CRANIAL NERVES

&
BRAIN STEM

dr. Freddy Hasudungan Aritonang, M.Sc., Sp.S

CRANIAL NERVES
 Cranial Nerves
• 12 pairs
• Emerging from the brain stem (except CN I and
CN II)
• They have their nuclei (somatomotor,
somatosensitive, sensoric, parasympathic)
• Outside brain - ganglias (sympathic,
parasympathetic)
• Sympathetic fibres join along the course, from
plexuses following the blood vessels
http://www.becomehealthynow.com/images/organs/nervous/cranial_nerves.jpg
Nerve Cranialis
Nerve Cranialis
 I – N. Olfactorius

• Olfactory nerve
• Rather bundle of nerve
fibres than a nerve
• Pure sensoric nerve
• Bipolar neurons
• Ability to regenerate
• N. terminalis, n. vomeronasalis -
rudiments
 Bulbus olfactorius
Cranial Nerve I:
Olfactory Bipolar
cells
Foramen:
cribiform
plate of ethmoid
Region Entered:
nasal cavity
Components:
special sensory
Target: olfactory
epithelium
Function: smell
50 million primary sensory receptor cells in 2.5 cm2
 Olfactory tract

• Fila olfactoria, bulbus – interconnection, tractus, trigonum,

stria olfactoria (med. + lat.), brain areas
• Disorders: anosmia, parosmia, kakosmia
 Second neurons:

First neurons: Unmyelinated

8-20 cilia of 30-200  in length
60  thick layer of mucous (lipid- ric
The mucous lipids assist in transporting the secretion that bathes the surface of
odorant molecules as only volatile materials receptors at the epithelium surface)
soluble in the mucous, can interact with the
olfactory receptors & produce the signals
that our brain interprets as odor
 Lateral stria
anterior olfactory nucleus

pyriform nucleus of horizontal limb of diagonal

cortex band
olfactory tubercle Medial stria

transitional entorhinal cortex

 Olfactory Tract Connections& Lesion
 Lateral stria primary olfactory cortex
(periamygdaloid & prepiriform areas) secondary
olfactory cortex (entorhinal area (area 28))
 Medial stria cross the anterior commisure to
join contralateral olfactory bulb

Unilateral anosmia : Compression due to abcess, glioma,

meningioma of frontal lob or hypothalamus which may
result in ipsilateral optic atropy & contralateral papilledema
Foster-Kennedy syndrome
 II – N. Opticus

• Optic nerve
• Diencephalon pouch
• Consist of axons of the 3rd nerves of the optic tract
• Covers: vagina externa + interna (from meninges)
• A.+ V. centralis retinae

• Pars intraocularis
• Pars orbitalis
• Pars canalis optici
• Pars intracranialis
Cranial Nerve II:
Opticus

Foramen: optic
canal of sphenoid
Region Entered:
orbit
Components:
special sensory
Target, Function:
retina-vision
Optic tract
Pupils
The pupillary light reaction
• afferent : optic nerve
• efferent :parasympathic component of
third nerve on both side
Accomodation reaction
• afferrent : arises in the frontal lobe
• efferent : as for light reaction
Accuity
Abnormalities may arise from
• ocular problems
• optical problems
• retinal and orbital abnormalityof vision
Field
visual field abnormality arise from lesions at
different site:
• monocular field defect : lesion ant.optic chias
• bitemp. field defect : lesion optic chiasm
• homonym field defect : behind optic chiasm
• congruous hom field defect : lesion behind
lateral geniculae bodies
Fundus
 Normal Papil Optic Nerve
• Margin : Clear
• Color : Orange
• Cupping : positive or
negative
Papilledema
 Papilledema
• Margin : blurred
• Color : red
• Cupping : negative
• Veins : dilated, tortoise
• Retinal : hemorrhage,
exudates
 Primary Nerve Optic Atrophy

• Color : pale
• Margin : clear
• Cupping : (+)
• Arterial : normal / narrow
 Secondary Nerve Optic Atrophy

• Color : pale
• Margin : blurred
• Cupping : (-)
• Arterial : normal / narrow
• Veins : dilate - tortoise
1st neurone: rod & cone cells
of the retina
2nd neurone: bipolar neurones
of the retina
3rd neurone: multipolar
neurones of the retina
Axons of the ganglion opticum
run via the N. opticus to the
chiasma
 In the chiasma opticum, fibres of the
nasal part of the retina cross to
the contralateral side,
and those of the
temporal part continue ipsilaterally
Each tractus opticus consists of
fibres
transporting the information
from the contralateral halves of the
visual field
corpus geniculatum
laterale&mediale (some fibres),
hypothalamus go directly to the
cortex of the
brain
4th neurone: corpus geniculatum
laterale areas 17&18 around the
sulcus calcarinus (area striata)
 Causes of Papillitis
&Retrobulbar Neuritis
 Multiple sclerosis
 Viral illness; Syphilis
 Temporal arteritis & other kinds of
inflammation of the arteries (vasculitis)
 Poisoning by chemicals: lead, methanol...
 Tumors that have spread to the optic n.
 Allergic reactions to beestings
 Meningitis
 Uveitis
 Arteriosclerosis
Extraocular Muscles
• The primary function of:
- the four rectus is to control the eye’s
movements from left to right and up and
down.
- the two oblique muscles move the eye
rotate the eyes inward and outward.
Extraocular Muscles
• The four rectus extraocular muscles are:
1. M. rectus medialis  innervated by 3rd nerve
2. M. rectus lateralis  innervated by 6th nerve
3. M. rectus superior
innervated by 3rd nerve
4. M. rectus inferior
• The two oblique extraocular muscles are:
1. M. obliques superior  innervated by 4th nerve
2. M. obliques inferior  innervated by 3rd nerve
 Innervation and action of the extra ocular muscle

Nerves Muscle Action Action

primary secondary
Oculomotor Superior rectus Moves ye up Adduct,rotates inward
Inferior rectus Moves eye down Adduct,rotates outward
Medial rectus Abduct None
Inferior oblique Moves eye up Abducts,rotates
outward
Trochlear
Superior oblique moves eye down Abducts,rotates inward

