Hal Blumenfeld is Assistant Professor in the Departments of Neurology and Neurobiology at Yale University School
of Medicine. He has taught neuroanatomy at Harvard, Yale, and Columbia Universities using the approach of Neuroanatomy
Through Clinical Cases, which the students greeted with highly favorable feedback. He has been awarded several
prestigious grants (from the National Institutes of Health, Pfizer, and the Dana Foundation) to pursue his research,
which focuses on epilepsy as a model system for investigating consciousness. Current projects include cellular
neurophysiology experiments using brain slices, in vivo recordings from animal models of epilepsy, and SPECT imaging
of subcortical seizure foci in humans. His clinical training included an internship in Internal Medicine at Columbia
Presbyterian Medical Center, a residency in Neurology at Massachusetts General Hospital, and a fellowship in Epilepsy
at Yale University School of Medicine. He studied Bioelectrical Engineering at Harvard University, then earned
an M.A. and Ph.D. (in Physiology and Cellular Biophysics) as well as his M.D. at Columbia University. Dr. Blumenfeld's
previous publications include numerous articles in peer reviewed journals, as well as two volumes in the Let's
Go travel guidebook series.
Summary
Neuroanatomy through Clinical Cases brings a pioneering interactive approach to the teaching of neuroanatomy,
using over 100 actual Clinical Cases and high-quality radiologic images to bring the subject to life. This approach
allows students to appreciate the clinical relevance of structural details as they are being learned, and to integrate
knowledge of disparate functional systems, since a single lesion may affect several different neural structures
and pathways.
Most of the book comprises chapters that explain the major neuroanatomical systems. Each chapter first presents
background material including an overview of relevant neuroanatomical structures and pathways, and a brief discussion
of related clinical disorders. The second half of each chapter is devoted to clinical cases. The cases begin with
a narrative of how the patient developed symptoms, and what deficits were found upon neurological examination.
Boldface type highlights important symptoms and signs. A series of questions challenges the reader to deduce the
neuroanatomical location of the patient's lesion, and the diagnosis. Discussion and answers follow, and an epilogue
reveals the actual outcome.
One of the book's most innovative features is the inclusion of CT and MRI scans that depict each patient's lesion.
These radiographs help the reader develop skills in interpreting the same kinds of diagnostic images employed in
clinical practice.
The book is intended primarily for first- or second-year medical students enrolled in a basic neuroanatomy, neurobiology
or neuroscience course. It is also a valuable resource for advanced medical students and residents, as well as
students of other health professions, notably physical therapy, occupational therapy, nursing, dentistry, speech
therapy, and neuropsychology.
Table of Contents
Preface
Acknowledgments
How to Use This Book
1. Introduction to Clinical Case Presentations
The General History and Physical Exam
Neurologic Differential Diagnosis
Relationship between the General Physical Exam and the Neurologic Exam
2. Neuroanatomy Overview and Basic Definitions
Basic Macroscopic Organization of the Nervous System
Basic Cellular and Neurochemical Organization of the Nervous System
CNS Gray Matter and White Matter; PNS Ganglia and Nerves
