Lessons On Brainstem Lesions: Dr. Dennis Bravo

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
3
4 Structures in midline
and begin with M
RULE of
FOUR*
4 Structures to the side

and begin with S
2
4
4 Motor nuclei in
midline and are divisors
of 12
( 3, 4, 6, 12)
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
and begin with M

and begin with S
2
4
4 Motor nuclei in
of 12
( 3, 4, 6, 12)
4 CN in medulla
4 CN in pons
4 CN above pons
and begin with M

and begin with S
4 Motor nuclei in
of 12
( 3, 4, 6, 12)
4 CN in medulla
4 CN in pons
4 CN above pons
and begin with M
4 Motor nuclei in
of 12
( 3, 4, 6, 12)

and begin with S
4 CN in medulla
4 CN in pons
4 CN above pons
and begin with M
4 Motor nuclei in
of 12
( 3, 4, 6, 12)

and begin with S
4 CN in medulla
4 CN in pons
4 CN above pons
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
Above Pons
RULE #4
Olfactory (CN1)
Optic (CN2)
Occulomotor (CN3)
Trochlear (CN4)
e
n
i
l
id ures
M ct
u
r
t
S
Motor pathway
(Corticospinal tract)
DE
FIC
I
Contalateral weakness
More Info
Medial lemniscus
Medial longditudinal
fasciculus
Motor nucleus and
nerve
e
n
i
l
id ures
M ct
u
r
t
S
Motor pathway
Medial lemniscus
DE
FIC
I
Contralateral propioception/
vibration loss
More Info
fasciculus
Motor nucleus and
nerve
e
n
i
l
id ures
M ct
u
r
t
S
Motor pathway
DE
FIC
I
Medial lemniscus
Contralateral
propioception/ vibration
loss
fasciculus
Ipsilateral internuclear
ophthalmoplegia
Motor nucleus and

nerve
More Info
e
n
i
l
id ures
M ct
u
r
t
S
Motor pathway
DE
FIC
I
Medial lemniscus
Contralateral
propioception/ vibration
loss
fasciculus
Ipsilateral internuclear
ophthalmoplegia
Motor nucleus and

nerve
Ipsilateral CN
function loss
l
a
r
e
s
t
e
a
L ctur
u
r
t
S
Spinocerebellar
pathway
DE
FIC
I
Ipsilateral ataxia
More Info
Spinothalamic
Sensory nucleus of
CN5
Sympathetic pathway
l
a
r
e
s
t
e
a
L ctur
u
r
t
S
Spinocerebellar
pathway
Spinothalamic
DE
FIC
I
Ipsilateral ataxia
Contralateral pain/temp
sensory loss
More Info
Sensory nucleus of
CN5
Sympathetic pathway
l
a
r
e
s
t
e
a
L ctur
u
r
t
S
Spinocerebellar
pathway
DE
FIC
I
Ipsilateral ataxia
Spinothalamic
sensory loss
Sensory nucleus of
CN5
Ipsilateral pain/ temp

loss in face
More Info
Sympathetic pathway
l
a
r
e
s
t
e
a
L ctur
u
r
t
S
Spinocerebellar
pathway
DE
FIC
I
Ipsilateral ataxia
Spinothalamic
sensory loss
Sensory nucleus of
CN5
Ipsilateral pain/ temp

loss in face
Sympathetic pathway
Ipsilateral Horners
syndrome
More Info
N
C
4 ulla
ed
M
Glossopharyngeal
CN9
Vagus CN10
Spinal accessory CN11
Hypoglossal CN12
DE
FIC
I
Ipsilateral pharyngeal
sensory loss
N
C
4 ulla
ed
M
DE
FIC
I
Glossopharyngeal
CN9
sensory loss
Vagus CN10
Ipsilateral palatal
weakness
More Info
Hypoglossal CN12
N
C
4 ulla
ed
M
DE
FIC
I
Glossopharyngeal
CN9
sensory loss
Vagus CN10
Ipsilateral palatal
weakness
Ipsilateral shoulder
weakness
Hypoglossal CN12
N
C
4 ulla
ed
M
DE
FIC
I
Glossopharyngeal
CN9
sensory loss
Vagus CN10
Ipsilateral palatal
weakness
Ipsilateral shoulder
weakness
Hypoglossal CN12
Ipsilateral weakness of
tongue
More Info
DE
N
C
4 ns
Po
FIC
I
Trigeminal CN5
Ipsilateral facial
sensory loss
More Info
Abducent CN6
Facial CN7
Auditory CN8
DE
N
C
4 ns
Po
FIC
I
Trigeminal CN5
Ipsilateral facial
sensory loss
Abducent CN6
Ipsilateral eye
abduction weakness
More Info
Facial CN7
Auditory CN8
DE
N
C
4 ns
Po
FIC
I
Trigeminal CN5
Ipsilateral facial
sensory loss
Abducent CN6
Ipsilateral eye
abduction weakness
Facial CN7
Ipsilateral facial
weakness
More Info
Auditory CN8
DE
N
C
4 ns
Po
FIC
I
Trigeminal CN5
Ipsilateral facial
sensory loss
Abducent CN6
Ipsilateral eye
abduction weakness
Facial CN7
Ipsilateral facial
weakness
Auditory CN8
Ipsilateral deafness
N ns
C
o
4
P
e
v
o
b
A
DE
FIC
I
Olfactory CN1
Not in midbrain
Optic CN2
Not in midbrain
Occulomotor CN3
Eye turned out and

down
More Info
Trochlear CN4
N ns
C
o
4
P
e
v
o
b
A
DE
FIC
I
Olfactory CN1
Not in midbrain
Optic CN2
Not in midbrain
Occulomotor CN3
Eye turned out and

down
Trochlear CN4
Eye unable to look down

when looking towards nose
More Info
Lets 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
58 year old woman