Abdusens none
Lateral rectus Moves eye out
Extraocular Eye Movement
 III - N. Oculomotorius
• nc. oculomotorius (somatomotor)
• nc. Edinger-Westphal (PS)
• Ramus superior + inferior (r. communicans ad ggl. ciliare)
• Palsy: diplopia, divergent strabismus, ptosis, mydriasis
• Innervates:
– m. rectus superior
– m. rectus medialis
– m. rectus inferior
– m. obliquus inferior
– m. levator palpebrae sup.
Cranial Nerve III: Foramen: Superior
orbital fissure
Oculomotor Region Entered: Orbit
Somatomotor Comp.:
Target, Function:
levator palpebrae sup.
superior rectus
medial rectus
inferior rectus
inferior oblique
Visceromotor Comp.:
preganglionic
parasympathetic to:
ciliary ganglion
R eye
 ggl. ciliare
• Ciliary ganglion
m. sphincter pupilae m. dilatator pupilae

m. ciliaris
THIRD CRANIAL NERVE PALSIES
During primary gaze, weakness of
the muscles innervated by, result in:
 Ptosis of the lid
 Mydriasis
 Outwardly turned eye
Pupil is completely spared:
• Myopathy
• but all other muscles innervated by the
3rd nerve are affected: diabetic 3rd
nerve paresis (ischemic process)
 Fixed dilated pupils: 3rd nerve
compression
- Aneurysm of the post. communicating
art
- Trauma
- Intracranial mass lesion
- Increasingly unresponsive patient with
3rd n. palsy: transtentorial herniation
Neurologic examination with CT or MRI
• When CT does not show blood: Lumbar
puncture (suspected SAH)
• Cerebral angiography: if aneurysm is
suspected
+ Nuc. Ruber infarction in
midbrain

contralat. tremor +
İpsilat. 3rd n. palsy &
fixed pupilla
Pupillary Reflex:
Afferent: NII
Edinger-Westpal nuc.
Efferent: NIII parasympath.
Argyll Robertson pupil
Accomodation Retained
Light reflex absent
•
• Ptosis • Myosis
Loss of sweating on the affected side of the face
• Enophthalmus

From hypothalamus, sympathetic nn. descend

ipsilat. through the brainstem & cervical cord &
riches the sympathetic chain via the motor root of
T1. From there, fibers pass along the outer sheath
of the internal carotid artery&its opht.branch &to
the pupilla. Fibers to the face travel with the ext.
carotid artery
Pancoast tm, mass compress. cervical symp.
chain
 IV - N. Trochlearis
• Trochlear nerve, pure somatomotor
• Innervates m. obliquus superior
• Nucleus trochlearis
• Only one which emerges from the brain stem dorsally
• sinus cavernosus, fissura orbitalis superior, ATC Zinni
• Palsy: diplopia when looking down and laterally (downstairs)
 Cranial Nerve IV: Trochlear

 Affect vertical eye position

when the eye is turned inward
 The patient sees double images:
one above & slightly to the
side of the other
 By tilting the head to the side
opposite the palsied m., the pt
may achieve full ocular motility without double vision

Causes: idiopathic, closed head trauma, aneurysms,

tm, MS
 VI - N. Abducens
• Abducens nerve, pure motor (nc. abducens)
• Innervates m. rectus lateralis
• Dorello´s canal, sinus cavernosus, fissura orbitalis superior,
ATC Zinni
• Palsy: diplopia, convergent strabism
 Cranial Nerve
VI: Abducens
Foramen: Superior
orbital fissure
Region Entered:
Orbit
Components:
Somatomotor
Target, Function:
to lateral rectus
(best abductor!)
• Idiopathic: improvement within 2 mo
• Elderly or diabetic pts: small vessel disease
• Compression in cavernous sinus: severe
headache & anesthesia in the area of n.V1
• Increased intracranial pressure:
shift in the brain stretch the 6th n.
• Trauma (basilar skull fracture)
• Infections & tumors affecting the meninges
• Aneurysm, MS
• Wernicke's encephalopathy
 Saccadic Eye Movements
Frontal eye Retina
field Optik nerve
(FEF & SEF)
Medial rectus
Corpus
Lat. rectus
geniculatum lat.
MLF
Mesensephalon Area 17. & 19.
VI ııı ıv
FEF
Nuc. Abducens
P Pons
P vı Mesencephalon
R VIIIN
F MLF MLF Pons (VI. contral.
III. & n. nuclei)
 Saccadic Eye Movements
Frontal eye field
(FEF & SEF)

Medial rektus
Lateral rektus

MLF Mesencephalon
ııı
VI ıv

Nuc.VI
P Pons
vı
P VIII
R MLF MLF
F
 Saccadic Eye Movements
Frontal eye field
(FEF & SEF)

Medial rektus
Lateral rektus

MLF Mesencephalon
ııı
VI ıv

Nuc. Abducens
Pons
vı
P
VIII
P MLF MLF
R
F
 Vertical Gaze Vestibulo-ocular Reflexe paths
Rapid turn of the head to the left
• Bilateral control
• Center: Dorsal rostral Ant. motion of the
mesencephalon fluid in the labyrinth
• 3 integral structures:
- riMLF
Cupula is stimulated
- Cajal’s interstitial nuc.
- Posterior commisure
• Inputs from PPRF & Ipsilat. IIIrd & contralat. VIth
vestibular nuclei nerves are stimulated
• Each riMLF projects
ipsilaterally to III & IV n.
nuclei Eyes turn right in order to
sustain forward gaze
Superior Orbital
Fissure Syndrome IV

VI

III

preganglionic parasympathetic
to: ciliary ganglion
(innervation of sphincter
pupillae and ciliary muscle)
 V – N. Trigeminus
• Trigeminal nerve – 3 branches
• 3 sensoric nuclei:
– nc. mesencephalicus
– nc. pontinus
– nc. spinalis (in medulla oblongata)
• 1 motor nucleus: nc. motorius
• Vegetative part joins along the course
• Emerging from the pons
• Sensoric : ganglion trigeminale (Gasseri)
• PS ganglions (ciliare, pterygopalatinum, oticum, submandibulare)
 Cranial Nerve V: Trigeminal
V1-Trigeminal ophthalmic
Major branches: Lacrimal, Frontal, Nasociliary

Foramen: superior
orbital fissure
Region Entered: orbit
Components: general
sensory
Target, Function:
general sensation
from skin and
mucosa in region
at & above orbit
 V1 – n. opthalmicus
• Sensoric nerve
• 3 main branches:
– n. frontalis
– n. lacrimalis (sensitive + PS)
– n. nasociliaris
• Connections with nerves for eye-movement
(sensitive fibres)
• Parasympatic fibres for n. lacrimalis from
connection from n. zygomaticus (V2)
V1 – n. opthalmicus
Cornea
Reflex

