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Lessons on
Brainstem
  Lesions
  Dr. Dennis Bravo
Case
A 58 y/o was referred to you because of recent
  onset of left hemiparesis, left-sided loss of
    propioception and right-sided tongue
deviation. What CNS structures are affected?
    Explain the symptoms with regards to
   structures affected. Where is the lesion?
review
         of
Brainstem Structure
Brainstem Anatomy



Midbrain
 Pons
Medulla
Brainstem Anatomy



Midbrain
 Pons
Medulla
Rules of 4*
1. 4 structures in ‘midline’ and begin with ‘M’
2. 4 motor nuclei in midline and are those that
are divisors of 12 (3,4,6,12)
3. 4 structures to the ‘side’ (lateral) and begin
with ‘S’
4. 4 CN in medulla, 4 in pons and 4 above
pons
*Gates, P. 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 2005; 35: 263-266
1                                                             2
                                                              4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’                                                 of 12
                                                                 ( 3, 4, 6, 12)
                                              RULE of
                                              FOUR*




               3                                                             4
                                                                   4 CN in medulla
4 Structures to the side
                                                                     4 CN in pons
   and begin with ‘S’
                                                                   4 CN above pons


*Gates, P. 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 2005; 35: 263-266
2
                                                              4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’                                                 of 12
                                                                 ( 3, 4, 6, 12)




               3                                                             4
                                                                   4 CN in medulla
4 Structures to the side
                                                                     4 CN in pons
   and begin with ‘S’
                                                                   4 CN above pons


*Gates, P. 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 2005; 35: 263-266
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’                                                 of 12
                                                                 ( 3, 4, 6, 12)




               3                                                             4
                                                                   4 CN in medulla
4 Structures to the side
                                                                     4 CN in pons
   and begin with ‘S’
                                                                   4 CN above pons


*Gates, P. 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 2005; 35: 263-266
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’                                                 of 12
                                                                 ( 3, 4, 6, 12)




                                                                             4
                                                                   4 CN in medulla
4 Structures to the side
                                                                     4 CN in pons
   and begin with ‘S’
                                                                   4 CN above pons


*Gates, P. 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 2005; 35: 263-266
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’                                                 of 12
                                                                 ( 3, 4, 6, 12)




                                                                   4 CN in medulla
4 Structures to the side
                                                                     4 CN in pons
   and begin with ‘S’
                                                                   4 CN above pons


*Gates, P. 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 2005; 35: 263-266
RULE #1
    4 Medial Structures

 •Motor pathway
 •Medial leminiscus
 •Medial longitudinal
 fasciculus
 •Motor nucleus and nerve
RULE #2
 4 Medial Motor Nucleus


 •CN divides number 12
 •CN 3, 4, 6, 12 are midline
 •3, 4, 6, 12 nucleus are midline
 •5, 7, 9, 11 lateral
RULE #3
     4 Side Structures


 •Spinocerebellar pathway
 •Spinothalamic pathway
 •Sensory nucleus of CN5
 •Sympathetic pathway
4 Medulla Cranial
RULE #4   Nerves


  •Glossopharyngeal (CN9)
  •Vagus (CN10)
  •Spinal accessory (CN11)
  •Hypoglossal (CN12)
RULE #4
  4 Pons Cranial Nerves


   •Trigeminal (CN5)
   •Abducent (CN6)
   •Facial (CN7)
   •Auditory (CN8)
4 Cranial Nerves
RULE #4  Above Pons


  •Olfactory (CN1)
  •Optic (CN2)
  •Occulomotor (CN3)
  •Trochlear (CN4)
ne s
    li e
                                          DE
  id ur                                     FIC
M ct                                            I  T
S tru
        Motor pathway
                           Contalateral weakness
   (Corticospinal tract)
                              More Info
    Medial lemniscus


  Medial longditudinal
      fasciculus

   Motor nucleus and
         nerve
ne s
    li e
                                              DE
  id ur                                           FIC
M ct                                                  I   T
S tru
        Motor pathway
                           Contalateral weakness
   (Corticospinal tract)

                           Contralateral propioception/
    Medial lemniscus              vibration loss
                                 More Info
  Medial longditudinal
      fasciculus

   Motor nucleus and
         nerve
ne s
    li e
                                            DE
  id ur                                        FIC
M ct                                               I  T
S tru
        Motor pathway
                           Contalateral weakness
   (Corticospinal tract)

                                Contralateral
    Medial lemniscus       propioception/ vibration
                                     loss

