1、為了更加專業、優秀、快捷地學習先進的醫學知識Medicine e-books: Convenient， Advanced，更新更好的醫學專業書籍，請到醫書！For more medical e-books, please go toProfessional為了祖國的現代醫學更快地趕上發達我們全體醫生需要共同努力！，Dowmload with freeMeb 小組Meb 小組本所使用的所有，包括但不僅局限于書籍、軟件、光盤等，全部來源于互聯網合法提供的內容，本站僅負責收集、整理后供站內網友學習、交流使用，不含有任何商業目的，不以為目的，資料來源于互聯網，本站不對所提供資料擔保其、科學性、準確性，

2、不對所提供所有資料所產生的任何后果承擔任何國家或地區法律上的責任，請網友學習中自覺遵守本和當地的，切勿用于的商業目的使用，否則一切后果自負，與本無任何關系！本站上傳或一切形式的國家、中國的的資料和，一切形式的具有、 穢、等違法內容的任意形式的資料！鄭重：請網友后在 24 小時內刪除從本站的資料！請及時認真學習現代科學知識！請您！Meb 小組2009 年 2 月N E U R O A N A T O M YDraw It to Know ItThis page intentionally left blankN E U R O A N A T O M YDraw It to Know ItA D

3、 A M F I S C H , M D Washington University in St. LouisSchool of Medicine Department of NeurologySt. Louis, MO120091Oxford University Press, Inc., publishes works that further Oxford Universitys objective of excellencein research, scholarship, and education.Oxford New YorkAuckland Cape Town Dar es S

4、alaamKarachiKuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei TorontoWith oces inArgentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine VietnamCopyright © 2009

5、by Adam Fisch. Published by Oxford University Press, Inc.198 Madison Avenue, New York, New York 10016Oxford is a registered trademark of Oxford University Presss. No part of this publication may be reproduced,stored in a retrieval system, or transmitted, in any form or by any means, electronic, mech

6、anical, photocopying, recording, or otherwise,without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication DataFisch, Adam.Neuroanatomy : draw it to know it / Adam Fisch.p. cm.Includes bibliographical references and index. ISBN 978-0-19-536994-61. Neuroanato

7、myGraphic methods. I. Title. QM451.F57 2009611 .8dc222008047543975 4 3862 1Printed in the United States of America on acid-free paperThis 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

8、left blankF O R E W O R D Nneuroimaging, the actual practice of neurology, whether it is done by a neurologist or anon-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 funct

9、ional neuroanatomy, clinical neurology becomes incomprehensible.In his wonderful book, Neuroanatomy: DrawIt to Know It, neurologist Adam Fisch applies my old neuroanatomy professors colored pencil idea in a manner that actually works, and its fun! Over the course of 39 chapters, most of the clinical

10、ly important neuroanatomically 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

11、 experienced neurologist, as the topics are organized in a fashion that illuminates the principle of anatomical- pathophysiological correlation, which is thetool with which neurologists approach clinical problems.This book should be of great interest to all neurologists, neurosurgeons, neurology res

12、idents and students of neurology. Others who see patients with neurological complaints, such as internists, emergency physicians and obstetrician-gynecologists should also review their neuroanatomy if they wish to provide excellent care to their patients. As anyEUROANATOMY IS A nightmare formost med

13、ical students. The complex array ofnuclei, ganglia, tracts, lobes, Brodmann areasand cortical layers seem to the uninitiated as theheight of useless trivia. My own memory of my neuroanatomy class in medical school is vivid. Our professor, a Ph.D. neuroanatomist, ordered each member of the class to b

14、uy 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 s

15、tudent 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 psychia

16、try, 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 understanding of the neuroanatomy. Non-neurologists in particular, many of whom see large numbers of patients with neurological compla

17、ints, 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 andVIIexperienced tea

18、cher 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, theinformation learned in this manner is likely to stick. Adam Fisch has done us all a great service

19、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 Womens Hospital Professor of NeurologyHarvard Medical SchoolBoston, MAVIIIFOREWORD P R E F A C E MY NEUROANATOMY MENTO

20、R, the latebody, imagine cognitive sensory decits, and rigorously draw and re-draw the structures and pathways of the nervous system until they become second nature.The text is comprehensive but pearls of neuroanatomy are highlighted for those who are short on time. Anatomic and radiographic images

21、accompany the gures to clarify what the drawings cannot. Synonymous terms are listed to mitigate confusion; inter-textual discrepancies are brought to attention; and historical and current contexts for the anatomical structures are discussed. Inshort, this book provides the tools you need to learn n

22、euroanatomy in a practical and complete way so that you can use it at the bedside.I apologize to readers who are unable to perform exercises in this book due to physical impairments. If you have trouble imagining them, please write to me and I will gladly try to nd alternative exercisesfor you.Neuro

23、anatomy is hardly simple but it should always be fun, so lets enjoy this trip throughthe nervous system and every trip back through it.Dr. William DeMyer, often remarked, “ifyou cant draw it, you dont know it.” Histeaching method was straightforward: to learn thestructures and ber pathways of the ne

