Neuroanatomy: Draw It to Know It

Visit the link below to download the full version of this book:
https://cheaptodownload.com/product/neuroanatomy-draw-it-to-know-it-2nd-edition-
full-pdf-download/
This page intentionally left blank
Second Edition

Neuroanatomy
Draw It to Know It

Adam Fisch, MD
JWM Neurology and
Adjunct Professor of Neurology
Indiana University School of Medicine
Indianapolis, IN

1
1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.
Oxford New York
Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2012 by Adam Fisch

Published by Oxford University Press, Inc.
198 Madison Avenue, New York, New York 10016
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
_________________________________________________________________
Library of Congress Cataloging-in-Publication Data
Fisch, Adam.
Neuroanatomy : draw it to know it/Adam Fisch.—2nd ed.
p.; cm.
Includes bibliographical references and index.
ISBN 978-0-19-984571-2 (pbk.)
I. Title.
[DNLM: 1. Nervous System—anatomy & histology. 2. Anatomy, Artistic—methods.
3. Medical Illustration. WL 101]
611.’8—dc23 2011037944
_________________________________________________________________
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice.
Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this
material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it
was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications
are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check
the product information and clinical procedures with the most up-to-date published product information and data sheets
provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make
no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without
limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the
drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility
for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the
contents of this material.

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
 The first edition of this book was dedicated to the
memory of my younger brother, David.

This edition is dedicated to my children, Ava and Ezra, who

were born during the rewrite of this book and who
renew my faith that good things still happen.
This page intentionally left blank
Foreword from the First Edition

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

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

Neuroanatomy is at once the most fascinating and most difficult subject in the field of
anatomy. When we master it, we can resolve the most perplexing diagnostic riddles in
medicine, and yet we struggle with the numerous neuroanatomical structures and path-
ways, the intertextual inconsistencies in nomenclature and opinion, and the complex spa-
tial relationships. So here, we bring the differences in nomenclature and opinion to the
forefront to mitigate them and we present the material in an active, kinesthetic way.
In this book, we approach each neuroanatomical lesson by beginning fresh with a
blank page, and from there we build our diagram in an instructive, rather than a didactic
format. With each lesson, we create a schema that provides a unique place for each neuro-
anatomical item. This, then, allows us to rehearse the schema and in the process memorize
the fundamental neuroanatomical items. And because we are all students of anatomy—
and not art—our purpose with each lesson is to learn a schematic that we can reproduce
in the classroom, the laboratory, or at the bedside in a way that is especially designed for
the “left-brained” among us.
Some of us possess pigeon-like navigational skills, whereas others of us find ourselves
getting lost in our own houses. The ease with which we learn anatomy is inherently related
to the strength of our spatial cognition, which makes it harder for those of us who struggle
with complex spatial relationships to master the subject matter1. When it comes to the
task of deciphering a complicated illustration, specifically in studying the details of an
illustration, it has been shown that we rely heavily on the right frontoparietal network2–4.
In Neuroanatomy: Draw It to Know It, we shift the process of learning neuroanatomy
away from the classic model of spatial de-encoding, away from the right frontoparietal
network, to the formulation of memorizable scripts or schemas, which task the prefrontal
cortices more intensively, instead5,6. In so doing, we provide the less spatially-inclined
with a different entry zone into the world of neuroanatomy.
This book reconciles the most burdensome impasses to our learning: we highlight
inconsistencies, remove spatial complexities, and create an active, instructive text that
adheres to the principle—when we can draw a pathway step by step, we know it.
x Preface

