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
4 Structures in midline
and begin with M
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
4 Structures to the side
and begin with S
4 CN in medulla
4 CN in pons
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
3
1
4
RULE of
FOUR*
4 Structures in midline
and begin with M
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
4 Structures to the side
and begin with S
4 CN in medulla
4 CN in pons
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
3 4
4 Structures in midline
and begin with M
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
4 Structures to the side
and begin with S
4 CN in medulla
4 CN in pons
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
3 4
4 Structures in midline
and begin with M
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
4 Structures to the side
and begin with S
4 CN in medulla
4 CN in pons
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
4 Structures in midline
and begin with M
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
4 Structures to the side
and begin with S
4 CN in medulla
4 CN in pons
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 Medial Structures

Motor pathway

Medial leminiscus

Medial longitudinal
fasciculus

Motor nucleus and nerve

RULE #1
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 #2
4 Side Structures

Spinocerebellar pathway

Spinothalamic pathway

Sensory nucleus of CN5

Sympathetic pathway
RULE #3
4 Medulla Cranial
Nerves

Glossopharyngeal (CN9)

Vagus (CN10)

Spinal accessory (CN11)

Hypoglossal (CN12)
RULE #4
4 Pons Cranial Nerves

Trigeminal (CN5)

Abducent (CN6)

Facial (CN7)

Auditory (CN8)
RULE #4
4 Cranial Nerves
Above Pons

Olfactory (CN1)

Optic (CN2)

Occulomotor (CN3)

Trochlear (CN4)
RULE #4
Motor pathway
(Corticospinal tract)
Medial lemniscus
Medial longditudinal
fasciculus
Motor nucleus and
nerve
Contalateral weakness
D
E
F
I
C
I
T
M
i
d
l
i
n
e
S
t
r
u
c
t
u
r
e
s
More Info
Motor pathway
(Corticospinal tract)
Medial lemniscus
Medial longditudinal
fasciculus
Motor nucleus and
nerve
Contalateral weakness
Contralateral propioception/
vibration loss
D
E
F
I
C
I
T
M
i
d
l
i
n
e
S
t
r
u
c
t
u
r
e
s
More Info
Motor pathway
(Corticospinal tract)
Medial lemniscus
Medial longditudinal
fasciculus
Motor nucleus and
nerve
Contalateral weakness
Contralateral
propioception/ vibration
loss
Ipsilateral internuclear
ophthalmoplegia
D
E
F
I
C
I
T
M
i
d
l
i
n
e
S
t
r
u
c
t
u
r
e
s
More Info
Motor pathway
(Corticospinal tract)
Medial lemniscus
Medial longditudinal
fasciculus
Motor nucleus and
nerve
Contalateral weakness
Contralateral
propioception/ vibration
loss
Ipsilateral internuclear
ophthalmoplegia
Ipsilateral CN
function loss
D
E
F
I
C
I
T
M
i
d
l
i
n
e
S
t
r
u
c
t
u
r
e
s
Spinocerebellar
pathway
Spinothalamic
Sensory nucleus of
CN5
Sympathetic pathway
Ipsilateral ataxia
D
E
F
I
C
I
T
L
a
t
e
r
a
l
S
t
r
u
c
t
u
r
e
s
More Info
Spinocerebellar
pathway
Spinothalamic
Sensory nucleus of
CN5
Sympathetic pathway
Ipsilateral ataxia
Contralateral pain/temp
sensory loss
D
E
F
I
C
I
T
L
a
t
e
r
a
l
S
t
r
u
c
t
u
r
e
s
More Info
Spinocerebellar
pathway
Spinothalamic
Sensory nucleus of
CN5
Sympathetic pathway
Ipsilateral ataxia
Contralateral pain/temp
sensory loss
Ipsilateral pain/ temp
loss in face
D
E
F
I
C
I
T
L
a
t
e
r
a
l
S
t
r
u
c
t
u
r
e
s
More Info
Spinocerebellar
pathway
Spinothalamic
Sensory nucleus of
CN5
Sympathetic pathway
Ipsilateral ataxia
Contralateral pain/temp
sensory loss
Ipsilateral pain/ temp
loss in face
Ipsilateral Horners
syndrome
D
E
F
I
C
I
T
L
a
t
e
r
a
l
S
t
r
u
c
t
u
r
e
s
More Info
Glossopharyngeal
CN9
Vagus CN10
Spinal accessory CN11
Hypoglossal CN12
Ipsilateral pharyngeal
sensory loss
D
E
F
I
C
I
T
4

