Clinical Neuroanatomy, 27 ed.

CHAPTER 3. Signaling in the Nervous System

Along with muscle cells, neurons are unique in that they are excitable; that is, they respond to stimuli by generating electrical impulses. Electrical responses of neurons (modifications of the electrical potential across their membranes) may be local (restricted to the place that received the stimulus) or propagated (may travel through the neuron and its axon). Propagated electrical impulses are termed action potentials. Neurons communicate with each other at synapses by a process called synaptic transmission.


The membranes of cells, including nerve cells, are structured so that a difference in electrical potential exists between the inside (negative) and the outside (positive). This results in a resting potential across the cell membrane, which is normally about –70 mV.

The electrical potential across the neuronal cell membrane is the result of its selective permeability to certain charged ions. Cell membranes are highly permeable to most inorganic ions, but they are almost impermeable to proteins and many other organic ions. The difference (gradient) in ion composition inside and outside the cell membrane is maintained by ion pumps in the membrane, which maintain a nearly constant concentration of inorganic ions within the cell (Fig 3–1 and Table 3–1). The pump that maintains Na+ and K+ gradients across the membrane is Na, K-ATPase; this specialized protein molecule extrudes a+ from the intracellular compartment, moving it to the extracellular space, and imports K+ from the extracellular space, carrying it across the membrane into the cell. In carrying out this essential activity, the pump consumes adenosine triphosphate (ATP).


FIGURE 3–1 Na+ and K+ flux through the resting nerve cell membrane. Notice that the Na+/K+ pump (Na+/K+-ATPase) tends to extrude Na+ from the interior of the cell, but it carries K+ ions inward. (Reproduced, with permission, from Eccles JC: The Physiology of Nerve Cells. Johns Hopkins University Press, 1957.)

TABLE 3–1 Concentration of Some Ions Inside and Outside Mammalian Spinal Motor Neurons.


Two types of passive forces maintain an equilibrium of Na+ and K+ across the membrane: A chemical force tends to move Na+ inward and K+ outward, from the compartment containing high concentration to the compartment containing low concentration, and an electrical force (the membrane potential) tends to move Na+ and K+ inward. When the chemical and electrical forces are equally strong, an equilibrium potential exists.

For an idealized membrane that is permeable to only K+, the Nernst equation, which describes the relationship between these forces, is used to calculate the magnitude of the equilibrium potential (ie, the membrane potential at which equilibrium exists). Normally, there is a much higher concentration of K+ inside the cell ([K+]i) than outside the cell ([K+]o) (see Table 3–1). The Nernst equation, which would be used to determine membrane potential across a membrane permeable only to K+ ions, is as follows:




At physiologic temperatures


The equilibrium potential (ENa) for sodium can be found by substituting [Na+]i and [Na+]o in the Nernst equation; this potential would be found across a membrane that was permeable only to sodium. In reality, most cell membranes are not perfectly selective; that is, they are permeable to several ionic species. For these membranes, potential is the weighted average of the equilibrium potentials for each permeable ion, with the contribution for each ion weighted to reflect its contribution to total membrane permeability. This is described mathematically, for a membrane that is permeable to Na+ and K+, by the Goldman-Hodgkin-Katz equation (also known as the constant field equation):




As seen in this equation, membrane potential is affected by the relative permeability to each ion. If permeability to a certain ion increases (eg, by the opening of pores or channels specifically permeable to that ion), membrane potential moves closer to the equilibrium potential for that ion. Conversely, if permeability to that ion decreases (eg, by closing of pores or channels permeable to that ion), membrane potential moves away from the equilibrium potential for that ion.

In the membrane of resting neurons, K+ permeability is much higher (~20-fold) than Na+ permeability; that is, the PK–PNa ratio is approximately 20:1. Thus, when a neuron is inactive (resting), the Goldman-Hodgkin-Katz equation is dominated by K+ permeability so that membrane potential is close to the equilibrium potential for K (EK). This accounts for the resting potential of approximately –70 mV.


The generator (receptor) potential is a local, nonpropagated response that occurs in some sensory receptors (eg, muscle stretch receptors and pacinian corpuscles, which are touch-pressure receptors) where mechanical energy is converted into electric signals. The generator potential is produced in a small area of the sensory cell: the nonmyelinated nerve terminal. Most generator potentials are depolarizations, in which membrane potential becomes less negative. In contrast to action potentials (see the next section), which are all-or-none responses, generator potentials are graded (the larger the stimulus [stretch or pressure], the larger the depolarization) and additive (two small stimuli, close together in time, produce a generator potential larger than that made by a single small stimulus). Further increase in stimulation results in larger generator potentials (Fig 3–2). When the magnitude of the generator potential increases to about 10 mV, a propagated action potential (impulse) is generated in the sensory nerve.


FIGURE 3–2 Demonstration of a generator potential in a pacinian corpuscle. The electrical responses to a pressure (black arrow) of 1×, 2×, 3×, and 4× are shown. The strongest stimulus produced an action potential in the sensory nerve, originating in the center of the corpuscle (open arrow).