Spinal Cord and Peripheral Nervous System
Cerebral Cortex: Basic Organization and Primary Sensory and Motor Areas
Motor Systems
Somatosensory Systems
Stretch Reflex
Brainstem and Cranial Nerves
Limbic System
Association Cortex
Blood Supply to the Brain and Spinal Cord
3. The Neurologic Exam as a Lesson in Neuroanatomy
Overview of the Neurologic Exam
neuroexam.com
The Neurologic Exam: Examination Technique and What Is Being Tested
The Neurologic Exam as a Flexible Tool
Coma Exam
Brain Death
Conversion Disorder, Malingering, and Related Disorders
The Screening Neurologic Exam
4. Introduction to Clinical Neuroradiology
Imaging Planes
Computerized Tomography
Magnetic Resonance Imaging
Neuroangiography
Functional Neuroimaging
5. Brain and Environs: Cranium, Ventricles, and Meninges
ANATOMICAL AND CLINICAL REVIEW
Cranial Vault and Meninges
Ventricles and Cerebrospinal Fluid
Blood-Brain Barrier
Key Clinical Concepts
Headache
Intracranial Mass Lesions
Elevated Intracranial Pressure
Brain Herniation Syndromes
Head Trauma
Intracranial Hemorrhage
Hydrocephalus
Brain Tumors
Infectious Disorders of the Nervous System
Lumbar Puncture
Craniotomy
CLINICAL CASES
An Elderly Man with Headaches and Unsteady Gait
Altered Mental Status Following Head Injury
Delayed Unresponsiveness after Head Injury
Headache and Progressive Left-Sided Weakness
Sudden Coma and Bilateral Posturing during Intravenous Anticoagulation
Severe Head Injury
A Child with Headaches, Nausea, and Diplopia
Headaches and Progressive Visual Loss
An Elderly Man with Progressive Gait Difficulty, Cognitive Impairment, and Incontinence
A Young Man with Headache, Fever, Confusion, and Stiff Neck
BRIEF ANATOMICAL STUDY GUIDE
A Scuba Expedition through the Brain
6. Corticospinal Tract and Other Motor Pathways
ANATOMICAL AND CLINICAL REVIEW
Motor Cortex, Sensory Cortex, and Somatotopic Organization
Basic Anatomy of the Spinal Cord
General Organization of the Motor Systems
Lateral Corticospinal Tract
Autonomic Nervous System
Key Clinical Concepts
Upper Motor Neuron versus Lower Motor Neuron Lesions
Terms Used to Describe Weakness
Weakness Patterns and Localization
Detecting Subtle Hemiparesis at the Bedside
Unsteady Gait
Multiple Sclerosis
Motor Neuron Disease
CLINICAL CASES
Sudden Onset of Right Hand Weakness
Sudden Onset of Left Foot Weakness
Sudden Onset of Right Face Weakness
Pure Motor Hemiparesis I
Pure Motor Hemiparesis II
Progressive Weakness, Muscle Twitching, and Cramps
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
7. Somatosensory Pathways
ANATOMICAL AND CLINICAL REVIEW
Main Somatosensory Pathways
Posterior Column-Medial Lemniscal Pathway
Spinothalamic Tract and Other Anterolateral Pathways
Somatosensory Cortex
Central Modulation of Pain
The Thalamus
Key Clinical Concepts
Paresthesias
Spinal Cord Lesions
Sensory Loss, Patterns, and Localization
Spinal Cord Syndromes
Anatomy of Bowel, Bladder, and Sexual Function
CLINICAL CASES
Sudden Onset of Right Arm Numbness
Sudden Onset of Right Face, Arm, and Leg Numbness
A Fall Causing Paraplegia and a T10 Sensory Level
Left Leg Weakness and Right Leg Numbness
Sensory Loss over Both Shoulders
Body Tingling and Unsteady Gait
Hand Weakness, Pinprick Sensory Level, and Urinary Retention
BRIEF ANATOMICAL STUDY GUIDE
8. Spinal Nerve Roots
ANATOMICAL AND CLINICAL REVIEW
Segmental Organization of the Nervous System
Nerve Roots in Relation to Vertebral Bones, Discs, and Ligaments Dermatomes and Myotomes
Key Clinical Concepts
Disorders of Nerve, Muscle, and Neuromuscular Junction
Back Pain
Radiculopathy
Simplification: Three Nerve Roots to Remember in the Arm