C
N
M
e
d
u
l
l
a
Glossopharyngeal
CN9
Vagus CN10
Spinal accessory CN11
Hypoglossal CN12
Ipsilateral pharyngeal
sensory loss
Ipsilateral palatal
weakness
D
E
F
I
C
I
T
4

C
N
M
e
d
u
l
l
a
More Info
Glossopharyngeal
CN9
Vagus CN10
Spinal accessory CN11
Hypoglossal CN12
Ipsilateral pharyngeal
sensory loss
Ipsilateral palatal
weakness
Ipsilateral shoulder
weakness
D
E
F
I
C
I
T
4

C
N
M
e
d
u
l
l
a
Glossopharyngeal
CN9
Vagus CN10
Spinal accessory CN11
Hypoglossal CN12
Ipsilateral pharyngeal
sensory loss
Ipsilateral palatal
weakness
Ipsilateral shoulder
weakness
Ipsilateral weakness of
tongue
D
E
F
I
C
I
T
4

C
N
M
e
d
u
l
l
a
More Info
Trigeminal CN5
Abducent CN6
Facial CN7
Auditory CN8
Ipsilateral facial
sensory loss
D
E
F
I
C
I
T
4

C
N
P
o
n
s
More Info
Trigeminal CN5
Abducent CN6
Facial CN7
Auditory CN8
Ipsilateral facial
sensory loss
Ipsilateral eye
abduction weakness
D
E
F
I
C
I
T
4

C
N
P
o
n
s
More Info
Trigeminal CN5
Abducent CN6
Facial CN7
Auditory CN8
Ipsilateral facial
sensory loss
Ipsilateral eye
abduction weakness
Ipsilateral facial
weakness
D
E
F
I
C
I
T
4

C
N
P
o
n
s
More Info
Trigeminal CN5
Abducent CN6
Facial CN7
Auditory CN8
Ipsilateral facial
sensory loss
Ipsilateral eye
abduction weakness
Ipsilateral facial
weakness
Ipsilateral deafness
D
E
F
I
C
I
T
4

C
N
P
o
n
s
Olfactory CN1
Optic CN2
Occulomotor CN3
Trochlear CN4
Not in midbrain
Not in midbrain
Eye turned out and
down
D
E
F
I
C
I
T
4

C
N
A
b
o
v
e

P
o
n
s
More Info
Olfactory CN1
Optic CN2
Occulomotor CN3
Trochlear CN4
Not in midbrain
Not in midbrain
Eye turned out and
down
Eye unable to look down
when looking towards nose
D
E
F
I
C
I
T
4

C
N
A
b
o
v
e

P
o
n
s
More Info
Lets put your
knowledge to use...
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.
Always remember
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
58 year old woman

Left hemiparesis

Left-sided loss of
propioception

Right-sided
tongue deviation
Case
58 year old woman

Left hemiparesis

Left-sided loss of
propioception

Right-sided
tongue deviation

Motor (CS tract, R)

Medial
lemniscus, R

CN12, R
Case
Structure

Motor (CS tract, R)

Medial
lemniscus, R

CN12, R
Structure

Medial

Medial

Medulla

Motor (CS tract, R)

Medial
lemniscus, R

CN12, R
Location Structure

Medial

Medial

Medulla

Motor (CS tract, R)

Medial
lemniscus, R

CN12, R
Location
Medial medullary
syndrome (R)
Vertebral artery,
medullary branch (R)
Structure
58 year old woman