Left hemiparesis
Left-sided loss of
propioception
Right-sided
tongue deviation
Structure
Motor (CS tract, R)

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

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

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

Medial
Medulla
lemniscus, R
CN12, R
Medial medullary
syndrome (R)
Vertebral artery,
medullary branch (R)
Case
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
Structure
Sympathetic
tract, Left
Spinocerebellar
CN10, Left
Structure
Sympathetic
tract, Left
Spinocerebellar
CN10, Left
Location
Side, Left
Structure
Sympathetic
tract, Left
Side, Left
Medulla
Spinocerebellar
CN10, Left
Location
Side, Left
Structure
Sympathetic
tract, Left
Side, Left
Medulla
Lateral medullary
syndrome (L)
Spinocerebellar
CN10, Left
Posterior inferior
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
10 y/o girl
with the ff symptoms
Left-sided weakness
Right eye deviates medially
Righ-sided facial weakness
Structure
Case
Structure
10 y/o girl
Left-sided weakness
Motor (CS tract, R)
Case
Structure
10 y/o girl
Left-sided weakness
Motor (CS tract, R)
LR weakness, CN6 Right
Case
Structure
10 y/o girl
Left-sided weakness
Motor (CS tract, R)
CN7, Right
Location
Structure
Motor (CS tract, R)

CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)

CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)
Pons
CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)
Pons
Pons
CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)
Pons
Pons
CN7, Right
Medial Pons
Pons tumor
Location
Structure
Medial structure
Motor (CS tract, R)
Pons
Pons
CN7, Right
Medial Pons
Millard-Gubler
Syndrome
Pons tumor
Assignment
What is astrocytoma?
Where is it usually located?
Who are most often affected?
Case
70 y/o male hypertensive
suddenly developed
Left-sided ipsilateral
ophthalmoplegia
Loss of pupilary light reflex, left
eye
Paralysis of right arm and leg
Structure
Case
Structure

suddenly developed
ophthalmoplegia
eye
CN3, Left
Case
Structure

suddenly developed
ophthalmoplegia
CN3, Left

eye
CN3, Left
Case
Structure

suddenly developed
ophthalmoplegia
CN3, Left

eye
CN3, Left
Motor, CS tract, Left
Location
Structure
CN3, Left
CN3, Left
Location
Structure
Midbrain
CN3, Left
CN3, Left
Location
Structure
Midbrain
CN3, Left
Midbrain
CN3, Left
Location
Structure
Midbrain
CN3, Left
Midbrain
CN3, Left
Medial, Left
Location
Structure
Midbrain
CN3, Left
Midbrain
CN3, Left
Medial, Left
Medial Midbrain
Webers Syndrome
Case
suddenly developed
ophthalmoplegia
Right-sided propioception loss
Involuntary movement
Structure
Case
Structure

suddenly developed
ophthalmoplegia
CN3, Left
Case
Structure

suddenly developed
ophthalmoplegia
CN3, Left
Medial Lemniscus, Left
Case
Structure

suddenly developed
ophthalmoplegia
CN3, Left
Red nucleus, Left
Location
Structure
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left
CN3, Left
Medial, Left
Red nucleus, Left
Location
Structure
Midbrain, Left
CN3, Left
Medial, Left
Medial, Left
Red nucleus, Left
Location
Structure
Midbrain, Left
CN3, Left
Medial, Left
Medial, Left
Red nucleus, Left
Medial Midbrain
Benedikts Syndrome
Webers Syndrome
Benedikts Syndrome
CN3
CN3
Motor, CS tract
Medial Lemniscus
Corticobulbar tract
Red nucleus
Medial midbrain
Medial midbrain
Webers
Benedikts
Parinauds syndrome
Posterior midbrain
Superior colliculi
Center for upward
gaze
Inability to look up
(Dolls 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
Horners 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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Lessons on

are divisors of 12 (3,4,6,12)

4 Structures to the side

4 Structures to the side

4 Structures to the side

4 Structures to the side

4 Structures to the side

4 Medial Motor Nucleus

4 Pons Cranial Nerves

Motor nucleus and

Motor nucleus and

Ipsilateral pain/ temp

Ipsilateral pain/ temp

Spinal accessory CN11

Spinal accessory CN11

Spinal accessory CN11

Eye turned out and

Eye turned out and

Eye unable to look down

Lets put your

58 year old woman

58 year old woman

Motor (CS tract, R)

Motor (CS tract, R)

Motor (CS tract, R)

Motor (CS tract, R)

58 year old woman

58 year old woman

Righ-sided facial weakness

Righ-sided facial weakness

Motor (CS tract, R)

Motor (CS tract, R)

Right eye deviates medially

LR weakness, CN6 Right

Righ-sided facial weakness

Motor (CS tract, R)

Right eye deviates medially

LR weakness, CN6 Right

Righ-sided facial weakness

Motor (CS tract, R)

Motor (CS tract, R)

Motor (CS tract, R)

LR weakness, CN6 Right

Motor (CS tract, R)

LR weakness, CN6 Right

Motor (CS tract, R)

LR weakness, CN6 Right

Motor (CS tract, R)

LR weakness, CN6 Right

Paralysis of right arm and leg

70 y/o male hypertensive

Paralysis of right arm and leg

70 y/o male hypertensive

Loss of pupilary light reflex, left

Paralysis of right arm and leg

70 y/o male hypertensive

Loss of pupilary light reflex, left

Paralysis of right arm and leg

Motor, CS tract, Left

Motor, CS tract, Left

Motor, CS tract, Left

70 y/o male hypertensive

70 y/o male hypertensive