If
a person with a sectioned corpus callosum is given the same instructions, they
will do something quite peculiar. They will only put their right hand in their
pocket and say they have keys there. They will not even move their left hand,
much less report that there is loose change in the left pocket. The reason for
this is that the language functions of the cerebral cortex are localized to the
left hemisphere in 95 percent of the population. Additionally, the left
hemisphere is connected to the right side of the body through the corticospinal
tract and the ascending tracts of the spinal cord. Motor commands from the
precentral gyrus control the opposite side of the body, whereas sensory
information processed by the postcentral gyrus is received from the opposite
side of the body. For a verbal command to initiate movement of the right arm
and hand, the left side of the brain needs to be connected by the corpus
callosum. Language is processed in the left side of the brain and directly
influences the left brain and right arm motor functions, but is sent to
influence the right brain and left arm motor functions through the corpus
callous.
Likewise, the left-handed sensory perception of Focused In what is in the left
pocket travels across the corpus callous from the right brain, so no verbal
report on those contents would be possible if the hand happened to be in the
pocket. The cerebrum, particularly the cerebral cortex, is the location of
important cognitive functions that are the focus of the mental status exam. The
regionalization of the cortex, initially described on the basis of anatomical
evidence of cytoarchitecture, reveals the distribution of functionally distinct
areas. Cortical regions can be described as primary sensory or motor areas,
association areas, or multimodal integration areas. The functions attributed to
these regions include attention, memory, language, speech, sensation, judgment,
and abstract reasoning. The mental status exam addresses these cognitive
abilities through a series of subtests designed to elicit particular behaviors
ascribed to these functions. The loss of neurological function can illustrate
the location of damage to the cerebrum. Memory functions are attributed to the
temporal lobe, particularly the medial temporal lobe structures known as the
hippocampus and amygdala, along with the adjacent cortex. Evidence of the
importance of these structures comes from the side effects of a bilateral
temporal lobectomy that were studied in detail in patient HM.
Losses of
language and speech functions, known as aphasias, are associated with damage to
the important integration areas in the left hemisphere known as Broca’s or
Wernicke’s areas, as well as the connections in the white matter between them.
Different types of aphasia are named for the particular structures that are
damaged. Assessment of the functions of the sensorium includes praxis and
gnosis. The subtests related to these functions depend on multimodal
integration, as well as language-dependent processing. The prefrontal cortex
contains structures important for planning, judgment, reasoning, and working
memory. Damage to these areas can result in changes to personality, mood, and
behavior. The famous case of Phineas Gage suggests a role for this cortex in
personality, as does the outdated practice of prefrontal lobectomy. The twelve
cranial nerves are typically covered in introductory anatomy courses, and
memorizing their names is facilitated by numerous mnemonics developed by
students over the years of this practice. But knowing the names of the nerves
in order often leaves much to be desired in understanding what the nerves do. The
nerves can be categorized by functions, and subtests of the cranial nerve exam
can clarify these functional groupings. Three of the nerves are strictly
responsible for special senses whereas four others contain fibers for special
and general senses.
Three nerves are connected to the extraocular muscles
resulting in the control of gaze. Four nerves connect to muscles of the face,
oral cavity, and pharynx, controlling facial expressions, mastication,
swallowing, and speech. Four nerves make up the cranial component of the
parasympathetic nervous system responsible for pupillary constriction,
salivation, and the regulation of the organs of the thoracic and upper
abdominal cavities. Finally, one nerve controls the muscles of the neck,
assisting with spinal control of the movement of the head and neck. The cranial
nerve exam allows directed tests of forebrain and brain stem structures. The
twelve cranial nerves serve the head and neck. The vagus nerve (cranial nerve
X) has autonomic functions in the thoracic and superior abdominal cavities. The
special senses are served through the cranial nerves, as well as the general
senses of the head and neck. The movement of the eyes, face, tongue, throat,
and neck are all under the control of cranial nerves. Preganglionic parasympathetic
nerve fibers that control pupillary size, salivary glands, and the thoracic and
upper abdominal viscera are found in four of the nerves. Tests of these
functions can provide insight into damage to specific regions of the brain stem
and may uncover deficits in adjacent regions.