Simplification: Three Nerve Roots to Remember in the Leg
Key Clinical Concepts
Cauda Equina Syndrome
Common Surgical Approaches to the Spine
CLINICAL CASES
Unilateral Neck Pain and Tingling Numbness in the Thumb and Index Finger
Unilateral Occipital and Neck Pain
Unilateral Shoulder Pain and Weakness
Blisters, Pain, and Weakness in the Left Arm
Unilateral Shoulder Pain and Numbness in the Index and Middle Fingers
Unilateral Neck Pain, Hand Weakness, and Numbness in the Ring and Little Fingers
Pain and Numbness in the Medial Arm
Low Back Pain Radiating to the Sole of the Foot and the Small Toe
Unilateral Thigh Weakness with Pain Radiating to the Anterior Shin
Low Back Pain Radiating to the Big Toe
Saddle Anesthesia with Loss of Sphincteric and Erectile Function
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
9. Major Plexuses and Peripheral Nerves
ANATOMICAL AND CLINICAL REVIEW
Brachial and Lumbosacral Plexuses
Simplification: Five Nerves to Remember in the Arm
Simplification: Three Nerves Acting on the Thumb
Intrinsic and Extrinsic Hand Muscles
Simplification: Five Nerves to Remember in the Leg
Key Clinical Concepts
Common Plexus and Nerve Syndromes
Electromyography (EMG) and Nerve Conduction Studies
CLINICAL CASES
Complete Paralysis and Loss of Sensation in One Arm
A Newborn with Weakness in One Arm
A Blow to the Medial Arm Causing Hand Weakness and Numbness
Nocturnal Pain and Tingling in the Thumb, Pointer, and Middle Finger
Hand and Wrist Weakness after a Fall
Numbness and Tingling in the Pinky and Ring Finger
Unilateral Thigh Pain, Weakness, and Numbness in a Diabetic
Tingling and Paralysis of the Foot after a Fall
A Leg Injury Resulting in Foot Drop
Lateral Thigh Pain and Numbness after Pregnancy
BRIEF ANATOMICAL STUDY GUIDE
10. Cerebral Hemispheres and Vascular Supply
ANATOMICAL AND CLINICAL REVIEW
Review of Main Functional Areas of Cerebral Cortex
Circle of Willis: Anterior and Posterior Circulations
Anatomy and Vascular Territories of the Three Main Cerebral Arteries
Key Clinical Concepts
Clinical Syndromes of the Three Main Cerebral Arteries
Watershed Infarcts
Transient Ischemic Attack and Other Transient Neurologic Episodes
Ischemic Stroke: Mechanisms and Treatment
Carotid Stenosis
Dissection of the Carotid or Vertebral Arteries
Venous Drainage of the Cerebral Hemispheres
Key Clinical Concepts
Sagittal Sinus Thrombosis
CLINICAL CASES
Sudden-Onset Worst Headache of Life
Left Leg Weakness and Left Alien Hand Syndrome
Decreased Vision on One Side
Transient Episodes of Left Eye Blurriness or Right Hand Weakness
Nonfluent Aphasia with Right Face and Arm Weakness
Talking Ragtime
Dysarthria and Hemiparesis
Global Aphasia, Right Hemiplegia, and Hemianopia
Left Face and Arm Weakness
Left Hemineglect
Left Hemineglect, Hemiplegia, and Hemianopia
Unilateral Proximal Arm and Leg Weakness
Right Frontal Headache and Left Arm Numbness in a Woman with Gastric Carcinoma
BRIEF ANATOMICAL STUDY GUIDE
11. Visual System
ANATOMICAL AND CLINICAL REVIEW
Eyes and Retina
Optic Nerves, Optic Chiasm, and Optic Tracts
Lateral Geniculate Nucleus and Extrageniculate Pathways
Optic Radiations to Primary Visual Cortex
Visual Processing in the Neocortex
Key Clinical Concepts
Assessment of Visual Disturbances
Localization of Visual Field Defects
Blood Supply and Ischemia in the Visual Pathways
Optic Neuritis
CLINICAL CASES
A Dark Spot Seen with One Eye
Vision Loss in One Eye
Menstrual Irregularity and Bitemporal Hemianopia
Hemianopia after Treatment for a Temporal Lobe Tumor
Visual Changes Caused by Migraine Headaches?
