Brainstem (1)

Overview & Medulla Oblangata

By: Ahmed A. E. Eljack
 Objectives
By the end of this session you should be able to:
● Describe the brainstem, its internal and
external parts, and its anatomical relations.
● List the major functions of the brainstem.
● Describe the development of the brainstem.

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 Objectives
● Mention the different components of cranial
nerves.
● Describe the location and external features of
the medulla oblangata.

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 Objectives
● Describe the internal structure of the medulla
oblangata at different levels of section
● Mention the important clinical syndromes
affecting the medulla oblongata and their
clinical features.

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General Information on the
Brainstem

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 Definition and Relations
● The brainstem is the part of the brain that lies
between the cerebrum and the spinal cord.
● It has the following important functions:
○ Regulatory functions (respiratory and
cardiovascular centers along with autonomic
functions)

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 Definition and Relations
○ Cranial nerves nuclei (from III to XII)
○ Regulation of the level of consciousness
○ Serves as a conduit for ascending and
descending tracts
● It lies in the posterior cranial fossa.

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 Definition and Relations
● It’s composed of three parts mainly:
○ Midbrain.
○ Pons.
○ Medulla oblongata.
● The cerebellum is considered a part of the
brainstem in some references.

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Eljack’s Lecture Notes in Neuroscience. Fig. 4-1
©2015 all rights reserved 9
Siegel, A, Sapru, H.N. Essential Neuroscience.
(3rd ed.). Philadelphia: Lippincott Williams &
Wilkins; 2015. Fig. 9-1 10
External Features of the Brainstem
● There are four hillocks in the posterior aspect
of the midbrain: two superior and two inferior
colliculi.
● Pons is the largest part of the brainstem and it
has parallel horizontal fibers.

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External Features of the Brainstem
● The superior, middle, and inferior cerebellar
peduncles connect the midbrain, pons, and
medulla with the cerebellum, respectively.
● It may be difficult to distinguish the lower part
of the medulla from the spinal cord.

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Eljack’s Lecture Notes in Neuroscience. Fig. 4-1
©2015 all rights reserved 13
Siegel, A, Sapru, H.N. Essential Neuroscience.
(3rd ed.). Philadelphia: Lippincott Williams &
Wilkins; 2015. Fig. 9-1 14
Internal Structures of the Brainstem
● The brainstem constitute a passage for all
tracts that originate from the brainstem or
terminate in the spinal cord.
● All ascending tracts that reach cerebral cortex
pass through the brainstem.

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 Internal Components of the
Internal Structures of the Brainstem
Brainstem
● All cranial nerves nuclei are located in the
brainstem except the olfactory and optic
nerves.
● The tectum constitute the roof of the midbrain.
● The tegmentum is a part of the brainstem
resembling the core of the midbrain and pons.
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 Internal Components of the
Internal Structures of the Brainstem
Brainstem
● The reticular formation lies in the tegmentum of
the brainstem.
● The basilar areas lie anterior to the tegmentum.

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Haines, Duane. Fundamental
Neuroscience For Basic And
Clinical Applications. 4th ed.
Philadelphia: Elsevier, 2013. Fig.
10-2
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Principles of Cranial Nerves Nuclei

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 Importance of This Section
● Understanding these principle enable the
student to understand the complexity of the
cranial nerves development, origin, structure,
and functions.
● This part is poorly understood by medical
students which results in difficulty in learning
about cranial nerves.
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Classification of Cranial Nerves Components

● There are some overlaps and exceptions!

● According to the direction of the component:
○ Afferent: means going from peripheral
tissues to the brain (inward signal).
○ Efferent: means going from the brain to
peripheral tissues (outward signal). [consider
Efferent=Exit to memorize].
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Classification of Cranial Nerves Components

● According to the innervated tissue:

○ Somatic: innervates primarily skeletal
muscles, joints, tendons, skin, and other
somatic parts.
○ Visceral: innervates primarily smooth
muscles, viscera, and glands.

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Classification of Cranial Nerves Components

● According to the receptors and muscle:

○ General: standard afferents and efferents
going to different body parts.
○ Special: to the muscle from mesenchyme of
the branchial arches (muscles of
mastication) and from highly specialized
receptors (e.g. chemoreceptors).
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Classification of Cranial Nerves Components
● Every component has one classification of the
each category.
● Examples of components:
○ General somatic efferent (GSE).
○ Special visceral efferents (SVE).
○ General visceral efferent (GVE).
○ General somatic afferent (GSA).
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Snell, R.S. Clinical Neuroanatomy. (7th ed.). Philadelphia: Lippincott Williams &
Wilkins; 2010. Table 11-1 25
Haines, Duane. Fundamental
Neuroscience For Basic And Clinical
Applications. 4th ed. Philadelphia: Elsevier,
2013. Fig. 10-7 26
Anatomy of the Medulla Oblongata

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 External Features
● It develops from the myelencephalon (lower
part of the hindbrain.
● Connected to the pons rostrally and to the
spinal cord caudally.
● It has a conical shape (broader superiorly).

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 External Features
● The junction between the spinal cord and the
medulla is at the origin of the first cervical
spinal nerve (level of foramen magnum).
● The central canal of the spinal cord continues
to the lower part of the medulla.

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 External Features
● The medulla is divided based on the presence
of the fourth ventricle into:
○ Caudal (closed) medulla
○ Rostral (open) medulla

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Waxman, S.G. Clinical Neuroanatomy. (27th ed.).:
McGraw-Hill; 2013. Fig. 7-7B

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Waxman, S.G. Clinical Neuroanatomy. (27th ed.).: 32
McGraw-Hill; 2013. Fig. 7-7C
 External Features
● There is the anterior median fissure in the
anterior surface of the medulla.
● Lateral to the anterior median fissure lie the
medullary pyramids (containing the
corticospinal and corticobulbar tracts).