Neurons communicate by producing electrical impulses called action potentials. Action potentials are self-regenerative electrical signals that tend to propagate throughout a neuron and along its axon. The action potential is a depolarization of about 100 mV (a large signal for a neuron). The action potential is all or none. Its size is constant for each neuron.

Neurons can generate action potentials because they contain specialized molecules, called sodium channels, that respond to depolarization by opening (activating). When this occurs, the relative permeability of the membrane to Na+ increases, and the membrane moves closer to the equilibrium potential for Na+, as predicted by the Goldman-Hodgkin Katz equation, thus causing further depolarization. When a depolarization (from a generator potential, synaptic potential, or oncoming action potential) impinges on a neuronal membrane, sodium channels activate and, as a result, the membrane begins to further depolarize. This action tends to activate still other sodium channels, which also open and cause depolarization. If a sufficient number of sodium channels are activated, there is a depolarization of about 15 mV, and threshold is reached so that the rate of depolarization increases sharply to produce an action potential (Fig 3–3). Thus, the membrane generates an explosive, all-or-none action potential. As the impulse passes, repolarization occurs rapidly at first and then more slowly. Membrane potential thus returns to resting potential. The action potential tends to last for a few milliseconds.


FIGURE 3–3 Action potential (“spike potential”) recorded with one electrode inside cell. In the resting state, the membrane potential (resting potential) is about –70 mV. When the axon is stimulated, there is a small depolarization. If this depolarization reaches the firing level (threshold), there is an all-or-none depolarization (action potential). The action potential approaches ENa and overshoots the 0-mV level. The action potential ends when the axon repolarizes, again settling at resting potential. (Reproduced, with permission, from Ganong WF: Review of Medical Physiology, 22nd ed. McGraw-Hill, 2005.)

In some fibers, membrane potential becomes transiently hyperpolarized (the after-hyperpolarization) as a result of the opening of the K+ channels, which tends to drive the membrane toward EK. In the wake of an action potential, there is a refractory period of decreased excitability. This period has two phases: the initial absolute refractory period, during which another action potential cannot be generated, and the relative refractory period(lasting up to a few milliseconds), during which a second action potential can be generated but conduction velocity is decreased and threshold increased. The refractory period limits the ability of the axon to conduct high-frequency trains of action potentials.


Voltage-sensitive ion channels are specialized protein molecules that span the cell membrane. These doughnut-shaped molecules contain a pore that acts as a tunnel, permitting specific ions (eg, Na+ or K+), but not other ions, to permeate. The channel also possesses a voltage sensor, which, in response to changes in potential across the membrane, either opens (activates) or closes (inactivates) the channel.

The neuronal membrane has the ability to generate impulses because it contains voltage-sensitive Na+ channels, which are selectively permeable to Na+ and tend to open when the membrane is depolarized. Because these channels open in response to depolarization, and because by opening they drive the membrane closer to Na+ equilibrium potential (ENa), they tend to further depolarize the membrane (Fig 3–4). If a sufficient number of these channels are opened, there is an explosive, all-or-none response, termed the action potential (see Fig 3–3). The degree of depolarization necessary to elicit the action potential is called the threshold.


FIGURE 3–4 Ionic basis for the depolarization underlying the action potential. Voltage-sensitive Na+ channels open when the membrane is depolarized. This action results in increased Na+ permeability of the membrane, causing further depolarization and the opening of still other Na+ channels. When a sufficient number of Na+ channels have opened, the membrane generates an explosive, all-or-none depolarization—the action potential.

Other voltage-sensitive ion channels (voltage-sensitive K+ channels) open (usually more slowly than Na+ channels) in response to depolarization and are selectively permeable to K+. When these channels open, the membrane potential is driven toward the K+ equilibrium potential (EK), leading to hyperpolarization.


Myelin is present around some axons within the peripheral nervous system (PNS) (where it is produced by Schwann cells) and within the central nervous system (CNS) (where it is produced by oligodendrocytes). Myelination has profound effects on the conduction of action potentials along the axon.

Nonmyelinated axons, in the mammalian PNS and CNS, generally have a small diameter (less than 1 μm in the PNS and less than 0.2 μm in the CNS). The action potential travels in a continuous manner along these axons because of a relatively uniform distribution of voltage-sensitive Na+ and K+ channels. As the action potential invades a given region of the axon, it depolarizes the region in front of it, so that the impulse crawls slowly and continuously along the entire length of the axon (Fig 3–5). In nonmyelinated axons, activation of Na+ channels accounts for the depolarization phase of the action potential, and activation of K+ channels produces repolarization.


FIGURE 3–5 Conduction of the nerve impulse through a nonmyelinated nerve fiber. In the resting axon, there is a difference of –70 mV between the interior of the axon and the outer surface of its membrane (resting potential). During the conduction of an action potential, Na+ passes into the axon interior and subsequently K+ migrates in the opposite direction. In consequence, the membrane polarity changes (the membrane becomes relatively positive on its inner surface), and the resting potential is replaced by an action potential (+35 mV here). (Reproduced, with permission, from Junqueira LC, Carneiro J, Kelley RO: Basic Histology, 7th ed. Appleton & Lange, 1992.)