  Medial longditudinal     Ipsilateral internuclear
      fasciculus              ophthalmoplegia
                                 More Info
   Motor nucleus and
         nerve
ne s
    li e
                                            DE
  id ur                                         FIC
M ct                                                I T
S tru
        Motor pathway
                           Contalateral weakness
   (Corticospinal tract)

                                Contralateral
    Medial lemniscus       propioception/ vibration
                                     loss

  Medial longditudinal     Ipsilateral internuclear
      fasciculus              ophthalmoplegia

   Motor nucleus and           Ipsilateral CN
         nerve                  function loss
al                                DE
    er es
 at ur                                      FIC
L ct                                            IT
S tru
         Spinocerebellar
                           Ipsilateral ataxia
         pathway
                           More Info
      Spinothalamic


    Sensory nucleus of
          CN5


  Sympathetic pathway
al                                   DE
    er es
 at ur                                        FIC
L ct                                              I  T
S tru
         Spinocerebellar
                             Ipsilateral ataxia
         pathway

                           Contralateral pain/temp
      Spinothalamic              sensory loss
                               More Info
    Sensory nucleus of
          CN5


  Sympathetic pathway
al                                   DE
    er es
 at ur                                        FIC
L ct                                              I  T
S tru
         Spinocerebellar
                             Ipsilateral ataxia
         pathway

                           Contralateral pain/temp
      Spinothalamic              sensory loss


    Sensory nucleus of     Ipsilateral pain/ temp
          CN5                    loss in face
                               More Info
  Sympathetic pathway
al                                   DE
    er es
 at ur                                        FIC
L ct                                              I  T
S tru
         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
                                More Info
DE
 CN lla
4 u
                                           FIC
                                               I  T
  ed
M
   Glossopharyngeal      Ipsilateral pharyngeal
         CN9                  sensory loss


      Vagus CN10


 Spinal accessory CN11


   Hypoglossal CN12
DE
 CN lla
4 u
                                            FIC
                                                I T
  ed
M
   Glossopharyngeal      Ipsilateral pharyngeal
         CN9                  sensory loss

                           Ipsilateral palatal
      Vagus CN10
                               weakness
                              More Info
 Spinal accessory CN11


   Hypoglossal CN12
DE
 CN lla
4 u
                                            FIC
                                                I T
  ed
M
   Glossopharyngeal      Ipsilateral pharyngeal
         CN9                  sensory loss

                           Ipsilateral palatal
      Vagus CN10
                               weakness

                          Ipsilateral shoulder
 Spinal accessory CN11
                               weakness


   Hypoglossal CN12
DE
 CN lla
4 u
                                            FIC
                                                I  T
  ed
M
   Glossopharyngeal      Ipsilateral pharyngeal
         CN9                  sensory loss

                           Ipsilateral palatal
      Vagus CN10
                               weakness

                          Ipsilateral shoulder
 Spinal accessory CN11
                               weakness

                         Ipsilateral weakness of
   Hypoglossal CN12
                                  tongue
                              More Info
DE
 CN
4 ns
                                       FIC
                                           IT
 Po
                      Ipsilateral facial
   Trigeminal CN5
                        sensory loss
                        More Info
   Abducent CN6


        Facial CN7


       Auditory CN8
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
                       Ipsilateral facial
   Trigeminal CN5
                         sensory loss

                         Ipsilateral eye
   Abducent CN6
                      abduction weakness
                         More Info
        Facial CN7


       Auditory CN8
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
                       Ipsilateral facial
   Trigeminal CN5
                         sensory loss

                         Ipsilateral eye
   Abducent CN6
                      abduction weakness

                       Ipsilateral facial
        Facial CN7
                          weakness
                         More Info
       Auditory CN8
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
                       Ipsilateral facial
   Trigeminal CN5
                         sensory loss

                         Ipsilateral eye
   Abducent CN6
                      abduction weakness

                       Ipsilateral facial
        Facial CN7
                          weakness


       Auditory CN8   Ipsilateral deafness
DE
 4 CN ons                            FIC
       P                                 IT
    ve
A bo
     Olfactory CN1    Not in midbrain


       Optic CN2      Not in midbrain


                     Eye turned out and
   Occulomotor CN3
                           down
                        More Info
     Trochlear CN4
DE
 4 CN ons                                 FIC
       P                                      I  T
    ve
A bo
     Olfactory CN1      Not in midbrain