24、rvous system, draw and re-draw them, and when you think you know them well, draw them some more. This book tries to emulate his approach. It is written in an instructive rather than a didactic manner so that we use the material to learn it.The analogy is simple: if you want to become a table expert,

25、 put one together. Invariably, you will screw the legs on backwards and hammer on the top upside down rst, but how else will you learn about the washers and wing-nuts, bolts and llets that fasten one together? How else will you understand what makesa table strong or learn its weak points and the way

26、s to improve upon one? Reading about tables will never teach you: you have to put one together, yourself.With this book, we will trace nerve pathways down our limbs, demonstrate eye movements and vestibular directionality with our hands, palpate sensory distributions and muscle patterns across our f

27、ace andIXThis page intentionally left blankA C K N O W L E D G M E N T STO TRY TO ACKNOWLEDGE all of the peoplemmed Al-Lozi, Joseph Black, Kelly Brown, William DeMyer, Adriana Escandon, Stephen Duntley, Mark Jacquin, David Holtzman, William Landau, Abdullah Nassief, Robert Pascuzzi, Beth Ward, Thoma

28、s Woolsey, and AllysonZazulia.Id also like to thank Denny Fiske, Paul Lysy, and Michael Schwartz for their help generating the muscle testing photographs, and Tammie Benzinger and Robert Cargile in the Department of Neuroradiology at Washington University in St. Louis for their help creating the diu

29、sion tensor images.I owe special thanks to my family for all of their encouragement during this process.Most of all, though, I owe my wife, Kate, all of my love and gratitude for allowing the cat and me to devote our mornings, nights, and weekends to writing and illustrating this book. We look forwa

30、rd to being a part of your life, again.I ought to would be impossible andself-defeating so I will only mention a few.The foremost is Susan Pioli who, along with myuncle, Bruce, championed this book from the start.Without her enthusiasm for this project, it never would have been done. Id also like to

31、 thank my editor, Craig Panner, and his editorial assistant, David DAddona, as well as the books production manager, Jennifer Bossert; they, along with many others at Oxford University Press, steered this book to completion with remarkable vision.I am grateful to the faculty and sta in the Departmen

32、ts of Anatomy and Neurology at Indiana University and Washington University in St. Louis and to Robert J. Schwartzman of Drexel University School of Medicine for all they taught me about neuroanatomy and clinical neurology during my neurology training. Special thanks are owed toXIThis page intention

33、ally left blankC O N T E N T S2462428364454626876788286102108122130168186206234246Chapter 1, Organization of the Nervous SystemChapter 2, Orientational Terminology Chapter 3, Meninges and Ventricular System Chapter 4, Nerve Roots and RamiChapter 5, Brachial Plexus Chapter 6, Median Nerve Chapter 7,

34、Ulnar Nerve Chapter 8, Radial Nerve Chapter 9, Lumbosacral Plexus Chapter 10, Sciatic Nerve Chapter 11, Femoral Nerve Chapter 12, Cervical PlexusChapter 13, Sensory Maps of the BodyChapter 14, Peripheral Autonomic Nervous System Chapter 15, Structure of the Spinal Cord and Spinal Canal Chapter 16, S

35、pinal CordChapter 17, Reex Loops and Muscle ToneChapter 18, BrainstemChapter 19, Cranial and Spinal Nerve Overview Chapter 20, Somatomotor Cranial Nerves Chapter 21, Pharyngeal Arch Cranial Nerves Chapter 22, Vestibular SystemChapter 23, Skull BaseXIII260272294310327344350363382388402424430436438440

36、448453Chapter 24, CerebellumChapter 25, Surfaces of the Brain Chapter 26, White Matter Pathways Chapter 27, Basal GangliaChapter 28, Arterial Supply to the Central Nervous SystemChapter 29, ThalamusChapter 30, Hypothalamus Chapter 31, Limbic System Chapter 32, Olfactory System Chapter 33, Visual Pat

37、hways Chapter 34, Eye MovementsChapter 35, Central Auditory PathwaysChapter 36, LanguageChapter 37, MemoryChapter 38, ApraxiaChapter 39, Sleep Neurocircuitry ReferencesIndexXIVCON TEN TSNEUROANATOMYDraw It to Know ItC H A P T E R1Organization of the Nervous SystemTrst, in this chapter, lets march br

38、iskly through, we will learn thedorsal nerve root o the posterior spinal cord, which carries sensory bers, and attach a dorsal root ganglion onto it; sensory cell bodies lie within the dorsal root ganglion. Now, draw the ventral nerve root from the anterior surface of the spinal cord; it carries mot

39、or bers. Show the nerve roots form a mixed spinal nerve, and indicate it exits the spinal canal through a neural foramen.Mixed spinal nerves often intertwine into plexuses, which complicate the localization of peripheral nerve injuries. Within the upper extremity, show there are two dierent plexuses