Myelinated axons, in contrast, are covered by myelin sheaths. The myelin has a high electrical resistance and low capacitance, permitting it to act as an insulator. The myelin sheath is not continuous along the entire length of the axon. On the contrary, it is periodically interrupted by small gaps (approximately 1 μm long), called the nodes of Ranvier, where the axon is exposed. In mammalian myelinated fibers, the voltage-sensitive Na+ and K+ channels are not distributed uniformly. Na+ channels are clustered in high density (about 1000/pμ2) in the axon membrane at the node of Ranvier, but are sparse in the internodal axon membrane, under the myelin. K+ channels, on the other hand, tend to be localized in the “internodal” and “paranodal” axon membrane, that is, the axon membrane covered by the myelin (Fig 3–6).


FIGURE 3–6 Na+ and K+ channel distributions in myelinated axons are not uniform. Na+ channels (gNa) are clustered in high density in the axon membrane at the node of Ranvier, where they are available to produce the depolarization needed for the action potential. K+ channels (gK), on the other hand, are located largely in the internodal axon membrane under the myelin, so that they are masked. (Reproduced with permission from Waxman SG: Membranes, myelin and the pathophysiology of multiple sclerosis, N Engl J Med Jun 24;306(25):1529–33, 1982.)

Because the current flow through the insulating myelin is very small and physiologically negligible, the action potential in myelinated axons jumps from one node to the next in a mode of conduction that has been termed saltatory (Fig 3–7). There are several important consequences to this saltatory mode of conduction in myelinated fibers. First, the energy requirement for impulse conduction is lower in myelinated fibers; therefore, the metabolic cost of conduction is lower. Second, myelination results in an increased conduction velocityFigure 3–8 shows conduction velocity as a function of diameter for nonmyelinated and myelinated axons. For nonmyelinated axons, conduction velocity is proportional to (diameter)1/2. In contrast, conduction velocity in myelinated axons increases linearly with diameter. A myelinated axon can conduct impulses at a much higher conduction velocity than a nonmyelinated axon of the same size. To conduct as rapidly as a 10-μm myelinated fiber, a nonmyelinated axon would need a diameter of more than 100 μm. By increasing the conduction velocity, myelination reduces the time it takes for impulses to travel from one region to another, thus reducing the time needed for reflex activities and permitting the brain to operate as a high-speed computer.


FIGURE 3–7 A: Saltatory conduction in a myelinated axon. The myelin functions as an insulator because of its high resistance and low capacitance. Thus, when the action potential (cross-hatching) is at a given node of Ranvier, the majority of the electrical current is shunted to the next node (along the pathway shown by the broken arrow). Conduction of the action potential proceeds in a discontinuous manner, jumping from node to node with a high conduction velocity. B: In demyelinated axons there is loss of current through the damaged myelin. As a result, it either takes longer to reach threshold and conduction velocity is reduced, or threshold is not reached and the action potential fails to propagate. (Reproduced, with permission, from Waxman SG: Membranes, myelin and the pathophysiology of multiple sclerosis. N Engl J Med 1982;306:1529.)


FIGURE 3–8 Relationship between conduction velocity and diameter in myelinated and nonmyelinated axons. Myelinated axons conduct more rapidly than nonmyelinated axons of the same size.


Types of Fibers

Nerve fibers within peripheral nerves have been divided into three types according to their diameters, conduction velocities, and physiologic characteristics (Table 3–2). A fibers are large and myelinated, conduct rapidly, and carry various motor or sensory impulses. They are most susceptible to injury by mechanical pressure or lack of oxygen. B fibers are smaller myelinated axons that conduct less rapidly than A fibers. These fibers serve autonomic functions. C fibers are the smallest and are nonmyelinated; they conduct impulses the slowest and serve pain conduction and autonomic functions. An alternative classification, used to describe sensory axons in peripheral nerves, is shown in Table 3–3.

TABLE 3–2 Nerve Fiber Types in Mammalian Nerve.


TABLE 3–3 Numeric Classification Sometimes Used for Sensory Neurons.



A. Neuropathy

Peripheral neuropathies—diseases affecting peripheral nerves—are a very common cause of disability. Peripheral neuropathy occurs, for example, in about one-half of individuals with diabetes, and can occur as a complication of treatment with medications that include cancer chemotherapies. Many neuropathies affect large myelinated nerve fibers and, in these cases, there can be impaired motor function (weakness, muscle atrophy), loss of sensation (most often vibratory sensibility and joint position sense), and loss of deep tendon reflexes (ankle jerk, knee jerk etc.). The longest fibers are affected first, and thus the feet and hands are affected early in the disease course (Figure 3–9). The conduction velocity of sensory or motor nerves may be reduced, frequently to less than 40 m/s. Conduction block, whereby impulses fail to propagate past a point of axonal injury, can also occur. The reduction in conduction velocity can be measured in terms of increased conduction time between nerve stimulation and muscle contraction and in the longer duration of the muscle action potential. Slowing in conduction velocity occurs in neuropathies when there is demyelination, such as in Guillain-Barré syndrome and in some chronic or hereditofamilial neuropathies.


