samuel Alexander Kinnier Wilson as "pencil-like".


The anatomical link of the striatum with its primary targets, the pallidum and the substantia nigra was discovered later. For this, the Vogts proposed the simpler "pallidum". The structural similarity between the substantia nigra and globus pallidus was noted by Mirto in Together, the two are known as the pallidonigral ensemble, which represents the core of the basal ganglia. Altogether, the main structures of the basal ganglia are linked to each other by the striato-pallido-nigral bundle, which passes through the pallidum, crosses the internal capsule as the "comb bundle of Edinger", then finally reaches the substantia nigra.

Additional structures that later became associated with the basal ganglia are the "body of Luys" nucleus of Luys on the figure or subthalamic nucleus, whose lesion was known to produce movement disorders. Near the beginning of the 20th century, the basal ganglia system was first associated with motor functions, as lesions of these areas would often result in disordered movement in humans chorea, athetosis, Parkinson's disease.

The brain is protected by the cranial bones. Like the spinal cord. The brain is also protected by meninges. The cranial meninges surround the brain are continues with the spinal meaninges and have the same basic structure and bear the same names as the spinal meninges. Dura meter — pachymenix, tough fibrous tissue - outermost covering 2. Arachnoid - together with the pia meter is called Leptomeninges - middle, delicate thin cob-web like membrane 3.

Pia meter - innermost - soft thin membrane which closely lines brain and spinal cord extending into all fissures and sulci.

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