• Afferent:
N V1
• Efferent:
N VII
Ciliary
(blink) ganglion
 V2 – n. maxillaris
• Sensoric nerve
• Parasympathetic fibres for ggl. pterygopalatinum from n. facialis
• passes foramen rotundum, branches out in fossa pterygopalatina
– n. infraorbitalis
– n. zygomaticus
– nn. pterygopalatini
 V2-Trigeminal maxillary
Infraorbital, Zygomatic,Nasopalatine, Palatine

Foramen:rotundum
Region Entered:
pterygopalatine fossa
Components:
general sensory
Target, Function:
gen.sensation from
skin & mucosa
in region from
orbit to mouth
 V3 – n. mandibularis
– muscle branches (n. massetericus, nn. temporales profundi,
nn. pterygoidei)
– n. bucalis
– n. auriculotemporalis
– n. lingualis
– n. alveolaris inferior
 V3-Trigeminal mandibular
Buccal, Auriculotemporal, Lingual, Inf. alveolar & Meningeal

Foramen: ovale
with lesser petrosal
from CN9
Region Entered:
infratemporal fossa
Components:
brachiomotor
Target, Function:
muscles of masticat.
tensor tympani & veli
palatini, mylohyoid
ant. belly digastric
 Ganglia of trigeminus
ggl ciliare
• PS fibres for glands interconnects in the ganglias
• Sympatic fibres for smooth muscles pass through
• Sensitive fibres pass through

ggl pterygopalatinum

ggl submandibulare
ggl oticum
ggl. pterygopalatinum
• PS for lacrimal gland,
glands of nose, mouth
from n. petrosus major (n. VII)
 ggl. oticum

• PS from nucleus of CN. IX to

parotid gland
 Lesion of spinal tract V
IPSILATERAL deficits
in pain & temperature from the face etc.
(the pain information never gets to the
caudal spinal nucleus)
 Interruption of the trigeminothalamic tract
deficits in pain & temperature on the
contralateral side of the face
(comprised of axons that have crossed
the midline)
Sinus cavernosus
 Causes of Sensory Trigeminal Neuropathy
• Idiopathic • Trauma
• Systemic inflammatory disease • Aneurysm
• Sjögren's syndrome • Dural external carotid artery
• Progressive systemic sclerosis cavernous sinus fistula
(scleroderma) • Sickle ceil disease
• Mixed connective tissue • Diabetes mellitus
disease
• Syringobulbia
• Systemic lupus erythematosus
• Infections
• Dermatomyositis
• Sinusitis
• Rheumatoid arthritis
• Herpes simplex
• Sarcoidosis
• Herpes zoster
• Wegener's granulomatosis
• Hepatitis A infection
• Undifferentiated connective
tissue disease • Nonspecific viral infection
• Giant cell arteritis • Tuberculosis
• Idiopathic hypertrophic cranial • Whipple's disease
pachymeningitis • Leprosy
• Multiple sclerosis • Arachnoiditis
• Tumor • Tricloroethylene
– Intracranial or extracranial • Hydroxystilbamidine
– Metastatic • Amyloidosis
– Primary: Meningioma, • Spinal epidural anesthesia
Schwannoma, Epidermoid,
Chordoma
 VII- Facial Nerve

Anatomy:

• Mainly motor (some sensory fibres from

fibres controlling salivation and taste fibres
from the anterior tongue).

• Fibres loop around the VI nucleus

before leaving the pons medial to VIII

• passing through the internal acoustic meatus.

 Facial Nerve • Brachiomotor: m. of facial expr.:
Temporal, Zygomatic, Buccal, stapedius,stylohyoid, mylohyoid,
Mandibular, Cervical&Post. Auricular
post.belly digastric
• facial canal middle ear
chorda tympani
internal acoustic petrotympanic fissure
meatus  facial • Special sensory: taste, ant. 2/3
canal  tongue: facial canal middle
stylomastoid ear chorda tympani
foramen petrotympanic fissure
• Visceromotor: preganglionic
parasympathetic to submand.
ganglia (innervates submand.
&sublingual glands)
greater superficial petrosal 
pterygoid canal
pterygopalatine ganglia to
lacrimal, nasal & palatine gl.
• It emerges from the brainstem
between the pons and the medulla

• controls the muscles of facial

expression

• taste to the anterior two-thirds of the

tongue.

• supplies preganglionic parasympatic

fibers to several head and neck
ganglia.
• It passes through the petrous temporal in the
facial canal,

• widens to form the geniculate ganglion

(taste and salivation)on the medial side of the
middle ear

• turns sharply (and the chorda tympani

leaves)

• to emerge through the stylomastoid foramen

• to supply the muscles of facial expression.

http://images.google.com/imgres?imgurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_
graphics/fig7_2.gif&imgrefurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_2.html&h=308&w
=535&sz=109&hl=en&start=2&tbnid=eXdDZb5ejq4J4M:&tbnh=76&tbnw=132&prev=/
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http://icarus.med.utoronto.ca/carr/manual/afnp2.html
Facial nerve nucleus
• in the pons
the sensory part of the facial nerve
arises from the nervus intermedius
• The motor part of the facial nerve
enters the petrous temporal bone into
internal auditory meatus
intimately close to the inner ear (including
two tight turns) through the facial
canal then runs a tortuous course
emerges from the stylomastoid foramen
and
• passes through the parotid gland,
• divides into five major branches.
http://images.google.com/imgres?imgurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_
graphics/fig7_2.gif&imgrefurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_2.html&h=308&w
=535&sz=109&hl=en&start=2&tbnid=eXdDZb5ejq4J4M:&tbnh=76&tbnw=132&prev=/
images%3Fq%3Dfacial%2Bnerve%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG
Incomplete sensory regeneration

• Dysgeusia (impairment of taste)

• Ageusia (loss of taste)

• Dysesthesia (impairment of
sensation

• disagreeable sensation to normal

stimuli) may result.
• Though it passes through the parotid gland,
it does not innervate the gland.

• This action (parotis innervation)

is the responsibility of cranial nerve IX, the
glossopharyngeal nerve.

• Inside one of the tight turns in the facial

canal, the facial nerve forms the geniculate
ganglion.

• No other nerve in the body travels such a

long distance through a bony canal.
• Inside the facial canal Greater petrosal nerve
provides parasympathetic innervation to
lacrimal gland, as well as special taste
sensoryfibers to the palate via the nerve of
pterygoid canal.