FIGURE 3–9 Atrophy (loss of muscle mass) in the hands of a patient with hereditary sensorimotor neuropathy. Peripheral neuropathies affect the longest nerve fibers first, and the feet and hands thus are affected in early stages of the disease. (Courtesy of Dr. Catherina Faber.)

B. Demyelination

Demyelination, or damage to the myelin sheath, is seen in a number of neurologic diseases. The most common is multiple sclerosis, in which myelin within the brain and spinal cord is damaged as a result of abnormal immune mechanisms. As a result of loss of myelin insulation and exposure of the internodal axon membrane, which contains a low density of Na+ channels, the conduction of action potentials is slowed or blocked in demyelinated axons (see Fig 3–7). Clinical Illustration 3–1 describes a patient with multiple sclerosis.


C.B., an emergency room nurse, was well until, at 23 years of age, she noticed blurred vision in her left eye. Twenty-four hours later, her vision had dimmed, and a day later, she was totally blind in her left eye. A neurologist found a normal neurologic examination. A magnetic resonance scan demonstrated several areas of demyelination in the subcortical white matter of both cerebral hemispheres. Despite the persistence of these abnormalities, C.B. recovered full vision in 4 weeks.

A year later, C.B. had weakness in her legs, associated with tingling in her right foot. Her physician told her that she probably had multiple sclerosis. She recovered 3 weeks later with only mild residual weakness.

After a symptom-free interval for 2 years, C.B. noticed the onset of double vision and a tremor that was worse when she attempted to perform voluntary actions (“intention tremor”). On examination, the neurologist found signs suggesting demyelination in the brain stem and cerebellum. Again, the patient recovered with only mild residua.

C.B.’s history is typical for patients with the relapsing-remitting form of multiple sclerosis. This disorder, which occurs in young adults (20–50 years old), is due to inflammatory destruction of myelin sheaths within the CNS. This demyelination occurs in well-defined lesions (plaques) that are disseminated in space and in time (hence, the term “multiple sclerosis”). Remyelination, within the core of the demyelination plaques, occurs sluggishly if at all.

The relapsing-remitting course exemplified by C.B. presents an interesting example of functional recovery in a neurologic disorder. How does recovery occur? Recent studies have demonstrated molecular plasticity of the demyelinated axon membrane, which develops increased numbers of Na+ channels in regions that were formerly covered by the myelin sheath. This permits impulses to propagate in a continuous, slow manner (similar to nonmyelinated axons) along demyelinated regions of some axons. The slowly conducted impulses carry enough information to support clinical recovery of some functions, such as vision, even though the axons remain demyelinated.


Synapses are the junctions between neurons that permit them to communicate with each other. Some synapses are excitatory (increasing the probability that the postsynaptic neuron will fire), whereas others are inhibitory(decreasing the probability that the postsynaptic neuron will fire).

In the most general sense, there are two broad anatomic classes of synapses (Table 3–4). Electrical (or electrotonic) synapses are characterized by gap junctions, which are specialized structures in which the presynaptic and postsynaptic membranes come into close apposition. Gap junctions act as conductive pathways, so electrical current can flow directly from the presynaptic axon into the postsynaptic neuron. Transmission at electrical synapses does not involve neurotransmitters. Synaptic delay is shorter at electrical synapses than at chemical synapses. Whereas electrical synapses occur commonly in the CNS of inframammalian species, they occur only rarely in the mammalian CNS.

TABLE 3–4 Modes of Synaptic Transmission.


The second broad class of synapse, which accounts for the overwhelming majority of synapses in the mammalian brain and spinal cord, is the chemical synapse. At a chemical synapse a distinct cleft (about 30 nm wide) represents an extension of the extracellular space, separating the pre-and postsynaptic membranes. The pre- and postsynaptic components at chemical synapses communicate via diffusion of neurotransmitter molecules; some common transmitters that consist of relatively small molecules are listed with their main areas of concentration in the nervous system in Table 3–5. As a result of depolarization of the presynaptic ending by action potentials, neurotransmitter molecules are released from the presynaptic ending, diffuse across the synaptic cleft, and bind to postsynaptic receptors. These receptors are associated with and trigger the opening of (or, in some cases, closing of) ligand-gated ion channels. The opening (or closing) of these channels produces postsynaptic potentials. These depolarizations and hyperpolarizations are integrated by the neuron and determine whether it will fire or not (see Excitatory and Inhibitory Synaptic Actions section).

TABLE 3–5 Areas of Concentration of Common Neurotransmitters.


Neurotransmitter in presynaptic terminals is contained in membrane-bound presynaptic vesicles. Release of neurotransmitter occurs when the presynaptic vesicles fuse with the presynaptic membrane, permitting release of their contents by exocytosis. Vesicular transmitter release is triggered by an influx of Ca2+ into the presynaptic terminal, an event mediated by the activation of presynaptic Ca2+ channels by the invading action potential. As a result of this activity-induced increase in Ca2+ in the presynaptic terminal, there is phosphorylation of proteins called synapsins, which appear to cross-link vesicles to the cytoskeleton, thereby preventing their movement. This action permits fusion of vesicles with the presynaptic membrane, resulting in a rapid release of neurotransmitter. The release process and diffusion across the synaptic cleft account for the synaptic delay of 0.5 to 1.0 ms at chemical synapses. This sequence is shown in diagrammatic form at the neuromuscular junction, a prototypic synapse, in Figure 3–10.


