AfraTafreeh.
com
Brainstem
Jason Ryan, MD, MPH
Terminology
• Dorsal • Rostral
• Posterior • Towards top of head
• Towards Back • Caudal
• Ventral • Towards tail
• Anterior • Away from head
[Link]
• Towards Front
[Link]
The Brainstem
Image courtesy of OpenStax college
The Brainstem
• Sensory and motor fibers
• Nuclei of cranial nerves
• Important to know what lies in each section
• Midbrain
• Pons [Link]
• Medulla
• Focus on
• Which cranial nerves each level?
• Where are the tracts traveling btw brain/cord?
• Medial versus lateral?
[Link]
Brainstem Sections
Midbrain
Mesencephalon
Cerebral Aqueduct
MLF
Spinothalamic Tract
Medial Lemniscus
[Link]
Cerebral
Peduncle
Red Nucleus Corticospinal Tract
Corticobulbar Tract
Oculomotor Nerve
[Link]
Benedikt Syndrome
• CN 3, medial leminiscus, red nucleus
• Oculomotor palsy
• Contralateral loss proprioception/vibration
• Involuntary movements
• Tremor
• Ataxia
Weber’s Syndrome
• CN3, corticospinal tract, corticobulbar tract
• Oculomotor nerve palsy
• Contralateral hemiparesis
• Pseudobulbar palsy
[Link]
• UMN cranial nerve motor weakness
• Exaggerated gag reflex
• Tongue spastic (no wasting)
• Spastic dysarthria
[Link]
Parinaud’s Syndrome
• Posterior midbrain
• Superior colliculus and pretectal area
• Can’t look up (vertical gaze palsy)
• Pseudo Argyll Robertson pupil
• Often from pinealoma/germinoma of pineal region
• Watch for cerebral aqueduct obstruction
• Non-communicating hydrocephalus
• Compression from a pineal tumor
Pons Vestibular
Spinal Tract
Nuclei (VIII)
& Nucleus
Trigeminal (V)
4th Ventricle
PPRF MLF
[Link]
Vestibular N
(CN VIII)
CN VII
Spinothalamic
Medial Tract
Lemniscus
Corticospinal
Tract
CN VI
[Link]
Medial Pontine Syndromes
• Corticospinal tract, CN 6, CN 7
• Contralateral hemiparesis
• CN 6 palsy
• Facial weakness/droop affected side
• Lateral gaze structures: MLF, CN VI nucleus
• Gaze palsies
• Can’t look to affected side
• Damage to either PPRF or nucleus CN VI
Lateral Pontine Syndromes
• Vestibular nuclei: nystagmus, vertigo, N/V
• Spinothalamic tract: Contralateral pain/temp
• Spinal V nucleus: ipsilateral face pain/temp
• Sympathetic tract: Horner’s syndrome
[Link]
• Facial nucleus:
• Ipsilateral facial droop
• Loss corneal reflex
• Cochlear nuclei
• Deafness
• AICA stroke
[Link]
Medulla Vestibular
Nuclei (VIII) Hypothalamospinal
Tract
Spinal Nucleus
4th Ventricle
Nucleus Solitarius Trigeminal N (V)
Spinal Tract
Dorsal Motor Trigeminal N (V)
Nucleus X
CN X Spinothalamic
Tract
Nucleus
Ambiguus
Inferior Olivary
Nucleus
CN XII
Pyramids
Medial (corticospinal)
Lemniscus
Medial Medullary Syndrome
• Corticospinal, medial lemniscus, CN 12
• Contralateral Hemiparesis
• Contralateral loss of proprioception/vibration
• Flaccid paralysis tongue
[Link]
• Deviation to side of lesion
• Anterior spinal artery stroke
[Link]
Lateral Medullary Syndrome
Wallenberg's Syndrome
• Vestibular nuclei: Nystagmus, vertigo, N/V
• Sympathetic tract: Horner’s syndrome
• Spinothalamic tract: Contralateral pain/temp
• Spinal V nucleus: ipsilateral face pain/temp
• Nucleus ambiguus (IX, X)
• Hoarseness, dysphagia
• PICA Stroke
How to Find Lesions
• Option 1: Know the syndromes
• Option 2: Use the Rule of 4s
[Link]
[Link]
Rule of 4s
• 4 CNs in: • 4 midline columns
• Medulla • Motor nucleus
• Pons • Motor pathway
• Above Pons • MLF
• 4 CNs divide into 12 • Medial Lemniscus
• III, IV, VI, XII • 4 lateral (side) columns
• Motor nuclei are midline • Sympathetic
• 4 CNs do not divide/12 • Spinothalamic
• V, VII, IX, XI • Sensory
• All are lateral • Spinocerebellar
Dr. Peter Gates. The rule of 4 of the brainstem: a simplified method for
understanding brainstem anatomy and brainstem vascular syndromes
for the non-neurologist. Internal Medicine Journal Volume 35, Issue
4, pages 263–266, April 2005
Localizing Lesions
• Medial vs. Lateral
• Which tracts affected?
• Medulla vs. Pons vs. Midbrain
• Which cranial nerves affected?