References
1 . Garg, A. X., Norman, G. & Sperotable, L. How medical students learn spatial anatomy. Lancet 357, 363–364
(2001).
2 . Walter, E. & Dassonville, P. Activation in a frontoparietal cortical network underlies individual differences in
the performance of an embedded figures task. PLoS One 6 (2011).
3 . Walter, E. & Dassonville, P. Visuospatial contextual processing in the parietal cortex: an fMRI investigation of
the induced Roelofs effect. Neuroimage 42, 1686–1697 (2008).
4 . Aradillas, E., Libon, D. J. & Schwartzman, R. J. Acute loss of spatial navigational skills in a case of a right
posterior hippocampus stroke. J Neurol Sci 308 (2011).
5 . Knutson, K. M., Wood, J. N. & Grafman, J. Brain activation in processing temporal sequence: an fMRI study.
Neuroimage 23, 1299–1307 (2004).
6 . Rushworth, M. F., Johansen-Berg, H., Gobel, S. M. & Devlin, J. T. The left parietal and premotor cortices:
motor attention and selection. Neuroimage 20 Suppl 1, S89–100 (2003).
Acknowledgments

I’d like to thank my wife, Kate, and the rest of my family and friends for putting up with
my decision to rewrite this book, and I’d like to thank my editor, Craig Panner, and the
rest of the Oxford University Press team for all of their hard work.
To rewrite this book, I started over entirely. I spent the first year creating a muscle–
nerve directory and the following year creating a brain atlas, and then I went to work on
rewriting the book, itself. I threw out all of the original illustrations and redrafted them as
I wrote the individual tutorials. Taking advantage of the ability to keyword search the
massive library of books now available online and taking advantage of several fundamen-
tal reference materials I'd used during the creation of the muscle–nerve directory and
brain atlas, I was able to create detailed illustrations and scripts that maintained the sim-
plicity of the original book but greatly improved upon its level of detail. As well, feedback
from the first edition helped me understand how to provide the information a student
of neuroanatomy needs without sacrificing the clinical relevance a clinician is looking for.
In creating the tutorials, I came to understand that the text should serve as a play-by-play
manual that tersely defines each step in the drawing—only after the steps were solidified
did I flesh out the material, itself. When the tutorials were written and finalized, I then
broke them down into their individual steps, which served as an invaluable editorial
process.
Rewriting this book was all-consuming and I am eternally grateful to those closest to
me for giving me the time and space to see it to completion. There are many, many people
who have helped me along the way and I hope the end product of this book will prove
your patience and efforts worthwhile. I believe this book represents the best that neuro-
anatomy education has to offer and I am exceedingly grateful to those around me who
gave me the opportunity and freedom to have a second crack at it.
This page intentionally left blank
Contents

1. General Organization 3

2. Meninges and Ventricular System 13

3. Peripheral Nervous System—Upper Extremity 27

4. Peripheral Nervous System—Lower Extremity 55

5. Peripheral Nervous System—Sensory Maps 71

6. Peripheral Nervous System—Autonomic Nervous System 91

7. Spinal Cord 105

8. Spinal Canal and Muscle–Nerve Physiology 127

9. Brainstem—Part One 139

10. Brainstem—Part Two 159

11. Cranial and Spinal Nerve Overview and Skull Base 173

12. Cranial Nerves 3, 4, 6, 12 195

13. Cranial Nerves 5, 7, 9, 10 211

14. Vestibular and Auditory Systems 231

xiv Contents

15. Cerebellum 247

16. Cerebral Gray Matter 267

17. Cerebral White Matter 287

18. Basal Ganglia 303

19. Arterial Supply 317

20. Diencephalon 339

21. Limbic and Olfactory Systems 357

22. Vision 379

23. Eye Movements 409

24. Cognition 425

25. Sleep and Wakefulness 439

Index 451
Neuroanatomy
This page intentionally left blank
1
General Organization

Overview of Neuroanatomy

Orientational Terminology

Divisions & Signs

4 Neuroanatomy: Draw It to Know It

Know-It Points

Orientational Terminology
■ The top of the cerebral hemisphere is dorsal and the ■ Towards midline is medial and towards the outside is
bottom is ventral. lateral.
■ The anterior aspect of the cerebral hemisphere is ■ Sagittal view is side-on.
rostral and the posterior aspect is caudal. ■ Coronal view is front-on.
■ The top of the brainstem is rostral and the bottom is ■ Axial view is horizontal.
caudal.
■ The anterior aspect of the brainstem is ventral and
the posterior aspect is dorsal.