FIGURE 3–10 Schematic representation of some of the events involved in neurotransmitter synthesis, release, and action at a prototypic synapse, the neuromuscular junction. Acetylcholine (ACh) is the transmitter at this synapse. Part of the nerve terminal is shown, lying in close apposition to a muscle endplate. Synthesis of ACh occurs locally, in the presynaptic terminal, from acetyl-coenzyme A (CoA) and choline (1). ACh is then incorporated into membrane-bound synaptic vessels (2). Release of ACh occurs by exocytosis, which involves fusion of the vesicles with the presynaptic membrane (3). This process is triggered by an influx of Ca2+, which occurs in response to propagation of the action potential into the presynaptic axons. The contents of approximately 200 synaptic vesicles are released into the synaptic cleft in response to a single action potential. The released ACh diffuses rapidly across the synaptic cleft (4) and binds to postsynaptic ACh receptors (5), where it triggers a conformational change that leads to an influx of Na+ ions, which depolarizes the membrane. When the channel closes, the ACh dissociates and is hydrolyzed by acetylcholinesterase (6). (Reproduced, with permission, from Murray RK, Granner DK, Mayes PA, Rodwell VW: Harper’s Biochemistry, 24th ed. Appleton & Lange, 1996.)


Directly Linked (Fast)

Transmitter molecules carry information from the presynaptic neuron to the postsynaptic neuron by binding at the postsynaptic membrane with either of two types of postsynaptic receptor. The first type is found exclusively in the nervous system and is directly linked to an ion channel (a ligand-gated ion channel). By binding to the postsynaptic receptor, the transmitter molecule acts directly on the postsynaptic ion channel. Moreover, the transmitter molecule is rapidly removed. This mode of synaptic transmission takes only a few milliseconds and is rapidly terminated; therefore, it is termed “fast.” Depending on the type of ion channel that is open or closed, fast synaptic transmission can be either excitatory or inhibitory (see Table 3–4).

Second-Messenger Mediated (Slow)

A second mode of chemical synaptic transmission, which is closely related to endocrine communication in nonneural cells, uses receptors that are not directly linked to ion channels; these receptors open or close ion channels or change the levels of intracellular second messengers via activation of G-proteins and production of second messengers. When the transmitter is bound to the receptor, the receptor interacts with the G-protein molecule, which binds guanosine triphosphate (GTP) and is activated. Activation of the G-protein leads to production of cyclic adenosine monophosphate (cAMP), diacylglycerol (DAG), or inositol triphosphate (IP3). Cyclic AMP, DAG, and IP3participate in the phosphorylation of ion channels, thus opening channels that are closed at the resting potential or closing channels that are open at the resting potential. The cascade of molecular events, leading from binding of transmitter at these receptors to opening or closing of channels, takes hundreds of milliseconds to seconds, and the effects on channels are relatively long-lasting (seconds to minutes). This mode of synaptic transmission has, therefore, been termed “slow.” G-protein coupled receptors have been identified for a broad range of neurotransmitters, including dopamine, acetylcholine (muscarinic ACh receptor), and neuropeptides (Tables 3–6 and 3–7).

TABLE 3–6 Common Neurotransmitters and Their Actions.


TABLE 3–7 Mammalian Neuropeptides.



In contrast to fast synaptic transmission, which is highly targeted and acts on only a single postsynaptic element, second-messenger-linked transmission is slower and may affect a wider range of postsynaptic neurons. Thus, this mode of synaptic transmission serves an important modulatory function.


Excitatory postsynaptic potentials (EPSPs) are produced by the binding of neurotransmitter molecules to receptors that result in the opening of channels (eg, Na+ or Ca2+ channels) or the closing of channels (eg, K+ channels), thus producing depolarization. In general, excitatory synapses tend to be axo-dendritic. In contrast, inhibitory postsynaptic potentials (IPSPs) in many cases are caused by a localized increase in membrane permeability to Cl or to K+. This tends to cause hyperpolarization and most commonly occurs at axosomatic synapses, where it is called postsynaptic inhibition (Fig 3–11).


FIGURE 3–11 Top: Schematic illustration of two types of inhibition in the spinal cord. In direct inhibition (also called postsynaptic inhibition), a chemical mediator released from an inhibitory neuron causes hyperpolarization (inhibitory postsynaptic potential) of a motor neuron. In presynaptic inhibition, a second chemical mediator released onto the ending (axon) of an excitatory neuron causes a reduction in the size of the postsynaptic excitatory potential. Bottom: Diagram of a specific inhibitory system involving an inhibitory interneuron (Renshaw cell).