40、: the cervical and brachial plexuses. Then, below them, indicate the thoracic nerves remain unmixed. Next, show the lumbosacral roots form the lumbosacral plexus, and specically indicate the lower lumbosacral rootsform the cauda equina before they exit the spinal canal.At the tip of a representative

41、 thoracic peripheral nerve, draw a neuromuscular junction synapse and attach muscle bers to it. Muscles and neuromuscle junctions are commonly aected parts of the peripheral nervous system as are the sensory receptors that exist at the tips of peripheral nerves.Lastly, include the peripheral autonom

42、ic nervous system, which we represent here with one of the two sympathetic paravertebral chains that ank the spinal cord. Prevertebral sympathetic ganglia and parasympathetic ganglia also constitute the peripheral autonomic nervous system. The peripheral autonomic nervous system most notablyexecutes

43、 cardiopulmonary and gastrointestinal functions.HROUGHOUT THIS BOOKanatomy of the nervous system in detail, butthe nervous system to form a broad perspective on it.Draw a coronal section through the brain. From outside to inside, label the meninges, cortex, subcortical white matter, basal ganglia, t

44、halamus, and ventricular system. In general, the meningesprotect and vascularize the nervous system; the cortex is the gray matter, highly cellular outer layer of the brain; the subcortical white matter carries impulses within the brain and ushers them to and from remote nervous system regions; the

45、basal ganglia are involved in motor and behavioral functions; the thalamus receives and modies sensory impulses, which it projects throughout the brain; and the ventricular system assists the meninges in their task of nourishing and supporting the rest of thenervous system.Below the brain, draw the

46、brainstem; it is afunnel-shaped structure with a bulbous out-pouching in the middle. From superior to inferior, show the brainstem comprises the midbrain, pons, and medulla. The brainstem is requisite for human life; it contains neuronal pools essential for survival and is the major thoroughfare for

47、 bers passing between the brain and spinal cord.On the lateral aspects of the brainstem, draw the leafy hemispheres of the cerebellum. The cerebellum is pivotal in motor coordination skills as well asnon-motor behavioral functions, such as learning.Next, draw the long, thin spinal cord with its cerv

48、ical and lumbosacral enlargements.Draw the2Figure 1-1Overview of nervous system anatomyOrganization of the Nervous System3ParavertebralSpinalDorsal rootMeningeschaincordganglionPeripheral nerveCortexCervicalVentralSubcorticalrootCervicalwhite matter& brachialBasalVentricularplexusesmotorsystemTh

49、or-nucleiacicNeuro-ThalamusThoracicspinal nervemuscularjunction MuscleMidbrainLumbosacralbersCere- Pons&bellumCoccygealLumbosacralMedullaplexusCauda equinaC H A P T E R2Orientational TerminologyTneurologists nd challenging. Take the timeHE NERVOUS SYSTEM has severalsynonymous with dorsal, inferi

50、or with ventral, anterior with rostral, and posterior with caudal.Next, include a sagittal section of the brainstem atorientational planes that even experiencedto learn them now, as this knowledge is requisitea 80 angle to the cerebral hemispheres (i.e., almostto understanding the remainder of the b

51、ook. If you try to skip this chapter, you will invariably nd yourself hopelessly disoriented later.At the top of the page, draw intersecting horizontal and vertical lines. Along the horizontalin perpendicular to it). During early embryogenesis, both the cerebral hemispheres and brainstem lie along t

52、he same orientational plane. However, as human forebrains develop, they undergo an 80 exionthat results in the so-called “cephalic exure” atthe junction between the brainstem and the cerebral hemispheres. Thus, the plane of the brainstem isline, label left as anterior and right as posterior. Labelth

53、e top of the vertical line as superior and the bottom as inferior. The two superiorinferior and anterior posterior orientational axes are consistent throughout the nervous system; that is, top is always superiorand bottom is always inferior, and front is always anterior and behind is always posterio

54、r. We are not so lucky with the dorsalventral and rostralcaudal orientational axes we will soon introduce becauseof the rotation of the neuraxis during embryogenesis.Next, lets draw a sagittal (aka longitudinal) section through the oblong cerebral hemisphere. The sagittal plane runs from anterior to

55、 posterior and the sagittal suture, which runs from the front to the back of the skull, is a good example of this plane of orientation. Label the top of the cerebral hemisphere as dorsal and the bottom as ventral. To remind yourself that dorsal is on top and ventral is on bottom, remember the dorsal

56、 n of a shark is on its back whereas its underbelly is ventral. Label the anterior portion of the hemisphere as rostral and the posterior portion as caudal. Rostral is related to the word “beak” and caudal is related to the word “tail.”Within the cerebral hemispheres, which orientational terms are s

57、ynonymous? Superior is80 to that of the cerebral hemispheres. Lets explorehow this aects the orientation of the dorsal-ventral and rostral-caudal axes of the brainstem; remember, the superiorinferior and anteriorposterior axesare unchanged throughout the nervous system. Label behind the brainstem as dorsal and in front of it as ventral. Then, label the top of the brainstem as rostral and the bottom as caudal. Now, within th