Sensory Nerves The olfactory,
optic, and vestibulocochlear nerves (cranial nerves I, II, and VIII) are
dedicated to four of the special senses: smell, vision, equilibrium, and
hearing, respectively. Taste sensation is relayed to the brain stem through
fibers of the facial and glossopharyngeal nerves. The trigeminal nerve is a
mixed nerve that carries the general somatic senses from the head, similar to
those coming through spinal nerves from the rest of the body. Testing smell is
straightforward, as common smells are presented to one nostril at a time. The
patient should be able to recognize the smell of coffee or mint, indicating the
proper functioning of the olfactory system. Loss of the sense of smell is
called anosmia and can be lost following blunt trauma to the head or through
aging. The short axons of the first cranial nerve regenerate on a regular
basis. The neurons in the olfactory epithelium have a limited life span, and
new cells grow to replace the ones that die off. The axons from these neurons
grow back into the CNS by following the existing axons—representing one of the
few examples of such growth in the mature nervous system. If all of the fibers
are sheared when the brain moves within the cranium, such as in a motor vehicle
accident, then no axons can find their way back to the olfactory bulb to
re-establish connections. If the nerve is not completely severed, the anosmia
may be temporary as new neurons can eventually reconnect. Olfaction is not the
pre-eminent sense, but its loss can be quite detrimental.
The enjoyment of food
is largely based on our sense of smell. Anosmia means that food will not seem
to have the same taste, though the gustatory sense is intact, and food will
often be described as being bland. However, the taste of food can be improved
by adding ingredients (e.g., salt) that stimulate the gustatory sense. Testing
vision relies on the tests that are common in an optometry office. The Snellen
chart ([link]) demonstrates visual acuity by presenting standard Roman letters
in a variety of sizes. The result of this test is a rough generalization of the
acuity of a person based on the normal accepted acuity, such that a letter that
subtends a visual angle of 5 minutes of an arc at 20 feet can be seen. To have
20/60 vision, for example, means that the smallest letters that a person can
see at a 20-foot distance could be seen by a person with normal acuity from 60
feet away. Testing the extent of the visual field means that the examiner can
establish the boundaries of peripheral vision as simply as holding their hands
out to either side and asking the patient when the fingers are no longer
visible without moving the eyes to track them. If it is necessary, further
tests can establish the perceptions in the visual fields. Physical inspection
of the optic disk, or where the optic nerve emerges from the eye, can be
accomplished by looking through the pupil with an ophthalmoscope. The Snellen
chart for visual acuity presents a limited number of Roman letters in lines of
decreasing size.
The line with letters that subtend 5 minutes of an arc from 20
feet represents the smallest letters that a person with normal acuity should be
able to read at that distance. The different sizes of letters in the other
lines represent rough approximations of what a person of normal acuity can read
at different distances. For example, the line that represents 20/200 vision
would have larger letters so that they are legible to the person with normal
acuity at 200 feet. The optic nerves from both sides enter the cranium through
the respective optic canals and meet at the optic chiasm at which fibers sort
such that the two halves of the visual field are processed by the opposite
sides of the brain. Deficits in visual field perception often suggest damage
along the length of the optic pathway between the orbit and the diencephalon.
For example, loss of peripheral vision may be the result of a pituitary tumor
pressing on the optic chiasm ([link]). The pituitary, seated in the sella turcica
of the sphenoid bone, is directly inferior to the optic chiasm. The axons that
decussate in the chiasm are from the medial retinae of either eye, and
therefore carry information from the peripheral visual field. Pituitary Tumor
The left panel of this figure shows the top view of the brain.