Information processing by neurons involves the integration of synaptic inputs from many other neurons. If they occur close enough in time, EPSPs (depolarizations) and IPSPs (hyperpolarizations) tend to sum with each other. As a neuron integrates the incoming synaptic information, it weighs the excitatory and inhibitory signals. Depending on whether or not threshold is reached at the impulse initiation zone (usually the axon initial segment), an action potential is either generated or not. If an action potential is initiated, it propagates along the axon to impinge, via its synapses, on still other neurons. The rate and pattern of action potentials carry information.


One of the unique properties of the nervous system is that it can learn and store information in the form of memories. It has long been suspected that memory has its basis in the strengthening of particular synaptic connections. In the past few years, much progress has been made in understanding synaptic plasticity. Long-term potentiation, characterized by the enhanced transmission at synapses that follow high-frequency stimulation, was first observed at synapses in the hippocampus (a part of the brain that plays an important role in memory) and may play a role in associative learning. Long-term potentiation depends on the presence of N-methyl-D-aspartate (NMDA) receptors in the postsynaptic membrane. These specialized glutamate receptors open postsynaptic Ca2+ channels in response to binding of the transmitter glutamate but only if the postsynaptic membrane is depolarized. Depolarization of the postsynaptic element requires the activation of other synapses, and the NMDA receptor-linked Ca2+ channels open only when both sets of synapses are activated. Thus, these synapses sense the “pairing” of two synaptic inputs in a manner analogous to conditioning to behavioral stimuli. Recent work suggests that, as a result of increased Ca2+ admitted into postsynaptic cells by this mechanism, protein kinases are activated and, via actions that are not yet fully understood, alter the synapse so as to strengthen it. These structural changes, triggered by specific patterns of synaptic activity, may provide a basis for memory.

The production of second messengers by synaptic activity may also play a role in regulation of gene expression in the postsynaptic cell. Thus, second messengers can activate enzymes that modify preexisting proteins or induce the expression of new proteins. This activation provides a mechanism whereby the synaptic activation of the cell can induce long-term changes in that cell. This is an example of plasticity within the nervous system. These changes in protein synthesis in the postsynaptic cell may participate in learning and memory and are probably important in nervous system development.


Presynaptic inhibition provides a mechanism for controlling the efficacy of transmission at individual synapses. It is mediated by axoaxonal synapses (see Fig 3–11). Binding of neurotransmitters to the receptors mediating presynaptic inhibition leads to a reduction in the amount of neurotransmitter secreted by the postsynaptic axon. This reduction is caused either by a decrease in the size of the action potential in the presynaptic terminal as a result of activation of K+ or Cl-channels or by reduced opening of Ca2+ channels in the presynaptic terminal, thereby decreasing the amount of transmitter release. Presynaptic inhibition thus provides a mechanism whereby the “gain” at a particular synaptic input to a neuron can be reduced without reducing the efficacy of other synapses that impinge on that neuron.


The axons of lower motor neurons project through peripheral nerves to muscle cells. These motor axons terminate at a specialized portion of the muscle membrane called the motor end-plate, which represents localized specialization of the sarcolemma, the membrane surrounding a striated muscle fiber (Fig 3–12). The nerve impulse is transmitted to the muscle across the neuromuscular synapse (also called the neuromuscular junction). The end-plate potential is the prolonged depolarizing potential that occurs at the end-plate in response to action potential activity in the motor axon. It is localized to the myoneural junction. The transmitter at the neuromuscular synapse is ACh. Small amounts of ACh are released randomly from the nerve cell membrane at rest; each release produces a minute depolarization, a miniature end-plate potential, about 0.5 mV in amplitude. These miniature end-plate potentials, also called quanta, reflect the random discharge of ACh from single synaptic vesicles. When a nerve impulse reaches the my-oneural junction, however, substantially more transmitter is released as a result of the synchronous discharge of ACh from many synaptic vesicles. This causes a full end-plate potential that exceeds the firing level of the muscle fiber.


FIGURE 3–12 Schematic illustrations of a myoneural junction. A: Motor fiber supplying several muscle fibers. B: Cross section as seen in an electron micrograph.


A large number of molecules act as neurotransmitters at chemical synapses. These neurotransmitters are present in the synaptic terminal, and their action may be blocked by pharmacologic agents. Some presynaptic nerves can release more than one transmitter; differences in the frequency of nerve stimulation probably control which transmitter is released. Some common transmitters are listed in Table 3–5.

Some neurons in the CNS also accumulate peptides. Some of these peptides act much like conventional transmitters; others appear to be hormones. Some relatively well-understood neurotransmitters and their distributions are discussed next.


ACh is synthesized by choline acetyltransferase and is broken down after release into the synaptic cleft by acetyl-cholinesterase (AChase). These enzymes are synthesized in the neuronal cell body and are carried by axonal transport to the presynaptic terminal; synthesis of ACh occurs in the presynaptic terminal.

ACh acts as a transmitter at a variety of sites in the PNS and CNS. ACh, for example, is responsible for excitatory transmission at the neuromuscular junction (N-type, nico-tinic ACh receptors). It is also the transmitter in autonomic ganglia and is released by preganglionic sympathetic and parasympathetic neurons. Postganglionic parasympathetic neurons, as well as one particular type of postganglionic sympathetic axon (ie, the fibers innervating sweat glands), use ACh as their transmitter (M-type, muscarinic receptors).