Left-sided
meiosis,
anhydrosis, ptosis

Left-sided ataxia

Uvula deviated
to right
Case
58 year old woman

Left-sided
meiosis,
anhydrosis, ptosis

Left-sided ataxia

Uvula deviated
to right

Sympathetic
tract, Left

Spinocerebellar

CN10, Left
Case
Structure

Sympathetic
tract, Left

Spinocerebellar

CN10, Left
Structure

Side, Left

Side, Left

Medulla

Sympathetic
tract, Left

Spinocerebellar

CN10, Left
Location Structure

Side, Left

Side, Left

Medulla

Sympathetic
tract, Left

Spinocerebellar

CN10, Left
Lateral medullary
syndrome (L)
Posterior inferior
cerebellar artery (L)
Location Structure
Assignment
In lateral medullary syndrome
(Wallenberg syndrome), there are
associated analgesia and
thermoanalgesia of the ipsilateral
face. Why? What brainstem
structure is affected?
10 y/o girl
with the ff symptoms
Case
Left-sided weakness
Right eye deviates medially
Righ-sided facial weakness
Structure
10 y/o girl
with the ff symptoms
Case
Left-sided weakness
Right eye deviates medially
Righ-sided facial weakness
Motor (CS tract, R)
Structure
10 y/o girl
with the ff symptoms
Case
Left-sided weakness
Right eye deviates medially
Righ-sided facial weakness
Motor (CS tract, R)
LR weakness, CN6 Right
Structure
10 y/o girl
with the ff symptoms
Case
Left-sided weakness
Right eye deviates medially
Righ-sided facial weakness
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Structure
Location
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Structure
Location
Medial structure Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Structure
Location
Medial structure
Pons
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Structure
Location
Medial structure
Pons
Pons
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Structure
Location
Medial structure
Pons
Pons
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Medial Pons Pons tumor
Structure
Location
Medial structure
Pons
Pons
Motor (CS tract, R)
LR weakness, CN6 Right
CN7, Right
Medial Pons Pons tumor
Millard-Gubler Syndrome
Structure
Assignment
What is astrocytoma?
Where is it usually located?
Who are most often affected?
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Loss of pupilary light reex, left
eye
Paralysis of right arm and leg
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Loss of pupilary light reex, left
eye
Paralysis of right arm and leg
CN3, Left
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Loss of pupilary light reex, left
eye
Paralysis of right arm and leg
CN3, Left
CN3, Left
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Loss of pupilary light reex, left
eye
Paralysis of right arm and leg
CN3, Left
Motor, CS tract, Left
CN3, Left
Structure
Location
CN3, Left
Motor, CS tract, Left
CN3, Left
Structure
Location
Midbrain
CN3, Left
Motor, CS tract, Left
CN3, Left
Structure
Location
Midbrain
Midbrain
CN3, Left
Motor, CS tract, Left
CN3, Left
Structure
Location
Midbrain
Midbrain
Medial, Left
CN3, Left
Motor, CS tract, Left
CN3, Left
Structure
Location
Midbrain
Midbrain
Medial, Left
CN3, Left
Motor, CS tract, Left
CN3, Left
Medial Midbrain Webers Syndrome
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Right-sided propioception loss
Involuntary movement
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Right-sided propioception loss
Involuntary movement
CN3, Left
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Right-sided propioception loss
Involuntary movement
CN3, Left
Medial Lemniscus, Left
Structure
70 y/o male hypertensive
suddenly developed
Case
Left-sided ipsilateral
ophthalmoplegia
Right-sided propioception loss
Involuntary movement
CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Structure
CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Structure Location
Midbrain, Left CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Structure Location
Midbrain, Left
Medial, Left
CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Structure Location
Midbrain, Left
Medial, Left
Medial, Left
CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Structure Location
Midbrain, Left
Medial, Left
Medial, Left
CN3, Left
Medial Lemniscus, Left
Red nucleus, Left
Medial Midbrain Benedikts Syndrome
Structure Location
Webers Syndrome Benedikts Syndrome
CN3
Medial Lemniscus
Red nucleus
CN3
Motor, CS tract
Corticobulbar tract
Medial midbrain Medial midbrain
Benedikts Webers
Parinauds syndrome

Posterior midbrain

Superior colliculi

Center for upward

gaze

Inability to look up
(Dolls eye)

Argylle-Robertson
pupil
Any questions?
The End
Brain stem
90% 10%
RETURN
Brain stem
90% 10%
LESION
RETURN
Brain stem
90% 10%
LESION
Contralateral
paralysis
RETURN
Return
LESION
Return
LESION
Contralateral
sensory loss
Return
Return
Return
Return
Return
LESION
Return
LESION
Ipsilateral
ataxia
Brain Stem
Pain
&
temperature
LESION
Contralateral
sensory loss
Return
Return
LESION
Return
LESION
Ipsilateral facial
sensory loss
Return
Meiosis
Ptosis
Anhydrosis
Horners Syndrome
Return
Deviated
to the right
Return
Levator uvalae
Vagus Vagus
Return
Deviated
to the right
Levator uvalae
Vagus Vagus
Lesion
Return
Deviated
to the right
Levator uvalae
Vagus Vagus
Lesion
Uvula deviates
OPPOSITEthe lesion
Return
Deviated
to the LEFT
Tongue
deviates
OPPOSITE the
lesion
Return
Return
Return
Facial weakness
Return
Return
Cranial Nerve 3

EOM except lateral

rectus & superior
oblique

Down and out

Ptosis

Absent pupillary
light reex
Return