       Optic CN2        Not in midbrain


                      Eye turned out and
   Occulomotor CN3
                            down

                      Eye unable to look down
     Trochlear CN4   when looking towards nose

                          More Info
Let’s put your
knowledge to use...
Always remember

        “Pathways and tracts pass through the
   entire length of the brainstem and can be
   likened to ‘meridians of longitude‘ whereas
   the various cranial nerves can be regarded
   as ‘parallels of latitude‘.
        If you establish where the meridians of
   longitude and parallels of latitude intersect
   then you have established the site of the
   lesion.”
Gates, P. 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 2005; 35: 263-266
Case


58 year old woman
•Left hemiparesis
•Left-sided loss of
propioception
•Right-sided
tongue deviation
Case                   Structure



58 year old woman
•Left hemiparesis     •Motor (CS tract, R)
•Left-sided loss of   •Medial
propioception         lemniscus, R
•Right-sided          •CN12, R
tongue deviation
Structure




•Motor (CS tract, R)
•Medial
lemniscus, R
•CN12, R
Location           Structure




•Medial         •Motor (CS tract, R)
•Medial         •Medial
                lemniscus, R
•Medulla        •CN12, R
Location               Structure




•Medial              •Motor (CS tract, R)
•Medial              •Medial
                     lemniscus, R
•Medulla             •CN12, R
  Medial medullary      Vertebral artery,
   syndrome (R)       medullary branch (R)
Case

58 year old woman
•Left-sided
meiosis,
anhydrosis, ptosis
•Left-sided ataxia
•Uvula deviated
to right
Case                 Structure


58 year old woman
•Left-sided          •Sympathetic
meiosis,             tract, Left
anhydrosis, ptosis
•Left-sided ataxia   •Spinocerebellar
•Uvula deviated      •CN10, Left
to right
Structure




•Sympathetic
tract, Left

•Spinocerebellar
•CN10, Left
Location          Structure




•Side, Left      •Sympathetic
                 tract, Left

•Side, Left      •Spinocerebellar
•Medulla         •CN10, Left
Location                Structure




•Side, Left           •Sympathetic
                      tract, Left

•Side, Left           •Spinocerebellar
•Medulla              •CN10, Left
  Lateral medullary      Posterior inferior
    syndrome (L)        cerebellar artery (L)
Assignment

   In lateral medullary syndrome
(Wallenberg syndrome), there are
associated analgesia and
thermoanalgesia of the ipsilateral
face. Why? What brainstem
structure is affected?
Case                Structure


10 y/o girl
with the ff symptoms

Left-sided weakness

Right eye deviates medially


Righ-sided facial weakness
Case                     Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)

Right eye deviates medially


Righ-sided facial weakness
Case                      Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)

Right eye deviates medially   LR weakness, CN6 Right


Righ-sided facial weakness
Case                      Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)

Right eye deviates medially   LR weakness, CN6 Right


Righ-sided facial weakness          CN7, Right
Location         Structure




           Motor (CS tract, R)

           LR weakness, CN6 Right


                 CN7, Right
Location             Structure




Medial structure   Motor (CS tract, R)

                   LR weakness, CN6 Right


                         CN7, Right
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


                         CN7, Right
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


     Pons                CN7, Right
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


     Pons                CN7, Right


 Medial Pons           Pons tumor
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


     Pons                CN7, Right


 Medial Pons            Pons tumor
                   Millard-Gubler Syndrome
Assignment

What is astrocytoma?
Where is it usually located?
Who are most often affected?
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        ophthalmoplegia

 Loss of pupilary light reflex, left
               eye


 Paralysis of right arm and leg
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        ophthalmoplegia               CN3, Left

 Loss of pupilary light reflex, left
               eye


 Paralysis of right arm and leg
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        ophthalmoplegia               CN3, Left

 Loss of pupilary light reflex, left
               eye                    CN3, Left

 Paralysis of right arm and leg
Case                         Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        ophthalmoplegia                   CN3, Left

 Loss of pupilary light reflex, left
               eye                        CN3, Left

 Paralysis of right arm and leg       Motor, CS tract, Left
Location        Structure




               CN3, Left

               CN3, Left

           Motor, CS tract, Left
Location        Structure




Midbrain        CN3, Left

                CN3, Left

            Motor, CS tract, Left
Location        Structure




Midbrain        CN3, Left

Midbrain        CN3, Left

            Motor, CS tract, Left
Location          Structure




 Midbrain          CN3, Left

 Midbrain          CN3, Left


Medial, Left   Motor, CS tract, Left
Location           Structure




  Midbrain            CN3, Left

  Midbrain            CN3, Left


 Medial, Left     Motor, CS tract, Left


Medial Midbrain   Weber’s Syndrome
Case                  Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmoplegia


 Right-sided propioception loss



   Involuntary movement
Case                  Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmoplegia             CN3, Left

 Right-sided propioception loss



   Involuntary movement
Case                        Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmoplegia                  CN3, Left

 Right-sided propioception loss   Medial Lemniscus, Left


   Involuntary movement
Case                        Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmoplegia                  CN3, Left

 Right-sided propioception loss   Medial Lemniscus, Left


   Involuntary movement             Red nucleus, Left
Location         Structure




                CN3, Left

           Medial Lemniscus, Left


             Red nucleus, Left
Location            Structure




Midbrain, Left        CN3, Left

                 Medial Lemniscus, Left


                   Red nucleus, Left
Location            Structure




Midbrain, Left        CN3, Left

 Medial, Left    Medial Lemniscus, Left


                   Red nucleus, Left
Location            Structure




Midbrain, Left        CN3, Left

 Medial, Left    Medial Lemniscus, Left


 Medial, Left      Red nucleus, Left
Location             Structure




Midbrain, Left          CN3, Left

 Medial, Left      Medial Lemniscus, Left


 Medial, Left        Red nucleus, Left


Medial Midbrain   Benedikt’s Syndrome
Weber’s Syndrome      Benedikt’s Syndrome



       CN3                   CN3

 Motor, CS tract      Medial Lemniscus

Corticobulbar tract      Red nucleus

 Medial midbrain       Medial midbrain
Weber’s   Benedikt’s
Parinaud’s syndrome
•Posterior midbrain
•Superior colliculi
•Center for upward
gaze
•Inability to look up
(Doll’s eye)
•Argylle-Robertson
pupil
Any questions?
     The End
RETURN


      Brain stem




10%   90%
RETURN


LESION         Brain stem




         10%   90%
RETURN


LESION         Brain stem




         10%   90%
                       Contralateral
                        paralysis
Return
Return

LESION
Return

LESION




         Contralateral
         sensory loss
Return
Return
Return
Return


LESION
Return


      LESION



Ipsilateral
  ataxia
Return




LESION   Brain Stem

                            Contralateral
                            sensory loss

                 Pain
                  &
              temperature
Return
Return




         LESION
Return




             LESION




         Ipsilateral facial
           sensory loss
Horner’s Syndrome



 Meiosis
  Ptosis
Anhydrosis


             Return
Deviated
to the right



     Return
Vagus                    Vagus
        Levator uvalae




                         Return
Vagus                          Vagus
        Levator uvalae


                                  Lesion



                          Deviated
                         to the right



                              Return
Vagus                              Vagus
            Levator uvalae


                                      Lesion



                              Deviated
                             to the right
   Uvula deviates
 OPPOSITEthe lesion
                                  Return
Tongue
  deviates
OPPOSITE the
   lesion


  Deviated
 to the LEFT


   Return
Return
Return
Facial weakness




                  Return
Cranial Nerve 3
•EOM except lateral
rectus & superior
oblique
•Down and out
•Ptosis
•Absent pupillary
light reflex