Within the CNS, several well-defined groups of neurons use ACh as a transmitter. These groups include neurons that project widely from the basal forebrain nucleus of Meynert to the cerebral cortex and from the septal nucleus to the hippocampus. Cholinergic neurons, located in the brain stem tegmentum, project to the hypothalamus and thalamus, where they use ACh as a transmitter.

Considerable interest has been focused recently on the role of cholinergic CNS neurons in neurodegenerative diseases. Cholinergic neurons in the basal forebrain nucleus degenerate, and their cholinergic terminals in the cortex are lost in Alzheimer’s disease.


The amino acid glutamate has been identified as a major excitatory transmitter in the mammalian brain and spinal cord. Four types of postsynaptic glutamate receptors have been identified. Three of these are ionotropic and are linked to ion channels. These receptors are named for drugs that bind specifically to them. The kainate and AMPA types of glutamate receptor are linked to Na+ channels, and when glutamate binds to these receptors they produce EPSPs. The NMDA receptor is linked to a channel that is permeable to both Ca2+ and Na+. The NMDA-activated channel, however, is blocked (so that influx of these ions cannot occur) unless the postsynaptic membrane is depolarized. Thus, NMDA-type synapses mediate Ca2+ influx, but only when activity at these synapses is paired with excitation via other synaptic inputs that depolarize the postsynaptic neuron. The Ca2+ influx mediated by these synapses may lead to structural changes that strengthen the synapse. The NMDA-type glutamate synapses appear to be designed to detect coincident activity in two different neural pathways and, in response to such paired activity, alter the strength of the synaptic connection. It has been hypothesized that this alteration may provide a basis for memory.

metabotropic type of glutamate receptor has also been identified. When the transmitter glutamate binds to this receptor, the second messengers, IP3 and DAG, are liberated. This liberation can lead to increased levels of intracellular Ca2+, which may activate a spectrum of enzymes that alter neuronal function and structure.

It has been suggested that excessive activation of gluta-matergic synapses can lead to very large influxes of Ca2+ into neurons, which can cause neuronal cell death. Because glutamate is an excitatory transmitter, excessive glutamate release might lead to further excitation of neuronal circuits by positive feedback, resulting in a damaging avalanche of depolarization and calcium influx into neurons. This excitotoxic mechanism of neuronal injury may be important in acute neurologic disorders, such as stroke and CNS trauma, and possibly in some chronic neurodegenerative diseases, such as Alzheimer’s.


A. Myasthenia Gravis and the Myasthenic Syndrome

Myasthenia gravis is an autoimmune disorder in which antibodies against the ACh receptor (ie, the postsynaptic receptor at the neuromuscular junction) are produced. As a result, the responsiveness of muscle to activity in motor nerves and to synaptic activation is reduced. Patients classically complain of fatigue and weakness involving the limb muscles and, in some patients, bulbar muscles such as those controlling eye movement and swallowing. Upon repetitive electrical stimulation, the involved muscles rapidly show fatigue and finally do not respond at all; excitability usually returns after a rest period.

Myasthenic syndrome (also called Lambert-Eaton syndrome), in contrast, is a disorder involving the presynaptic component of the neuromuscular junction. Myas-thenic syndrome is a paraneoplastic disorder and often occurs in the context of systemic neoplasms, especially those involving the lung and breast. Antibodies directed against Ca2+ channels located in presynaptic terminals at the neuromuscular junction interfere with transmitter release, causing weakness.

B. Myotonia

In this class of disorders, affected muscles show a prolonged response to a single stimulus. Some of these disorders involve an abnormality of voltage-sensitive Na+ channels, which fail to close following an action potential. As a result, inappropriate, sustained muscle contraction may occur.


The catecholamines norepinephrine (noradrenaline), epi-nephrine (adrenaline), and dopamine are formed by hydroxylation and decarboxylation of the essential amino acid phenylalanine. Phenyl-ethanolamine-N-methyltransferase, the enzyme responsible for converting norepinephrine to epinephrine, is found in high concentration primarily in the adrenal medulla. Epinephrine is found at only a few sites in the CNS.

Dopamine is synthesized, via the intermediate molecule dihydroxyphenylalanine (DOPA), from the amino acid tyrosine by tyrosine hydroxylase and DOPA decarboxylase. Norepinephrine, in turn, is produced via hydroxylation of dopamine. Dopamine, like norepinephrine, is inactivated by monoamine oxidase (MAO) and catechol-O-methyltransferase (COMT).


Six months before presentation, a 35-year-old single woman began to complain that she occasionally saw double when watching television. The double vision often disappeared after she had some bed rest. Subsequently, she felt that her eyelids tended to droop during reading, but after a good night’s rest she felt normal again. Her physician referred her to a specialty clinic.

At the clinic, the woman said that she tired easily and her jaw muscles became fatigued at the end of a meal. No sensory deficits were found. A preliminary diagnosis was made and some tests were performed to confirm the diagnosis.

