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The insular cortex receives projections from the NTS, the parabrachial nucleus of the pons, and the lateral hypothalamic nuclei Direct stimulation of the insula produces cardiac arrhythmias and a number of other alterations in visceral function The cingulate and hippocampal gyri and their associated subcortical structures (substantia innominata and the amygdaloid, septal, piriform, habenular, and midbrain tegmental nuclei) have been identi ed as important cerebral autonomic regulatory centers Together they have been called the visceral brain (see Chap 25) Of particular importance in autonomic regulation is the amygdala, the central nucleus of which is a major site of origin of projections to the hypothalamus and brainstem The anatomy and the effects of stimulation and ablation of the amygdala have been discussed in Chap 25, in relation to the neurology of emotion.

In addition to the aforementioned central relationships, it should be noted that important interactions between the autonomic nervous system and the endocrine glands occur at a peripheral level The best-known example is in the adrenal medulla A similar relationship pertains to the pineal gland, in which norepinephrine (NE) released from postganglionic bers that end on pineal cells stimulates several enzymes involved in the biosynthesis of melatonin Similarly, the juxtaglomerular apparatus of the kidney and the islets of Langerhans of the pancreas may function as neuroendocrine transducers insofar as they convert a neural stimulus (in these cases adrenergic) to an endocrine secretion (renin, glucagon, and insulin, respectively) The numerous autonomic-endocrine interactions are elaborated in the next chapter Finally, there is the essential role that the hypothalamus plays in the initiation and regulation of autonomic activity, both sympathetic and parasympathetic.

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Sympathetic responses are most readily obtained by stimulation of the posterior and lateral regions of the hypothalamus, and parasympathetic responses from the anterior regions The descending sympathetic bers are largely or totally uncrossed, although their pathway or pathways have not been sharply de ned According to Carmel, bers from the caudal hypothalamus at rst run in the prerubral eld, dorsal and slightly rostral to the red nucleus, and then ventral to the ventrolateral thalamic nuclei; then they descend in the lateral tegmentum of the midbrain, pons, and medulla to synapse in the intermediolateral cell column of the spinal cord Consistent with this schema, a case described by Luhan and Pollack demonstrated that a small infarct in the territory of supply of the superior cerebellar artery, just posterior to the medial lemniscus, caused an ipsilateral Horner syndrome.

In the medulla, the descending sympathetic pathway is located in the posterolateral retro-olivary area, where it is frequently involved in lateral medullary infarctions In the cervical cord, the.

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Grif n JW, et al (eds): Peripheral Neuropathy, 3rd ed Philadelphia, Saunders, 1993, pp 980 989 CHALK CH, DYCK PJ, CONN DL: Vasculitic neuropathy, in Dyck PJ, Thomas PK, Grif n JW, et al (eds): Peripheral Neuropathy, 3rd ed Philadelphia, Saunders, 1993, pp 1424 1436 CHANCE PF, LENSCH MW, LIPE H, et al: Hereditary neuralgic amyotrophy and hereditary neuropathy with liability to pressure palsies: Two distinct entities Neurology 44:2253, 1994 CHIA, L, FERNANDEZ A, LACROIX D, et al: Contribution of nerve biopsy ndings to the diagnosis of disabling neuropathy in the elderly A retrospective review of 100 consecutive patients Brain 119:1091, 1996 COLLINS MP, PERIQUET MI, MENDELL JR, et al: Nonsystemic vasculitic neuropathy: Insights from a clinical cohort Neurology 61:623, 2003 CORNBLATH DR, MCARTHUR JC, KENNEDY PGE, et al: In ammatory demyelinating peripheral neuropathies associated with human T-cell lymphotropic virus type III infection Ann Neurol 21:32, 1987.

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