Divisions & Signs

■ Cerebral cortical pyramidal cells are upper motor ■ Lower motor neuron injury causes flaccid muscle
neuron. tone, hypoactive muscle stretch reflexes, and absent
■ Cranial nerve nuclei and spinal motor neurons are pathologic reflexes (eg, negative Babinski’s sign).
lower motor neuron.
■ Upper motor neuron injury causes spastic muscle
tone, hyperactive muscle stretch reflexes,
and pathologic reflexes (eg, positive Babinski’s sign).
 1. General Organization 5

F I G U R E 1 - 1 Plate 4 (top) and plate 8 (bottom) from the 1810 atlas of Franz Joseph Gall and Johann Kaspar Spurzheim—Anatomie et physiologie du
systeme nerveux.
6 Neuroanatomy: Draw It to Know It

Overview of Neuroanatomy
To begin, we will draw an overview of the anatomy of segments of the spinal cord from top to bottom as fol-
the nervous system. First, we will address the brain, lows: cervical, thoracic, lumbosacral, and coccygeal. The
brainstem, and cerebellum. Begin with a coronal section cervical segment mostly communicates with the upper
through the brain. From outside to inside, label the extremities, upper trunk, head, and neck; the thoracic
meninges, which protect and nourish the nervous segment mostly communicates with the trunk and abdo-
system; the cortex, which constitutes the outer, cellular men; and the lumbosacral segment communicates with
gray matter portion of the brain; the subcortical white the abdominal-pelvic region and the lower extremities.
matter, which constitutes the underlying nerve axons; Draw a dorsal nerve root off of the posterior spinal
the basal ganglia, which are most notably involved in cord; identify it with its dorsal root ganglion, which
motor function but are also important for behavioral houses the sensory cell bodies. Then, draw the ventral
and cognitive functions; the thalamus, which in combi- root from the anterior surface of the spinal cord; it con-
nation with the metathalamus relays most of the afferent tains the motor fibers that exit from the gray matter of
information that enters the nervous system to various the spinal cord. Next, show that the motor and sensory
regions throughout the cerebral cortex; the hypothala- roots meet to form a mixed spinal nerve within a neural
mus, which lies along the third ventricle and is the center foramen. Then, show that the cervical nerves interweave
for autonomic nervous system function; and the cere- to form the cervical and brachial plexuses. Now, indicate
brospinal fluid system, which assists the meninges in that the lower lumbosacral nerve roots descend through
supporting and nourishing the nervous system. the lumbar cistern and exit the spinal canal to form the
Below the brain, draw the brainstem. From superior lumbosacral plexus. Next, indicate that the majority of
to inferior, show the midbrain, identified by its crus cere- the thoracic nerves remain unmixed. Then, show that
bri, then the pons, identified by its bulbous basal out- after the nerves exit their plexuses, they continue as
pouching, and finally the medulla. The brainstem peripheral nerve fibers. Now, draw a representative neu-
contains cranial nerve nuclei, which command oculob- romuscular junction and a sensory cell receptor and
ulbar motility, facial sensation, and many craniofacial attach muscle fibers to them. Neurotransmissions pass
and thoracoabdominal autonomic functions. And the across the neuromuscular junctions to stimulate muscle
brainstem also contains many additional neuronal pools fibers, and peripheral nerve receptors detect sensory
essential for survival as well as the fiber tracts that pass impulses from the musculoskeletal system and skin.
between the brain and spinal cord. On the posterior Lastly, to represent the divisions of the autonomic
aspect of the brainstem, draw the leafy hemispheres of nervous system, draw a parasympathetic ganglion and a
the cerebellum; the cerebellum is important for balance sympathetic paravertebral chain segment; the parasym-
and orientation, postural stability, and coordination. pathetic nervous system is active in states of rest whereas
Next, we will address the spinal cord and peripheral the sympathetic nervous system is active in states of
nervous system. Draw the long, thin spinal cord with heightened awareness—it produces the “fight-or-flight”
its cervical and lumbosacral enlargements. Label the response.
 1. General Organization 7