What is the differential diagnosis? Which diagnostic procedures, if any, would be useful? What is the most likely diagnosis?

Cases are discussed further in Chapter 25. Questions and answers pertaining to Section I (Chapters 13) can be found in Appendix D.


Dopaminergic neurons generally have an inhibitory effect. Dopamine-producing neurons project from the substantia nigra to the caudate nucleus and putamen (via the nigrostriatal system) and from the ventral tegmental area to the limbic system and cortex (via the mesolimbic and mesocortical projections). In Parkinson’s disease, there is degeneration of the dopaminergic neurons and the substantia nigra. Thus, dopaminergic projections from the substantia nigra to the caudate nucleus and putamen are damaged, and the inhibition of neurons in the caudate nucleus and putamen is impaired. The dopaminergic projection from the ventral tegmental area to the limbic system and cortex may be involved in schizophrenia; antipsychotic drugs such as phenothiazines act as dopamine receptor antagonists and can temporarily reduce psychotic behavior in some patients with schizophrenia.

Dopamine-containing neurons have also been found in the retina and the olfactory system. In these areas they appear to mediate inhibition that filters sensory input.


Norepinephrine-containing neurons in the PNS are located in the sympathetic ganglia and project to all of the postganglionic sympathetic neurons except those innervating sweat glands, which are innervated by axons that use ACh as a transmitter. Norepinephrine-containing cell bodies in the CNS are located in two areas: the locus ceruleus and the lateral tegmental nuclei. Although the locus ceruleus is a relatively small nucleus containing only several hundred neurons, it projects widely into the cortex, hippocampus, thalamus, midbrain, cerebellum, pons, medulla, and spinal cord. The nora-drenergic projections from these cells branch extensively and are distributed widely. Some of the axons branch and project to both the cerebral cortex and the cerebellum. Noradrenergic neurons in the lateral tegmental areas of the brain stem appear to have a complementary projection, projecting axons to regions of the CNS that are not innervated by the locus ceruleus.

The noradrenergic projections from the locus ceruleus and the lateral tegmental area appear to play a modulatory role in the sleep-wake cycle and in cortical activation and may also regulate sensitivity of sensory neurons. Some evidence suggests that abnormal paroxysmal activity in the locus ceruleus can result in panic attacks.


Serotonin (5-hydroxytryptamine) is an important regulatory amine in the CNS. Serotonin-containing neurons are present in the raphe nuclei in the pons and medulla. These cells are part of the reticular formation, and they project widely to the cortex and hippocampus, basal ganglia, thalamus, cerebellum, and spinal cord. Serotonin-containing neurons can also be found in the mammalian gastrointestinal tract, and serotonin is present in blood platelets.

Serotonin is synthesized from the amino acid tryptophan. It has vasoconstrictor and pressor effects. Some drugs (eg, re-serpine) may act by releasing bound serotonin within the brain. In small doses, lysergic acid diethylamide (LSD), a structural analog of serotonin, is capable of evoking mental symptoms similar to those of schizophrenia. The vasoconstrictive action of LSD is inhibited by serotonin.

Serotonin-containing neurons, along with norepinephrine-containing neurons, appear to play an important role in determining the level of arousal. Firing levels of neurons in the raphe nuclei, for example, are correlated with sleep level and show a striking cessation of activity during rapid eye movement sleep. Lesions of the serotonin-containing neurons in the raphe nuclei can produce insomnia in experimental animals. Serotonin-containing neurons may also participate in the modulation of sensory input, particularly for pain. Selective serotonin reuptake inhibitors, which increase the amount of serotonin available at the postsynaptic membrane, are used clinically as antidepressants.

Gamma-Aminobutyric Acid

Gamma-aminobutyric acid (GABA) is present in relatively large amounts in the gray matter of the brain and spinal cord. It is an inhibitory substance and probably the mediator responsible for presynaptic inhibition. GABA and glutamic acid decarboxylase (GAD), the enzyme that forms GABA from L-glutamic acid, occur in the CNS and the retina. Two forms of GABA receptor, GABAA and GABAB, have been identified. Both mediate inhibition but by different ionic pathways (see Table 3–6). Inhibitory interneurons containing GABA are present in the cerebral cortex and cerebellum and in many nuclei throughout the brain and spinal cord. The drug baclofen acts as an agonist at GABAB receptors; its inhibitory actions may contribute to its efficacy as an antispasticity agent.


The general term endorphins refers to some endogenous morphine-like substances whose activity has been defined by their ability to bind to opiate receptors in the brain. Endorphins (brain polypeptides with actions like opiates) may function as synaptic transmitters or modulators. Endorphins appear to modulate the transmission of pain signals within sensory pathways. When injected into animals, endorphins can be analgesic and tranquilizing.


Two closely related polypeptides (pentapeptides) found in the brain that also bind to opiate receptors are methionine enkephalin (met-enkephalin) and leucine enkephalin (leu-enkephalin). The amino acid sequence of met-enkephalin has been found in alpha-endorphin and beta-endorphin, and that of beta-endorphin has been found in beta-lipotropin, a polypeptide secreted by the anterior pituitary gland.


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