• Nerve to stapedius – a provides motor

innervation for stapedius muscle in middle
ear

• Chorda tympani provides parasympathetic

innervation to submandibular and sublingual
glands and special sensory taste fibers for
he anterior 2/3 of the tongue
Outside skull (distal to stylomastoid
foramen)
• Posterior auricular nerve controls
movements of some of the scalp muscles
around the ear

Five major facial branches (in parotid

gland)

• Temporal branch of the facial nerve

• Zygomatic branch of the facial nerve
• Buccal branch of the facial nerve
• Cervical branch of the facial nerve
• Marginal mandibular branch of the facial
http://images.google.com/imgres?imgurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_
graphics/fig7_2.gif&imgrefurl=http://www.med.yale.edu/caim/cnerves/cn7/cn7_2.html&h=308&w
=535&sz=109&hl=en&start=2&tbnid=eXdDZb5ejq4J4M:&tbnh=76&tbnw=132&prev=/
images%3Fq%3Dfacial%2Bnerve%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG
 Facial weaknes.

LMN lesion
• the forehead is paralysed the final common
pathway
UMN lesion
• the upper facial muscles are partially spared
because of alternative pathways in the
brainstem.
• There appear to be different pathways
for voluntary and emotional movement.

CVD usually
• weaken voluntary movement often sparing
involuntary movements
Causes of a single VII lesion:
LMN:
• Bell's palsy, polio, otitis media, skull
fracture,
• cerebello-pontine angle tumours,
• parotid tumours, Herpes zoster
• (Ramsay-Hunt syndrome), lyme disease

UMN:
• spares the forehead bilateral innervation
Stroke, tumour.
Bell´s palsy

weakness on one side of their face.

Postauricular pains:
Almost 50% of patients experience pain
in the mastoid region.
The pain frequently occurs simultaneously
with the paresis,
25% of patients.
Tear flow:
Fewer tears arrive at the lacrimal sac and
verflow occurs.
The production of tears is not accelerated.
http://www.emedicine.com/emerg/topic56.htm
Altered taste:
• complain about taste disorders,
• a reduced sense of taste.
• only half the tongue being involved.

Dry eyes

Hyperacusis

• Impaired tolerance to typical levels of

noise
• due to an increased irritability to the
sensory
• neural mechanism.
Function:

Efferent
Its main function is
motor control of most of the
muscles of facial expression.

It also innervates
the posterior belly of the digastric muscle,
the stylohyoid muscle, and
the stapedius muscle of the middle ear.
All of these muscles are striated muscles
of
branchiomeric origin developing from the
2nd
pharyngeal arch.
The facial nerve
• supplies parasympathetic fibers
submansdibular gland and
sublingual glands via chorda tympani and
the submandibular ganglion.

Parasympathetic innervation
• serves to increase the flow of saliva from these
glands.
supplies parasympathetic innervation to the
nasal mucosa and the lacrimal gland via the
pterygopalatine ganglion.
Bell's palsy is one type of

• idiopathic acute facial nerve paralysis

which is more accurately described
as a multiple cranial nerve ganglionitis
that involves the facial nerve

• most likely results from viral infection

• also sometimes as a result of Lyme

disease.
Testing the facial nerve

Voluntary facial movements

• wrinkling
• closing the eyes tightly
(lagophthalmos the brow,
• pursing the lips and,
• showing teeth
• frowning
• puffing out the cheeks, all test the
• facial nerve.

There should be
no noticeable asymmetry.
Upper motor neuron lesion,
• only the lower part of the face
• on the opposite side will be affected,
• due to the bilateral control
• to the upper facial muscles.

Lower motor neuron lesions

• both upper and lower facial weakness
on the same side of the lesion

• Taste can be tested on the anterior of the

tongue, this can be tested with a swab
dipped in a flavoured solution, or with
• electronic stimulatio
(similar to putting your tongue on a battery).
Aberrant reinnervation of the facial nerve

• After the impaired neural conductionof the

facial nerve begins
• the regeneration and repair process, some
fibers take an unusual course and connect to
neighboring fibers.

This aberrant reconnection produces

unusual neurologic pathways.

• they are accompanied by involuntary

movement
(eg, the movement of a closed eye following
that of the uncovered one).
these involuntary movements
accompanying voluntary movement
termed synkinesis.
DALIL UMN / UPPER MOTOR
NEURON
BIASANYA SEMUA UMN :
SPASTIS
REFLEX MENINGGI
REFLEX PATHOLOGIS POSITIVE
TIDAK ADA ATROFI

NAMUN

ADA DALIL UMN:

SETINGGI LESI LMN

DIBAWAH LESI UMN
N FACIALIS

UPPER MOTOR NEURON / CENTRAL

PARESE N VII sentral contralateral
HEMIPARESE contralateral
CABANG MULUT N VII PARESE

NUCLEAR / SETINGGI NUCLEUS

PARESE N VII UMN namun seperti LMN
CABANG MATA
CABANG MULUT TERKENA
namun HEMIPARESE ALTERNANS

LOWER MOTOR NEURON / PERIFER

CABANG MATA (lagopthtalmus)
CABANG MULUT TERKENA
 Hemifacial spasm

http://www.botulinumtoxin-ambulanz.de/hemispasmus.htm
Hemifacial spasm

First described by Gowers in 1884,

hemifacial spasm (HFS) represents
a segmental myoclonus of muscles
innervated by the facial nerve.

The disorder presents

in the fifth or sixth decade of life,
almost always unilaterally,
although bilateral involvement may occur
rarely in severe cases.

HFS generally begins with

brief clonic movements of the orbicularis oculi and
spreads over years to other facial muscles
(corrugator, frontalis, orbicularis oris, platysma,
zygomaticus).

http://emedicine.com/NEURO/topic154.htm
Hemispasmus facialis
• Kontraksi spt mioklonus dari otot2 yg
dipersarafi N.VII satu sisi muka
• Jarang sekali pada kedua sisi
• kontraksi tsb hanya bertahan dlm waktu yg
pendek