Brain, Brainstem, & Cerebellum Spinal Cord & Peripheral Nervous System
Dorsal root
Spinal ganglion
Meninges
cord
Cortex Peripheral nerve
Subcortical Ventral
white matter Cervical
root Cervical Sensory
Basal & brachial receptor
ganglia Cerebro- plexuses
spinal
Hypo- fluid Thalamus Thoracic
thalamus Thoracic Neuro-
spinal nerve muscular
Midbrain junction Muscle
Lumbo- fibers
Cere- Pons sacral
bellum & Lumbosacral
Medulla Coccygeal plexus

Cauda
Peripheral Autonomic Nervous System equina

Sympathetic Parasympathetic
chain ganglion

D R AWI N G 1 - 1 Overview of Neuroanatomy

8 Neuroanatomy: Draw It to Know It

Orientational Terminology
Here, we will draw the orientational planes of the ner- Next, draw a coronal section through the brain—a
vous system. To begin, draw intersecting horizontal and coronal view of the brain bears resemblance to an ornate
vertical lines. Label the left side of the horizontal line as crown. Indicate that the top of the brain is dorsal (also
anterior and right side as posterior. Label the top of the superior) and the bottom is ventral (also inferior). For
vertical line as superior and the bottom as inferior. this view, we need to additionally introduce the lateral–
Throughout the nervous system, front is always anterior medial and left-right planes of orientation. Label the
and behind is always posterior, top is always superior and midline as medial and the outside edges of the hemi-
bottom is always inferior. The anteroposterior and super- spheres as lateral. For the left–right planes of orientation
oinferior planes and medial-lateral planes, which we will we need to include both the anatomic and radiographic
introduce later, are static: they do not change orienta- perspectives. Label the left-hand side of the page as radio-
tion—unlike the rostral-caudal and dorsal-ventral planes, graphic right and anatomic left and the right-hand side as
which we introduce next. radiographic left and anatomic right. These planes refer
Next, let’s draw a side-on, sagittal view of the oblong to the standardized ways in which coronal radiographic
cerebral hemisphere. Label the top of the cerebral hemi- images and anatomic sections are viewed: in radiographic
sphere as dorsal and the bottom as ventral: the dorsal fin images, the head is viewed face-forward and in anatomic
of a shark is on its back whereas a shark’s underbelly is its sections, the head is viewed from behind.
ventral surface. Label the anterior portion of the cerebral Lastly, draw an axial (aka horizontal or transverse) sec-
hemisphere as rostral and the posterior portion as caudal. tion through the brain — the top of the page is the front
Rostral relates to the word “beak” and caudal relates to of the brain and the bottom is the back. Label the front of
the word “tail.” the section as rostral (also anterior) and the back as caudal
Now, draw a sagittal view of the brainstem at a nega- (also posterior). Label the left-hand side of the section as
tive 80-degree angle to the cerebral hemisphere. During radiographic right and anatomic left and the right-hand
embryogenesis, human forebrains undergo an 80-degree side as radiographic left and anatomic right. Radiographic
flexion at the junction of the brainstem and the cerebral axial images are viewed from below (as if the patient’s feet
hemispheres. Label the posterior aspect of the brainstem are coming out at you) whereas anatomic axial sections
as dorsal and the anterior aspect as ventral. Then, label are viewed from above (as if the patient’s head is coming
the superior aspect of the brainstem as rostral and the up at you). Label the center of the cerebral hemispheres as
inferior aspect as caudal. medial and their periphery as lateral.1–8
 1. General Organization 9

CORONAL
Dorsal (superior)
Superior
Radiographic Radiographic
right & left &
Anterior Posterior anatomic anatomic
left right

Inferior
Lateral Medial Lateral
Ventral (inferior)

SAGITTAL AXIAL
Dorsal Rostral (anterior)

Rostral Caudal
Radiographic Radiographic
right & left &
Rostral anatomic anatomic
Dorsal left right
Ventral
Ventral Caudal
Lateral Medial Lateral

Caudal (posterior)

D R AWI N G 1 - 2 Orientational Terminology