CNs
[Link]
Midbrain
Pons
Tracts
Medulla
Medial ---------- Lateral
[Link]
4 Above Pons CNs
Deficit
Olfactory CN1 Not in midbrain
Optic CN2 Not in midbrain
Oculomotor CN3 Eye turned out and down
Eye unable to look down when
Trochlear CN4
looking towards nose
4 Pons CNs
Deficit
Trigeminal CN5 Ipsilateral facial sensory loss
Abducens CN6 Ipsilateral eye abduction weakness
Facial CN7 Ipsilateral facial weakness/droop
[Link]
Auditory CN8 Ipsilateral deafness
[Link]
4 Medulla CNs
Cranial Nerve Deficit
Glossopharyngeal CN9 Ipsilateral pharyngeal sensory loss
Vagus CN10 Ipsilateral palatal weakness
Spinal accessory CN11 Ipsilateral shoulder weakness
Hypoglossal CN12 Ipsilateral weakness of tongue
Midline Structures (M)
Midline Structure Deficit
Motor pathway
Contralateral weakness
(Corticospinal tract)
Loss contralateral
Medial lemniscus
proprioception/ vibration
[Link]
Medial longditudinal
Ipsilateral INO
fasciculus
Motor nucleus and Ipsilateral CN motor loss
nerve (3,4,6,12)
[Link]
Side/Lateral Structures (S)
Lateral Structure Deficit
Spinocerebellar
Ipsilateral ataxia
pathway
Contralateral pain/temp
Spinothalamic
sensory loss
Sensory nucleus of
Ipsilateral pain/ temp
CN5
loss in face
Ipsilateral Horner’s
Sympathetic pathway
syndrome
Rule of 4s Caveats
• Trigeminal Nerve (V)
• Lesion: loss of ipsilateral pain/temp face
• Rule of 4 Pons Nuclei and side (lateral tract)
• Don’t use to localize to Pons
• Use for lateral tract localization
[Link]
• Vestibulocochlear (VIII)
• Don’t use vestibular signs to localize to pons
• Vestibular signs can be medulla/pons
• Lesion: hearing loss
[Link]
Case 1
• A 75-year-old man presents for evaluation of
weakness. He reports that two hours ago he suddenly
was unable to move his left arm or leg. He denies any
difficulty with speech. On examination, he is able to
move all facial muscles normally. There is no
ophthalmoplegia. On tongue protrusion, the tongue is
deviated to the right. He in unable to detect lower or
upper extremity vibration on the left.
Case 1
• Complete motor weakness
• Not MCA or ACA stroke
• Tongue involved: brainstem lesion
• Motor pathway involved – left side weak
• Right medial lesion [Link]
• Medial lemniscus involved left (vibration/prop)
• Right medial lesion
• CN XII involved – tongue deviation
• Medulla
• Answer: Right medial medullary syndrome
• Anterior spinal artery
[Link]
Brainstem Blood Supply
Lateral Medial
PCA 3 Midbrain
4
AICA
6 5,7,8
Pons
Basilar
PICA Medulla
12 9,10,11
ASA
Case 2
• Right sided weakness
• Left eye down/out, dilated
[Link]
[Link]
Case 2
• Right sided weakness
• Motor pathway
• Medial lesion
• Complete motor loss: not MCA, ACA
• Left eye down/out, dilated
• CNIII
• Left medial midbrain lesion
• Weber’s syndrome
• Stroke of branches of PCA
Case 3
• Unable to do left hand finger to nose test
• Loss of pain and temperature to left face
• Left eyelid droop, small pupil
• Loss of pain/temp right arm and leg
[Link]
• Hoarse voice
• Loss of gag reflex left throat
• Palate raised on right side
[Link]
Case 3
• Unable to do left hand finger to nose test Left ataxia
• Loss of pain and temperature to left face Left CN V
• Left eyelid droop, small pupil Left Horner’s
• Loss of pain/temp right arm and leg Left ST Tract
• Hoarse voice CN X
• Loss of gag reflex left throat CN IX
• Palate raised on right side CN X
Case 3
• Left ataxia = spinocerebellar
• Left face pain/temp = sensory (CN V) face
• Left Horner’s = sympathetic
• Right pain/temp = left spinothalamic
[Link]
• Speaking, gag, palate = CN IX, X
• Left lateral medulla
• Wallenberg's syndrome
• Left PICA stroke
[Link]
Case 4
• Right deafness/tinnitus
• Loss right finger to nose
• Right facial numbness
• No corneal reflex
• Right facial spasms
Case 4
• Right deafness/tinnitus Right VIII
• Loss right finger to nose Right spinocerebellar
• Right facial numbness Right sensory
• No corneal reflex Right CN V
[Link]
• Right facial spasms Right CN VII
Right Lateral Pons
Cerebellopontine angle syndrome
Often caused by tumors (schwannomas)
[Link]
Rule of 4s
Side Midline
Sympathetic
Spinothalamic 3
Midbrain
Sensory V 4
Spinocerebellar
6 5,7,8 Pons
Motor
Motor Nucleus
Motor Pathway
Medulla
MLF 12 9,10,11
Medial Lemniscus
S M
Brainstem Blood Supply
Lateral Medial
PCA 3 Midbrain
4
[Link]
AICA
6 5,7,8
Pons
Basilar
PICA Medulla
12 9,10,11
ASA