Tic Fasialis

• kontraksi yg bertahan lebih lama dan lebih

mirip suatu distonia

http://www.botulinumtoxin-ambulanz.de/hemispasmus.htm
Facial myokymia
appears as

• vermicular twitching under the skin,

often with a wavelike spread.
• may occur with any brainstem process.
• Severe cases may benefit from BTX.
• Most cases are idiopathic andresolve
without treatment over several weeks.
http://images.google.com/imgres?imgurl=http://www.neuro.wustl.edu/neuromuscular/pics/
diagrams/facialnsm2.jpg&imgrefurl=http://www.neuro.wustl.edu/neuromuscular/pathol/diagrams/
viianat.htm&h=389&w=392&sz=38&hl=en&start=14&tbnid=zCc9cGNo1qVHmM:&tbnh=
122&tbnw=123&prev=/images%3Fq%3Dfacial%2Bnerve%26gbv%3D2%26svnum%3D10%26hl%
3Den%26sa%3DG
 Lesion at A: Ipsilateral
C  paralysis of all facial
movements
 corneal reflex is lost
 sensory area to ear is
lost
Lesion at B:
B A(+) impaired
 sublingual, submandi-
bular glands’
secretions&
 taste over ant. 2/3 of
the tongue
 hyperacusis
Lesion at C: A&B(+) im-
A paired ipsilat.lacrimation
 Causes of Peripheral Facial Nerve Palsy
• Idiopathic (Bell's palsy)
• Infectious: • Neoplastic
– Herpes simplex – Schwannoma
– Herpes zoster – Neurofibroma
– Otitis media – Meningioma
– Borrelia burgdorferi – Cholesteatoma
– Human immunodeficiency virus – Parotid gland tumor
– Syphilis – Metastasis
– Infectious mononucleosis – Carcinomatous meningitis
– Mastoiditis – Leukemia
– Poliomyelitis • Metabolic
– Meningitis – Diabetes mellitus
– Malaria – Hypothyroidism
– Leprosy – Uremia
– Rubella – Porphyria
– Mumps • Trauma: Surgical trauma to nerve
– Osteomyelitis
– Cat scratch disease
• Congenital, Familial
• Inflammatory • Miscellaneous
– Pregnancy
– Guillain-Barré syndrome
– Paget's disease
– Sarcoidosis
– Osteopetrosis
– Multiple sclerosis
– Arteritis – Hypertension
– Diphtheria-pertussis-tetanus
– Melkersson-Rosenthal syndrome vaccination
– Behçet syndrome – Pontine infarction
– Wegener's granulomatosis – Myasthenia gravis
– Lymphomatoid granulomatosis – Traumatic external carotid artery
– Kawasaki disease aneurysm
– Angioedema – Lumbar extradural blood patch
– Pseudotumor (Tolosa-Hunt syndrome) – Vascular malformation
– Amyloidosis – Pseudotumor cerebri
– Idiopathic hypertrophic cranial – Ethylene glycol poisoning
pachymeningitis
 VIII - N. Vestibulocochlearis
Ganglion Vestibulare (SSA) - Meatus internus acusticus - Nuclei Vestibulares

Ganglion Cochlearе (SSA) - Canalis spiralis - Nuclei Cochleares

Cranial Nerve VIII:
Vestibulocochlear
1st neurone: bipolar cells of the
gang. cochleare 2nd neurone:
multipolar neurones of nuclei
cochleares
Auditory path. 2nd neurones  corpus
trapezoideum  opposite
side  form lemniscus
lat. colliculus inferior
 3rd or 4th neurone
colliculus superior
cerebellum & corpus
geniculatum mediale

4th or 5th neurone:

Heschl's transverse gyrus &
Wernicke's centre of the
 Vestibular path
1st neurone: bipolar
cells of the ganglion
vestibulare form the
N. vestibularis on
FLM the floor of the
internal acoustic
meatus

2nd & following neurones: from

nuc. ruber nuc.vestibularis lat. (Deiter's) to:
nuc. vestibularis - formatio reticularis - motor nuclei
sup. (Bechterew's) of nerves III, IV & VI - nuc. ruber & as
supplies some the tr. vestibulosp. into the ant.
fibres to column of the sp. cord
Cranial Nerve VIII: Vestibulocochlear
Disease affecting hearing
Acoustic neuroma (8th n)
Presbyacusis (cochlea)
Trauma “
Wax (ext.&middle ear)
Otitis media “
Otosclerosis “
Disease affecting balance
Vascular diseases(b.stem)
Demyelination “
Drugs (DPH, streptomycin)
Viral, benign conditions
Disease affecting hearing &
balance (cochlea&labyrinth)
Meniere

internal auditory
Cochleo-vestibular Disease
Main Symptoms Main Signs

• Deafness • Deafness
• Tinnitus • Nystagmus
• Vertigo
• Ataxia
• Loss of
balance • Positional

