Anatomy

Brainstem:
 Midbrain
 Pons
 Medulla oblongata
The brainstem at the cranocervical junction continues with the spinal cord.

Peduncles connect to cortices

 The midbrain is localized in the posterior fossa

 Motor fibres enter via the cerebral peduncles (brain sections mickey mouse ears cerebral peduncles at level of midbrain)

 Connected to cerebellum via:

 Superior
 Middle
 Inferior peduncles

Note: bleeds don’t respect vascular territories but if there is an infarct it will be a small area & can
have a good prognosis unless it’s the basilar artery then we are in trouble.

You are not dead until your brainstem is dead seat of life. Even if your heart is beating.

Blood supply:
 Vertebro- basilar system
Lateral aspect of:
 Medulla PICA
 Pons AICA
 Midbrain SCA (superior cerebellar artery)
Medical aspect supplied by circumferential
Major structures Oh oh oh to touch and feel very good Midbrain:
found in brainstem: Lateral aspect Medial aspect of virgins after hours III
1. Cranial nerve of brainstem brainstem  Olfactory (S) IV
Spinothalamic - Motor
nuclei Sympathetic nuclei all  Optic (S)
2. Spinothalamic Sensory motor nuclei  Oculomotor (M) Pons
tract cranial n lie medially  Trochlear (M) V
nuclei
3. Corticospinal  Trigeminal (B) VI
corticospinal
tract
tract  Abducent (M) VII
4. Sympathetic  Facial (B)
fibres  Vestibulocochlear (S) Pontomedullary junction VIII
5. Lemnisci  Glossopharyngeal (B)
 Vagus (B) Medulla:
 Accessory (M) IX
X
 Hyoglossus (M)
XII
Some say marry money, but my
brother says big boobs matter most

General features: 1. Cranial nerve fallout is ipsilateral to brainstem lesion

 If the lesion is in the brainstem the fallout will be on the same side as cranial n nucleus.
 Third n palsy R side= nerve affected also on right side of brainstem.
 This is because the corticobulbar fibres cross over before they reach the nucleus.
2. Long tract signs are contralateral to brainstem lesion.
 Long tracts= spinothalamic and corticospinal = contralateral to lesion.
 If you have that it means you have a pt who has cranial nerve fallout on R. side but
have involvements of arm+ leg on L. side.
 Immediately separates from cortical lesion face, arm +leg on SAME SIDE
3. Lateral lesions have contralateral sensory fallout (spinothalamic)
4. Medial lesions have contralateral motor fallout (corticospinal)
5. Skew deviation resulting in vertical diplopia (vertical malalignment§ which tells you it’s
a brainstem lesion but not where it is)
 Strokes (study these w prof Kakaza’s lecture slides)
Midbrain Pons Medulla oblongata
Weber syndrome: * commonest 1. Millard-Gubler Syndrome: Lateral medullary stroke Wallenberg synd
midbrain stroke  Stroke syndrome
 Localised to medial aspect of  Involves medial aspect of pons  Commonest stroke synd in brainstem
midbrain aa: PICA
Structure involved SX/signs
Clinical Features: Clinical features:  Cerebellar  Ipsilateral ataxia,
 Ipsilateral Cn III fallout  Ipsilateral VII fallout (LMN) peduncle nystagmus
 Contralateral weakness of  Contralateral weakness of arm  Sympathetic  Ipsilateral
arm & leg + legs (UMN) fibres Horner’s synd

aa: circumferential artery  Spinothalamic  Contralateral

aa: circumferential artery fibres sensory loss
 CN V  Ipsilateral facial
(sensory) numbness

 CN IX/XX  CN IX/X:
if you are having only abducent  Hoarse
nerve issues this is a false localising voice
sign. (this could just be due to raised  Dysarthria
ICP)  Dysphagia
You have to have abducent nerve  Ipsilateral
issue+ contralateral weakness for it to CN IXX/X
be a stroke in the brainstem. Paralysis
 Difficult to  Vertical diplopia
WE DO NOT EXPCECT STROKES TO localize (skew deviation)
CROSS VASCULAR BOUNDRIES!!
(unless it’s the basilar artery)  CN VIII/  Vertigo, n/v
peduncle
Locked in syndrome:
Here the lesion is crossing both the
corticospinal tracts so person gets
quadriplegia.
 It will also involve the bulbar
muscles locked in syndrome
 Hyponatraemia corrected too
quickly

2ndary to:
 Central pontine myelinolysis
 Glioma
 Tuberculoma

 Localized to centre of pons

 Clinical features:
 Quadriplegia
 Impaired horizontal
gaze intact vertical
gaze
 Bilateral facial
weakness
 Weakness of bulbar
muscles

Notes made by the aid of Neurology Handbook- University of Pretoria & Professor Kakaza lecture slides