                      Return
Return

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Brainstem Lesions

  • 1. Lessons on Brainstem Lesions Dr. Dennis Bravo
  • 2. Case A 58 y/o was referred to you because of recent onset of left hemiparesis, left-sided loss of propioception and right-sided tongue deviation. What CNS structures are affected? Explain the symptoms with regards to structures affected. Where is the lesion?
  • 3. review of Brainstem Structure
  • 6. Rules of 4* 1. 4 structures in ‘midline’ and begin with ‘M’ 2. 4 motor nuclei in midline and are those that are divisors of 12 (3,4,6,12) 3. 4 structures to the ‘side’ (lateral) and begin with ‘S’ 4. 4 CN in medulla, 4 in pons and 4 above pons *Gates, P. 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 2005; 35: 263-266
  • 7. 1 2 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) RULE of FOUR* 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. 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 2005; 35: 263-266
  • 8. 2 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. 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 2005; 35: 263-266
  • 9. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. 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 2005; 35: 263-266
  • 10. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. 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 2005; 35: 263-266
  • 11. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. 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 2005; 35: 263-266
  • 12. RULE #1 4 Medial Structures •Motor pathway •Medial leminiscus •Medial longitudinal fasciculus •Motor nucleus and nerve
  • 13. RULE #2 4 Medial Motor Nucleus •CN divides number 12 •CN 3, 4, 6, 12 are midline •3, 4, 6, 12 nucleus are midline •5, 7, 9, 11 lateral
  • 14. RULE #3 4 Side Structures •Spinocerebellar pathway •Spinothalamic pathway •Sensory nucleus of CN5 •Sympathetic pathway
  • 15. 4 Medulla Cranial RULE #4 Nerves •Glossopharyngeal (CN9) •Vagus (CN10) •Spinal accessory (CN11) •Hypoglossal (CN12)
  • 16. RULE #4 4 Pons Cranial Nerves •Trigeminal (CN5) •Abducent (CN6) •Facial (CN7) •Auditory (CN8)
  • 17. 4 Cranial Nerves RULE #4 Above Pons •Olfactory (CN1) •Optic (CN2) •Occulomotor (CN3) •Trochlear (CN4)
  • 18. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) More Info Medial lemniscus Medial longditudinal fasciculus Motor nucleus and nerve
  • 19. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral propioception/ Medial lemniscus vibration loss More Info Medial longditudinal fasciculus Motor nucleus and nerve
  • 20. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral Medial lemniscus propioception/ vibration loss Medial longditudinal Ipsilateral internuclear fasciculus ophthalmoplegia More Info Motor nucleus and nerve
  • 21. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral Medial lemniscus propioception/ vibration loss Medial longditudinal Ipsilateral internuclear fasciculus ophthalmoplegia Motor nucleus and Ipsilateral CN nerve function loss
  • 22. al DE er es at ur FIC L ct IT S tru Spinocerebellar Ipsilateral ataxia pathway More Info Spinothalamic Sensory nucleus of CN5 Sympathetic pathway
  • 23. al DE er es at ur FIC L ct I T S tru Spinocerebellar Ipsilateral ataxia pathway Contralateral pain/temp Spinothalamic sensory loss More Info Sensory nucleus of CN5 Sympathetic pathway
  • 24. al DE er es at ur FIC L ct I T S tru Spinocerebellar Ipsilateral ataxia pathway Contralateral pain/temp Spinothalamic sensory loss Sensory nucleus of Ipsilateral pain/ temp CN5 loss in face More Info Sympathetic pathway
  • 25. al DE er es at ur FIC L ct I T S tru 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 More Info
  • 26. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Vagus CN10 Spinal accessory CN11 Hypoglossal CN12
  • 27. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness More Info Spinal accessory CN11 Hypoglossal CN12
  • 28. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness Ipsilateral shoulder Spinal accessory CN11 weakness Hypoglossal CN12
  • 29. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness Ipsilateral shoulder Spinal accessory CN11 weakness Ipsilateral weakness of Hypoglossal CN12 tongue More Info
  • 30. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss More Info Abducent CN6 Facial CN7 Auditory CN8
  • 31. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness More Info Facial CN7 Auditory CN8
  • 32. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness Ipsilateral facial Facial CN7 weakness More Info Auditory CN8
  • 33. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness Ipsilateral facial Facial CN7 weakness Auditory CN8 Ipsilateral deafness
  • 34. DE 4 CN ons FIC P IT ve A bo Olfactory CN1 Not in midbrain Optic CN2 Not in midbrain Eye turned out and Occulomotor CN3 down More Info Trochlear CN4
  • 35. DE 4 CN ons FIC P I T ve A bo Olfactory CN1 Not in midbrain Optic CN2 Not in midbrain Eye turned out and Occulomotor CN3 down Eye unable to look down Trochlear CN4 when looking towards nose More Info
  • 37. Always remember “Pathways and tracts pass through the entire length of the brainstem and can be likened to ‘meridians of longitude‘ whereas the various cranial nerves can be regarded as ‘parallels of latitude‘. If you establish where the meridians of longitude and parallels of latitude intersect then you have established the site of the lesion.” Gates, P. 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 2005; 35: 263-266