nystagmus
 IX - N.Glossopharyngeus
Components
• SVM: from nucleus ambiguus to m. stylopharygeus
• GVM: preganglionic from nucleus salivatorius
inferior to ganglion oticum, postganglionic to
glandula parotidea
• SVS: from ganglion inferior, central processes to
nucleus tractus solitarii, peripheral processes to
posterior 1/3 of tongue
• GVS: from mucosa of posterior 1/3 of tongue,
pharynx, palatine tonsils, tuba auditiva & cavitas
tympanica, sinus & glomus caroticus, reach nucleus
tractus solitarii
 Cranial Nerve IX:
• Foramen: jugular
• Special visceromotor: Function: elevates pharynx
nucleus ambiguus  stylopharyngeus
• Gen. Sensory Components Function: general sensation of
external, middle ear & auditory tube
 geniculate ganglion spinal trigeminal nucleus
• Special Viscerosensory Component:
• Function: taste, posterior 1/3 tongue=>
inferior petrosal ganglion  rostral tractus solitarius
• Region Entered: infratemporal fossa
• Gen. Viscerosensory: Sensory receptors of ant. surface
epiglottis, root of tongue, border of soft palate, uvula, tonsil,
pharynx, eustachian tube, carotid sinus & body  caudal
tractus solitarius
• Gen.Visceromotor comp.: İnf.salivary nuc.tympani n.
lesser petrosal notic ganglionauriculotemporal n.
• Function: parotid gland secretion
Course: exit thru foramen jugularе
Branches
• Rami linguales: taste buds and mucosa of posterior 1/3 of tongue
• Rami pharyngei: plexus pharyngeus, sensory and parasympathetic fibers
• N. tympanicus: GVM thru n. tympanicus & n. petrosus minor reach
ganglion oticum, postganglionic thru n. auriculotemporais (Ⅴ3) for
glandula parotidea
• Ramus sinus caroticus: for sinus & glomus caroticus
• Rami tonsillares & ramus m. stylophayngei
Ganglion oticum : below foramen ovale
 X - N.Vagus
Components
• GVM: nucleus dorsalis n. vagi, interrupt in
parasympathetic ganglion, short postganglionic fibers
supply heart muscle, smooth muscles and glands
• SVM: nucleus ambiguus, for muscles of pharynx и
larynx
• GVS: from organs in neck, thorax, abdomen to nucleus
tractus solitarii
• GSS: auricle, meatus acousticus externus & dura
mater cerebri
Nervus Vagus Special Viscerosensory: taste in
epiglottisinf. Gang.rostral
tr. solitarius
Special visceromotor: (deglutition
phonation)
n. Ambiguuspalatal, pharynx
& larynx muscles
General viscerosensory:
post.epiglottis,larynx, trachea,
bronchi, esopagus, stomach, s
İntestine, colon inf.
ganglioncaudal tr. solitarius
General somatosensory: : auricle
ext. auditory meatussup.
ganglionspinal trigeminal nu
General Visceromotor: dorsal
motor nucleus preganglionic
parasympathetic to abdomen &
thorax cardiac depression, visc
mov., secretion
• Sensations from skin at back of ear,
external acoustic meatus, part of
tympanic membrane, larynx, trachea,
espophagus, thoracic and abdominal
viscera
• Sensations from bararoceptors and
chemoreceptors
• Special sensory – taste from epiglottis
and pharynx
• Somatic motor – Swallowing and voice
production via pharyngeal muscles
• Autonomic motor – smooth muscle of
abdominal viscera, visceral glands
secretions, relaxation of airways, and
normal or decreased heart rate.
• Damage causes hoarseness or loss of
voice, impaired swallowing, GI
dysfunction, blood pressure anomalies
(with CN IX), fatal if both are cut $
Course
• Exits thru foramen jugulare
• Descends in vagina carotica btw internal a. carotis
interna (communis) & v. jugularis interna
N. vagus dexter
• Enters thorax to the right of trachea
• Descends behind v. brachiocephalica dextra & v.
cava superior
• Passes behind the root of right lung
• Forms plexus esophageus posterior
• Forms truncus vagalis posterior in hiatus
esophageus, enters abdomen and gives off rami
gastrici posteriores celiaci
N. vagus sinister
• Enters thorax btw a. carotis communis & a.
subclavia sinistra, behind v.
brachiocephalicа sinistra
• Passes anterior to arch of aorta, giving off
n. laryngeus recurrens
• Passes behind the root og lefht lung
• Forms plexus esophageus anterior
• Forms truncus vagalis anterior inв hiatus
esophageus, enters abdomen, gives off rr.
gastrici anteriores & rr. hepatici
Branches in neck
• N. laryngeus superior: descens along pharynx
and gives off
– Ramus internus, pierces membrana thyrohyoidea
and supplies mucosa of larynx to rima glottis
– Ramus externus, supplies m. cricothyroideus
• Rami cardiaci cervicales superiores: descend
to plexus cardiacus
• Ramus meningeus, ramus auricularis, rami
pharyngei (plexus pharyngeus)
Thoracic branches
• N. laryngeus recurrens
– Right around а. subclavia sin., left around arcus
aortae
– Ascend in tracheo-esophageal sulcus
– Enter larynx behind art. cricothyroidea, and
turn into n. laryngeus inferior
– Supply: laryngeal mucosa below rima glottis,
laryngeal muscles except m. cricothyroideus
• Rami cardiaci inferiores
• Rami tracheales
• Rami esophagei
• Rami bronchiales
 N. laryngeus superior

Ramus internus

Ramus externus
Primary afferents in the IX and X
cranial nerves project to the NTS
vagal afferents
Right & Left
recurrent
laryngeal
nerves
Selected Causes of Vagus Nerve Dysfunction
• Lateral medullary syndrome
• Hyperextension
• injury of upper cervical spine
• Chronic lead poisoning
• Radiation therapy to head and neck
• Glomus vagale tumor
• Neuroma
• Schwannoma presenting as cerebellopontine angle
mass
• Nasopharyngeal diphtheria
• Viral or postviral mononeuritis
• Herpes simplex
• Cytomegalovirus
• Herpes zoster
• Multiple system atrophy
• Superior laryngeal neuralgia
 XI - N. Accessorius
N. accessorius

Nucleus
Nucl. ambiguus - caudal (SVM)
Nucl. spinalis n. accessorii (GSM)
Appearance
Sulcus retroolivaris – radix cranialis
Btw radices ventralis & dorsalis – radix spinalis
Course
Radix spinalis enters skull thru for. magnum,
joins radix cranialis
Exit
For. Jugulare
- pars cranialis – r. externus in n. vagus
- pars spinalis – r. externus
Supply
M. trapezius, m. sternocleidomastoideus
Cranial Nerve XI: Accessory
• Brachiomotor Comp:
Foramen:  exits by
jugular;  enters by
foramen magnum ant.
horn cells C1-C5
Target: trapezius,
sternokleidomastoid
Function: head & shoulde
movement
• Spc.Visceromotor Comp.:
Caudal nuc. ambiguus
vagus muscles of
larynx Function:
phonation
Symptoms of
the 11th n.
involvement
Torticollis
(dystonia)
Asymmetric
shoulders
Impaired arm
elevation
Cranial Nerve XII: Hypoglossal
• Foramen: hypoglossal
canal
• Region Entered: neck
• Components:
somatomotor
• Target, Function: all
tongue muscles, except
palatoglossus
 XII - N. Hypoglossus
• motor nerve of the tongue.
fibers arise from the cells of the hypoglossal
nucleus which is an upward prolongation of
the base of the anterior column of gray
substance of the medulla spinalis.

• This nucleus is about 2 cm. in length, and its

upper part corresponds with the trigonum
hypoglossi, or lower portion of
the medial eminence of the rhomboid fossa
http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
1. Colliculus superior
2. Colliculus inferior
3. Frenulum veli medullaris superioris
4. Velum medullare superius
5. Sulcus medianus
6. Fovea Superior
7. Colliculus facialis
8. Trigonum n. hypoglossi
9. Trigonum n. vagi
10. Tuberculum gracile
11. Sulcus medianus posterior
12. Sulcus intermedius posterior
13. Sulcus posterolateralis
14. Tuberculum trigeminale
15. Sulcus retroolivaris
16. Oliva
17. Sulcus lateralis cruris cerebri
18. Brachium colliculi inferioris
19. Crus cerebri
20. Corpus geniculatum laterale
21. Corpus geniculatum mediale
22. Brachium colliculi superioris
23. Thalamus -Pulvinar
The lower part of the nucleus

extends downward
into the closed part of the
medullaoblongata, and there lies in
relation to the ventro-lateral aspect of the
central canal.

The fibers run forward

through the medulla oblongata, and

emerge in the antero-lateral sulcus
between the pyramid and the olive.
this nerve are collected two bundles
• perforate the dura mater separately,
• opposite the hypoglossal canal in the
occipital bone
• and unite together after their passage
through it

in some cases the canal is divided into two

by a small bony spicule.
The nerve descends almost vertically to a
point corresponding with the angle of the
mandible.
It is at first deeply seated
beneath the internal carotid artery and
internal jugular vein, and
intimately connected with the vagus
nerve
http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
it then passes forward
between the vein and artery,
and lower down in the neck
becomes superficial below the Digastricus.