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 External Features
● The medullary olives lie posterolaterally to the
pyramids. They are produced by the inferior
olivary nuclei.
● The inferior cerebellar peduncles lie posterior
to the olives.

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Snell, R.S. Clinical Neuroanatomy. (7th ed.). Philadelphia:
Lippincott Williams & Wilkins; 2010. Fig. 5-9A 35
 External Features
● The posterior median sulcus lies in the posterior
part of the caudal medulla.
● Lateral to the posterior median sulcus in the
caudal medulla there are the gracile and
cuneate tubercles produced by the gracile and
cuneate nuclei, respectively.

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Snell, R.S. Clinical Neuroanatomy. (7th ed.). Philadelphia: Lippincott
Williams & Wilkins; 2010. Fig. 5-9B 37
 Basics on the Internal Features
● Medulla oblongata contains grey and white
matter.
● Sulcus limitans is important to differentiate
between sensory and motor nuclei.

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 Basics on the Internal Features
● We divided the medulla anatomically into four
levels:
○ Level of pyramidal (motor) decussation
○ Level of lemniscus (sensory) decussation
○ Level of the olives (midmedullary level)
○ Level of pontomedullary junction

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 Level of Pyramidal Decussation
● Around 90% of corticospinal tracts fibers
decussate at this level.
● The cuneate and gracile nuclei (posterior
column nuclei) appear at this level to their
respective fasciculi.

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 Level of Pyramidal Decussation
● The substantia gelatinosa of the spinal cord
becomes continuous with the spinal nucleus of
the trigeminal nerve.
● Fibers of the anterolateral system and fibers of
the spinal trigeminal tract lie adjecent to each
other in the lateral medulla.

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Haines, Duane. Fundamental Neuroscience For Basic And Clinical
Applications. 4th ed. Philadelphia: Elsevier, 2013. Fig. 11-6

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 Level of Lemniscus Decussation
● The internal arcuate fibers (forming the medial
lemniscus) decussate at this level anterior to
central grey and posterior to the pyramids.
● The spinal nucleus of the trigeminal nerve lies
lateral to the internal arcuate fibers.

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 Level of Lemniscus Decussation
● The nucleus ambiguus lies medial to the spinal
trigeminal nucleus (SE components to the
glossopharyngeal and vagus nerves).
● The spinothalamic and spinotectal tracts lie
lateral to the lemniscus decussation.

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Haines, Duane. Fundamental Neuroscience For Basic And Clinical
45
Applications. 4th ed. Philadelphia: Elsevier, 2013. Fig. 11-8
 Level of the Olives
● Section at this level passes across the inferior
part of the fourth ventricle.
● Many cranial nerve nuclei appear at this level.
● The most prominent nuclei are the olivary
nuclear complex especially the inferior olivary
nucleus.
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 Level of the Olives
● The restiform body forms a prominent
elevation on the posterolateral aspect of the
medulla. It contains many cerebellar afferents.
● The spinal trigeminal tract and nucleus are
interior to the restiform body.

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Haines, Duane. Fundamental Neuroscience For Basic And Clinical
Applications. 4th ed. Philadelphia: Elsevier, 2013. Fig. 11-11 48
Lesions of the Medulla Oblongata

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 Arnold-Chiari Syndrome
● Congenital herniation of cerebellar tonsils and
medulla through the foramen magnum.
● Results in hydrocephalus and involvement of
the last four cranial nerves along with
cerebellar signs.

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 Lateral Medullary Syndrome
● Also known as “Wallenberg’s syndrome”.
● Results from a vascular lesion of the vertebral
and posterior inferior cerebellar arteries.
● Signs and symptoms include:
○ Loss of pain and temperature on the
opposite side of the body and the ipsilateral
face
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Lateral Medullary Syndrome
○ Loss of coordination
○ Vertigo
○ Loss of the gag reflex
○ Difficulty with speech and swallowing
○ Horner’s syndrome

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Snell, R.S. Clinical Neuroanatomy. (7th ed.). Philadelphia:
Lippincott Williams & Wilkins; 2010. Fig. 5-31 53
 Medial Medullary Syndrome
● Also known as the “Déjérine’s syndrome”.
● Results from damage to the medial branches of
the vertebral artery or the anterior spinal artery.
● Signs and symptoms include:
○ Contralateral hemiparesis.

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 Medial Medullary Syndrome
○ Contralateral impaired prorioception and
tactile sensations
○ Ipsilateral paralysis of the tongue muscles
● In case of anterior spinal artery oclusion, signs
and symptoms may be bilateral

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Snell, R.S. Clinical Neuroanatomy. (7th ed.). Philadelphia:
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Lippincott Williams & Wilkins; 2010. Fig. 5-32
 Further Readings
● Sinnatamby, C.S. Last's Anatomy Regional and
Applied. (12th ed.). : Churchill Livingstone; 2011.
● Snell, R.S. Clinical Neuroanatomy. (7th ed.).
Philadelphia: Lippincott Williams & Wilkins; 2010.

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 Further Readings
● Eljack, A. A. E. Eljack’s Lecture Notes in
Neuroscience. Khartoum; 2015.
● Siegel, A, Sapru, H.N. Essential Neuroscience.
(3rd ed.). Philadelphia: Lippincott Williams &
Wilkins; 2015.

58
 Further Readings
● Waxman, S.G. Clinical Neuroanatomy. (27th
ed.). : McGraw-Hill; 2013.
● Medical Neuroscience MOOC by Duke
University | Coursera.
● Haines, Duane. Fundamental Neuroscience For
Basic And Clinical Applications. 4th ed.
Philadelphia: Elsevier, 2013
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