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
12. Brainstem I: Surface Anatomy and Cranial Nerves
ANATOMICAL AND CLINICAL REVIEW
Surface Features of the Brainstem
Skull Foramina and Cranial Nerve Exit Points
Sensory and Motor Organization of the Cranial Nerves
Functions and Course of the Cranial Nerves
CN I: Olfactory Nerve
Key Clinical Concepts
Anosmia (CN I)
CN II: Optic Nerve
CN III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves
CN V: Trigeminal Nerve
Key Clinical Concepts
Trigeminal Nerve Disorders (CN V)
CN VII: Facial Nerve
Key Clinical Concepts
Facial Nerve Lesions (CN VII)
Corneal Reflex and Jaw Jerk Reflex (CN V, VII)
CN VIII: Vestibulocochlear Nerve
Key Clinical Concepts
Hearing Loss (CN VIII)
Dizziness and Vertigo (CN VIII)
CN IX: Glossopharyngeal Nerve
CN X: Vagus Nerve
CN XI: Spinal Accessory Nerve
CN XII: Hypoglossal Nerve
Key Clinical Concepts
Disorders of CN IX, X, XI, and XII
Hoarseness, Dysarthria, Dysphagia, and Pseudobulbar Affect
Review: Cranial Nerve Combinations
CLINICAL CASES
Anosmia and Visual Impairment
Cheek Numbness and a Bulging Eye
Jaw Numbness and Episodes of Loss of Consciousness
Isolated Facial Weakness
Hearing Loss and Dizziness
Hoarse Voice Following Cervical Disc Surgery
Hoarseness, with Unilateral Wasting of the Neck and Tongue Muscles
Uncontrollable Laughter, Dysarthria, Dysphagia, and Left-Sided Weakness
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
13. Brainstem II: Eye Movements and Pupillary Control
ANATOMICAL AND CLINICAL REVIEW
Extraocular Muscles, Nerves, and Nuclei
Key Clinical Concepts
Diplopia
Oculomotor Palsy (CN III)
Trochlear Palsy (CN IV)
Abducens Palsy (CN VI)
The Pupils and Other Ocular Autonomic Pathways
Key Clinical Concepts
Pupillary Abnormalities
Ptosis
Cavernous Sinus and Orbital Apex
Key Clinical Concepts
Cavernous Sinus Syndrome (CN III, IV, VI, V1) and Orbital Apex Syndrome (CN II, III, IV, VI, V1)
Supranuclear Control of Eye Movements
Brainstem Circuits for Horizontal Eye Movements
Key Clinical Concepts
Brainstem Lesions Affecting Horizontal Gaze
Brainstem Circuits for Vertical and Vergence Eye Movements
Key Clinical Concepts
Parinaud's Syndrome
Control of Eye Movements by the Forebrain
Key Clinical Concepts
Right-Way Eyes and Wrong-Way Eyes
Cerebellar, Vestibular, and Spinal Control of Voluntary and Reflex Eye Movements
CLINICAL CASES
Double Vision and Unilateral Eye Pain
A Diabetic with Horizontal Diplopia
Vertical Diplopia
Left Eye Pain and Horizontal Diplopia
Unilateral Headache, Ophthalmoplegia, and Forehead Numbness
Ptosis, Miosis, and Anhidrosis
Wrong-Way Eyes
Horizontal Diplopia in a Patient with Multiple Sclerosis
Headaches and Impaired Upgaze
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
14. Brainstem III: Nuclei, Pathways, and Vascular Supply
ANATOMICAL AND CLINICAL REVIEW
Main Components of the Brainstem
Brainstem Sections
Cranial Nerve Nuclei and Related Structures
Long Tracts
Key Clinical Concepts
Locked-in Syndrome
Cerebellar Circuitry
Reticular Formation and Related Structures
Widespread Projection Systems of Brainstem and Forebrain: Consciousness, Attention, and Other Functions
Anatomy of the Sleep-Wake Cycle
Key Clinical Concepts
Coma and Related Disorders
Reticular Formation Motor, Reflex, and Autonomic Systems
Brainstem Vascular Supply
Key Clinical Concepts
Vertebrobasilar Vascular Disease
CLINICAL CASES
Face and Contralateral Body Numbness, Hoarseness, Horner's syndrome, and Ataxia
Hemiparesis Sparing the Face
Dysarthria and Hemiparesis
Unilateral Face Numbness, Hearing Loss, and Ataxia
Locked In
Wrong-Way Eyes, Limited Upgaze, Decreased Responsiveness, and Hemiparesis with an Amazing Recovery
Diplopia and Unilateral Ataxia
Intermittent Memory Loss, Diplopia, Sparkling Lights, and Somnolence
Intractable Hiccups
BRIEF ANATOMICAL STUDY GUIDE
15. Cerebellum
ANATOMICAL AND CLINICAL REVIEW
Cerebellar Lobes, Peduncles, and Deep Nuclei
Microscopic Circuitry of the Cerebellum
Cerebellar Output Pathways
Cerebellar Input Pathways
Vascular Supply to the Cerebellum
Key Clinical Concepts
Cerebellar Artery Infarcts and Cerebellar Hemorrhage