The nerve then loops around the occipital artery, and

crosses the external carotid and
lingual arteries
below the tendon of Digastricus.

It passes beneath the tendon of the Digastricus,

the Stylohyoideus, and
the Mylohyoideus,
lying between the last-named muscle and
the Hyoglossus, and
communicates at the anterior border of the
Hyoglossus with the lingual nerve;
it is then
continued forward
in the fibers of the Genioglossus
as far as the tip of the tongue,
distributing branches
to its muscular substance.
Branches of Communication.—
Its branches of communication
are, with the

1. N Vagus.
2. Sympathetic.
3. First and second cervical
nerves
4. Lingual.
 1. The communications with the vagus
take place
close to the skull,
numerous filaments
passing between the hypoglossal
and the ganglion nodosum of the vagus
through the mass of connective tissue which unites the
two nerves.
As the nerve winds around the occipital artery
it gives off a filament to the pharyngeal plexus.

2. The communication with the sympathetic

takes place opposite the atlas by branches
derived from the superior cervical ganglion,
and in the same situation the nerve is joined
by a filament derived from the loop
3. connecting the first and second cervical nerves.
http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
The branches of distribution
Meningeal. Thyrohyoid.
Descending. Muscular.

the meningeal descending thyrohyoid,

and the muscular twig to the Geniohyoideus,
are probably derived
mainly from the branch
which passes from the loop
between the first and second cervical
to join the hypoglossal
1. MeningealBranches

(dural branches)
As the hypoglossal
nerve passes through
the hypoglossal canal
it gives off, according
to Luschka, several
filaments to
the dura mater
in the posterior fossa
of the skull.
2. The Descending Ramus
(ramus descendens; descendens hypoglossi),
long and slender, quits the hypoglossal
where it turns around the occipital artery and
descends in front of or
in the sheath of the carotid vessels;
it gives a branch to
the superior belly of the Omohyoideus, and then
joins the communicantes cervicales
from the second and third cervical nerves;
just below the middle of the neck,
to form a loop, the ansa hypoglossi.
From the convexity of this loop
branches pass to supply
the Sternohyoideus,
the Sternothyreoideus, and
the inferior belly of the Omohyoideus.
http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
According to Arnold

another filament descends

in front of the vessels into the thorax, and
joins the cardiac and phrenic nerves.

3. The Thyrohyoid Branch

(ramus thyreohyoideus)
arises from the hypoglossal
near the posterior border of the hyoglossus;
it runs obliquely
across the greater cornu of the hyoid bone,
and supplies the Thyreohyoideus muscle.
http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
4. The Muscular Branches
distributed
to the Styloglossus
Hyoglossus
Geniohyoideus
Genioglossus.

At the under surface of the tongue numerous

slender branches pass upward into the
substance of the organ to supply its intrinsic
muscles.

http://www.theodora.com/anatomy/the_hypoglossal_nerve.html
http://images.google.com/imgres?imgurl=http://www.tu-dresden.de/mednch/nhome/
spezial/peripher/images/Figure10klein.jpg&imgrefurl=http://www.tu-dresden.de/mednch/
nhome/spezial/peripher/gesichtsnerv.htm&h=388&w=400&sz=35&hl=en&start=2&tbnid=
cilDwoKm5TZVeM:&tbnh=120&tbnw=124&prev=/images%3Fq%3Dhypoglossus%
2Bparese%2B%26gbv%3D2%26svnum%3D10%26hl%3Den%26sa%3DG
Infranuclear
paralysis of the
right trigeminal,
facial, and
hypoglossal
nerves, showing
deviation of the
mandible and
tongue to the
right
12th n. palsy:
Asymmetry
Deviation
Atrophy
Fasciculations
 Common Condition Affecting
9th, 10th & 12th Nerve Function

 Motor neuron disease Bulbar palsy

 Cerebrovascular disease •Dysartria
 Syringobulbia
 Erosive tm of the skull base
•Dysphagia
 Guillain-Barré syndrome •Dysphonia
 Recurrent laryngeal nerve palsy
•Aspiration
 Myastenia gravis
Brain Stem
 Morphological Subdivisions of the Brain

1. The Cerebrum: formed of right and left cerebral

hemisphere.

2. The Cerebellum: below the posterior part of the

cerebrum.

3. The Brain Stem.

 The Brain Stem

 The brain stem occupies the posterior cranial fossa.

 The brain stem lying infront of the cerebellum and
fourth ventricle.
 The brain stem formed of the following parts (from
downward):
1. Medulla oblongata.
2. Pons.
3. Midbrain.
 The Medulla Oblongata

The medulla oblongata is the lower part of the brain

stem (3 cm).

Extent:

Above: it is continuous with pons.

Below: it is continuous with the spinal cord at the

foramen magnum.
 Parts of the Medulla Oblongata

1. Closed Medulla: it is the lower half of the medulla, as

it encloses a central canal continuous with that of

spinal cord.

2. Open Medulla: it is the upper half of the medulla, as it

opens into the fourth ventricle.

 External Features of the Medulla Oblongata

A. Anterolateral Surface:
1. The anterior median fissure.
2. The pyramid: formed by the pyramidal (corticospinal)
tract.
3. Pyramidal decussation.
4. The olive: formed by the inferior olivary nucleus.
5. The anterolateral sulci: gives exit to the hypoglossal
nerves.
6. The posterolateral sulci: gives exit to the
glossopharyngeal, vagus and cranial accessory nerves.
7. The inferior cerebellar peduncle.
B. The posterior surface of the medulla oblongata:
1. The posterior surface of the upper half (open medulla):
from medial to lateral:
a. Posterior median fissure.
b. Inferior fovea.
c. Hypoglossal trigone (triangle).
d. Vagal trigone.
e. Vestibular trigone.
2. The posterior surface of the lower half (closed medulla):
from medial to lateral:
a. Posterior median fissure.
b. Gracile tract.
c. Cuneate tract.
Internal Structures of the Medulla Oblongata

The main nuclei of the medulla oblongata:

1. Gracile nucleus: proprioceptive and fine touch
from the lower 1/2 of the body.
2. Cuneate nucleus: proprioceptive and fine
touch from the upper 1/2 of the body.
3. Inferior olivary nucleus: extrapyramidal
function.
4. Inferior salivary nucleus: parasympathetic
function via the glossopharyngeal nerve.
5. Spinal descending nucleus of trigeminal nerve: pain
and temperature sensations from the face and scalp
via the trigeminal nerve.
6. Solitary nucleus: taste sensations via the facial,
glossopharyngeal and vagus nerves.
7. Nucleus ambiguous: motor function of the
glossopharyngeal, vagus and cranial accessory nerves.
8. Dorsal nucleus of vagus nerve: parasympathetic
via the vagus nerve.
9. Hypoglossal nucleus: motor function of the tongue via
the hypoglossal nerve.
 The Pons

Extent: it extends from the medulla oblongata below

to midbrain above and lies infront of the cerebellum

and fourth ventricle.