  • 38. Case 58 year old woman •Left hemiparesis •Left-sided loss of propioception •Right-sided tongue deviation
  • 39. Case Structure 58 year old woman •Left hemiparesis •Motor (CS tract, R) •Left-sided loss of •Medial propioception lemniscus, R •Right-sided •CN12, R tongue deviation
  • 40. Structure •Motor (CS tract, R) •Medial lemniscus, R •CN12, R
  • 41. Location Structure •Medial •Motor (CS tract, R) •Medial •Medial lemniscus, R •Medulla •CN12, R
  • 42. Location Structure •Medial •Motor (CS tract, R) •Medial •Medial lemniscus, R •Medulla •CN12, R Medial medullary Vertebral artery, syndrome (R) medullary branch (R)
  • 43. Case 58 year old woman •Left-sided meiosis, anhydrosis, ptosis •Left-sided ataxia •Uvula deviated to right
  • 44. Case Structure 58 year old woman •Left-sided •Sympathetic meiosis, tract, Left anhydrosis, ptosis •Left-sided ataxia •Spinocerebellar •Uvula deviated •CN10, Left to right
  • 46. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left
  • 47. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left Lateral medullary Posterior inferior syndrome (L) cerebellar artery (L)
  • 48. Assignment In lateral medullary syndrome (Wallenberg syndrome), there are associated analgesia and thermoanalgesia of the ipsilateral face. Why? What brainstem structure is affected?
  • 49. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Right eye deviates medially Righ-sided facial weakness
  • 50. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially Righ-sided facial weakness
  • 51. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially LR weakness, CN6 Right Righ-sided facial weakness
  • 52. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially LR weakness, CN6 Right Righ-sided facial weakness CN7, Right
  • 53. Location Structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  • 54. Location Structure Medial structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  • 55. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right CN7, Right
  • 56. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right
  • 57. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right Medial Pons Pons tumor
  • 58. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right Medial Pons Pons tumor Millard-Gubler Syndrome
  • 59. Assignment What is astrocytoma? Where is it usually located? Who are most often affected?
  • 60. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reflex, left eye Paralysis of right arm and leg
  • 61. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye Paralysis of right arm and leg
  • 62. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye CN3, Left Paralysis of right arm and leg
  • 63. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye CN3, Left Paralysis of right arm and leg Motor, CS tract, Left
  • 64. Location Structure CN3, Left CN3, Left Motor, CS tract, Left
  • 65. Location Structure Midbrain CN3, Left CN3, Left Motor, CS tract, Left
  • 66. Location Structure Midbrain CN3, Left Midbrain CN3, Left Motor, CS tract, Left
  • 67. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left
  • 68. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left Medial Midbrain Weber’s Syndrome
  • 69. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss Involuntary movement
  • 70. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Involuntary movement
  • 71. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Medial Lemniscus, Left Involuntary movement
  • 72. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Medial Lemniscus, Left Involuntary movement Red nucleus, Left
  • 73. Location Structure CN3, Left Medial Lemniscus, Left Red nucleus, Left
  • 74. Location Structure Midbrain, Left CN3, Left Medial Lemniscus, Left Red nucleus, Left
  • 75. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Red nucleus, Left
  • 76. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left
  • 77. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left Medial Midbrain Benedikt’s Syndrome
  • 78. Weber’s Syndrome Benedikt’s Syndrome CN3 CN3 Motor, CS tract Medial Lemniscus Corticobulbar tract Red nucleus Medial midbrain Medial midbrain
  • 79. Weber’s Benedikt’s
  • 80. Parinaud’s syndrome •Posterior midbrain •Superior colliculi •Center for upward gaze •Inability to look up (Doll’s eye) •Argylle-Robertson pupil
  • 81. Any questions? The End
  • 82. RETURN Brain stem 10% 90%
  • 83. RETURN LESION Brain stem 10% 90%
  • 84. RETURN LESION Brain stem 10% 90% Contralateral paralysis
  • 87. Return LESION Contralateral sensory loss
  • 92. Return LESION Ipsilateral ataxia
  • 93. Return LESION Brain Stem Contralateral sensory loss Pain & temperature
  • 95. Return LESION
  • 96. Return LESION Ipsilateral facial sensory loss
  • 97. Horner’s Syndrome Meiosis Ptosis Anhydrosis Return
  • 99. Vagus Vagus Levator uvalae Return
  • 100. Vagus Vagus Levator uvalae Lesion Deviated to the right Return
  • 101. Vagus Vagus Levator uvalae Lesion Deviated to the right Uvula deviates OPPOSITEthe lesion Return
  • 102. Tongue deviates OPPOSITE the lesion Deviated to the LEFT Return
  • 103. Return
  • 104. Return
  • 105. Facial weakness Return
  • 106. Cranial Nerve 3 •EOM except lateral rectus & superior oblique •Down and out •Ptosis •Absent pupillary light reflex Return
  • 107. Return