Clinical Findings and Localization of Cerebellar Ataxia
Differential Diagnosis of Ataxia
CLINICAL CASES
Sudden Onset of Unilateral Ataxia
Walking like a Drunkard
A Boy with Headaches, Nausea, Slurred Speech, and Ataxia
Nausea, Progressive Unilateral Ataxia, and Right Face Numbness
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
16. Basal Ganglia
ANATOMICAL AND CLINICAL REVIEW
Basic Three-Dimensional Anatomy of the Basal Ganglia
Input, Output, and Intrinsic Connections of the Basal Ganglia
Parallel Basal Ganglia Pathways for Movement, Eye Movement, Cognition, and Emotion
Ansa Lenticularis, Lenticular Fasciculus, and the Fields of Forel
Key Clinical Concepts
Movement Disorders
Parkinson's Disease and Related Disorders
Huntington's Disease
Stereotactic Surgery and Movement Disorders
CLINICAL CASES
Unilateral Flapping and Flinging
Irregular Jerking Movements and Marital Problems
Asymmetrical Resting Tremor, Rigidity, Bradykinesia, and Gait Difficulties
Bilateral Bradykinesia, Rigidity, and Gait Instability with No Tremor
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
17. Pituitary and Hypothalamus
ANATOMICAL AND CLINICAL REVIEW
Overall Anatomy of the Pituitary and Hypothalamus
Important Hypothalamic Nuclei and Pathways
Endocrine Functions of the Pituitary and Hypothalamus
Key Clinical Concepts
Pituitary Adenoma and Related Disorders
Diabetes Insipidus and SIADH
Panhypopituitarism
CLINICAL CASES
Moon Facies, Acne, Amenorrhea, and Hypertension
Impotence, Anorexia, Polyuria, Blurred Vision, Headaches, and Hearing Loss
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
18. Limbic System: Homeostasis, Olfaction, Memory, and Emotion
ANATOMICAL AND CLINICAL REVIEW
Overview of Limbic Structures
Olfactory System
Hippocampal Formation and Other Memory-Related Structures
Key Clinical Concepts
Memory Disorders
The Amygdala: Emotions, Drives, and Other Functions
Other Limbic Pathways
Key Clinical Concepts
Seizures and Epilepsy
Anatomical and Neuropharmacological Basis of Psychiatric Disorders
CLINICAL CASES
Sudden Memory Loss after a Mild Head Injury
Progressive Severe Memory Loss, with Mild Confabulation
Transient Diplopia, Lethargy, and Hemiparesis, Followed by a Sustained Memory Deficit
Episodes of Panic, Olfactory Hallucinations, and Loss of Awareness
Episodes of Staring, Lip Smacking, and Unilateral Semipurposeful Movements
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
19. Higher-Order Cerebral Function
ANATOMICAL AND CLINICAL REVIEW
Key Clinical Concepts
The Mental Status Exam
Unimodal and Heteromodal Association Cortex
Principles of Cerebral Localization and Lateralization
The Dominant Hemisphere: Language Processing and Related Functions
Key Clinical Concepts
Differential Diagnosis of Language Disorders
Bedside Language Exam
Broca's Aphasia
Wernicke's Aphasia
Simplified Aphasia Classification Scheme
Other Syndromes Related to Aphasia
Disconnection Syndromes
The Nondominant Hemisphere: Mechanisms of Attention and Spatial Processing
Lateralized Aspects of Attention
Spatial Analysis and Integration
Key Clinical Concepts
Hemineglect Syndrome
Other Clinical Features of Nondominant Hemisphere Lesions
The Frontal Lobes: Anatomy and Functions of an Enigmatic Brain Region
Key Clinical Concepts
Frontal Lobe Disorders
Visual Association Cortex: Higher-Order Visual Processing
Key Clinical Concepts
Disorders of Higher-Order Visual Processing
Auditory Hallucinations
Attention, Awareness, and Other General Network Functions of the Brain
Key Clinical Concepts
Attentional Disorders
Delirium and Other Acute Mental Status Disorders
Dementia and Other Chronic Mental Status Disorders
CLINICAL CASES
Acute Severe Aphasia, with Improvement
Nonsensical Speech
Aphasia with Preserved Repetition
Impaired Repetition
Inability to Read, with Preserved Writing Skills
Left Hemineglect
Abulia
Blindness without Awareness of Deficit
Sudden Inability to Recognize Faces
Musical Hallucinations
Progressive Dementia, Beginning with Memory Problems
Additional Cases
BRIEF ANATOMICAL STUDY GUIDE
Epilogue: A Simple Working Model of the Mind Index to Cases Subject Index