 External Features of the Pons

A. The anterior surface of the pons: presents the following

features:
1. The basilar groove: for basilar artery.
3. The middle cerebellar peduncle.
4. The trigeminal nerve.
5. The abducent nerve.
6. The facial nerve.
7. The vestibule-cochlear nerve.
B. The posterior surface of the pons: presents the
following features:
1. The median longitudinal sulcus: the middle line.
2. The medial eminence: for facial nucleus.
3. The facial colliculus: it produced by the facial nucleus.
4. The medullary stria: transverse nerve fibers
which separate the posterior surface of pons from
that of medulla oblongata.
5. Superior fovea.
6. Vestibular trigon.
 Internal structures of the pons
1. Pontine nuclei: they form part of the cortico-ponto-
cerebellar pathway.
2. Transverse fibers: pontocerebellar fibers.
3. Longitudinal fibers: which include pyramidal and
cortico-pontine fibers.
4. Nuclei of the trigeminal nerve:
a. Motor nucleus.
b. Sensory nuclei.
5. Nucleus of the abducent nerve.
6. Nuclei of the facial nerve:
a. Motor nucleus.
b. Superior salivary nucleus: parasympathetic
function.
7. Nuclei of the vestibulocochlear nerve.
8. Lateral lemniscus: for auditory sensation.
9. Spinal lemniscus: it is a band of ascending fibers
carrying pain, temperature and crude touch from the
opposite side of the body below the head.
10. Trigeminal lemniscus: it is a band of ascending
fibers carrying pain, temperature and touch and
proprioception from the opposite side of the face and scalp.
11. Medial lemniscus: for deep sensation and fine touch from
the opposite side of the body below the head.
 The Midbrain

Extent:
It extends between the pons below and the diencephalon
above.
Connection:
It connects pons and cerebellum to the subthalamic
region of the diencephalon.
 External features of the midbrain

A. The anterior surface of the midbrain: presents the

following features:

1. Two cerebral peduncles.

2. Oculomotor nerve: emerging from the medial

side of the cerebral peduncle.

B. The posterior surface of the midbrain: presents the following
features:
1. Four colliculi which include:
a. Two superior colliculi (Visual function).
b. Two inferior colliculi (Auditory function).
2. Two superior cerebellar peduncles.
3. Superior medullary velum (membrane): lies
between the two superior cerebellar peduncles.
4. The trochlear nerve.
C. The lateral surface of the midbrain: presents the following
features:
1. Brachium of superior colliculus.
2. Brachium of inferior colliculus.
 Internal Structures of the Midbrain

In transverse section of the midbrain, the Sylvius aqueduct

divides it into two main parts:
1. Tectum: the smaller dorsal part behind the Sylvius
aqueduct, and consists of:
a. Two Superior Colliculi: reflex centers of vision.
b. Two Inferior Colliculi: reflex centers of hearing.
2. Two cerebral peduncles: the larger ventral part
infront of aqueduct, it consists of three parts:
a. Crus cerebri: the most anterior part which consists
of pyramidal and corticonuclear fibers.
b. Substantia Nigra: a thick lamina of gray mater. It
is an extrapyramidal center.
c. Tegmentum: the posterior part of the cerebral
peduncle. It contains ascending tracts,
nuclei of III & IV cranial nerves, reticular
formation of the midbrain.
 Internal Structures of the Midbrain

The main nuclei of the midbrain:

1. Nucleus of oculomotor nerve.
2. Nucleus of the trochlear nerve.
3. Red nucleus: it is an important extrapyramidal centre.
4. Mesencephalon nucleus of the trigeminal nerve: for deep
sensation.
5. Inferior colliculus: it is a centre for auditory reflexes.
6. Superior colliculus: it is a centre for visual reflexes.
7. Substantia nigra: it is an extrapyramidal centre.
8. Reticular formation.
 Function of the Brain Stem
• Cardiovascular center.
• Respiratory and cough center.
• Swallowing and vomiting center.
• Sleep center.
• Center for eye movement.
• Reticular nuclei.
• Alertness and consciousness
• Vestibular nuclei.
• Conduction function.
• It contains the important nuclei of cranial nerves III
through XII.
• Important as extrapyramidal function (substantia
 Reticular Formation of the Brain Stem

Location: in the brain stem mainly in the midbrain.

Connections: the reticular formation is connected to:
1. Cerebral cortex.
2. Basal ganglia.
3. Cerebellum.
4. Spinal cord.
5. Thalamus, hypothalamus, and limbic system.
6. Nuclei of the cranial nerves.
 Functions of the Reticular Formation

1. Control the level of consciousness (wakefulness)

trough the ARAS.
2. Regulation of the stretch reflexes and muscle tone.
3. Pain inhibition.
4. Control of sleep.
5. Control visceral functions (e.g. heart rate, BP,
respiration, salivation, swallowing and vomiting).
6. Serotonin production.
 Conduction Function

The brain stem plays important role for conduction

(afferent and efferent pathway).
The Four Lemnisci:
1. Medial Lemniscus: for deep sensation and fine
touch below the head. Started from Gracile and
Cuneate nuclei and ends in the thalamus
2. Lateral Lemniscus: for auditory sensation.
3. Trigeminal Lemniscus: started from trigeminal
nuclei “after decussation” and ends in the
thalamus.
4. Spinal Lemniscus: ventral and lateral spinothalamic
 Medial Longitudinal Bundle

Origin: midbrain.
Function: rotational movement of the head and eyes:
• Coordinates movement of the medial and
lateral recti muscles of both eyes.
• Coordinates movements the head and eyes in
response to cochlear stimuli.
• Coordinates movement of the facial muscles
(lips), tongue, and soft palate.
 Breathing Center

The respiratory neurons are located bilaterally in the

medulla oblongata and divided into two group:
1. Posterior respiratory group: modulate respiratory
patterns.
2. Anterior respiratory group: coordinates the
innervation of both inspiratory and expiratory muscles.
 Postural Reflexes

• Posture is defined as the active muscular resistance to

displacement body by gravity.
There are two types of postural reflexes:
1. Static Reflexes: maintain the balance during rest.
2. Statokinetic Reflexes: maintain the balance during
movement.