43.1. The brainstem is located within the ___crania fossa. It is continuous with the superiorly, where the midbrain merges with the thalamus, and the —____ inferiorly, at the level of the caudal medulla, 43.2. The brainstem is continuous with the spinal cord at the ____of the ‘occipital bone, where the spinal cord enters the skull. The diencephalon is continuous with the brainstem at the a gap or deficiency in the falx cerebelli. ———— 43.3. The brainstem is divided into three parts or divisions, the: ____, __ and , from inferior to superior. Se EERIE Ee rT 43,4. The brainstem contains the nuclei associated with many of the cranial nerves. 43.5. The most _______ division of the brainstem, the _____, contains nucle! associated with cranial nerves Vill, IX, X, and XII, 43.6. The middle division of the brainstem, the \V.VI, and VIL , contains nuclei associated with cranial nerves —— 43.7. The most division of the brainstem, the , contains nuclei associated “ with cranial nerves Ill and IV. rer43 wm Surface of the Brainstem [EEE 43.8. Next to each cranial nerve, indicate the division of the brainstem it is most closely associated with: M1 oculomotor: WV trochlear: Vill vestibulocochlear: AX glossopharyngeal X vagus: ‘XA hypogloss Se UE I Rneneneememeeeeeeee 43.9. The term “pons” is Latin for bridge. The pons serves as the bridge connecting the tothe ___. The cerebellum is responsible for coordination of activity. nr rence oncntenne 43.10. The cerebellum covers the posterior aspect of the brainstem. The three large fiber bundles connecting the _______ to the _____are known as the cerebellar peduncles. 43.11. There are sets of peduncles: superior, middle, and inferior. Place an S, M, and I on the appropriate peduncle in the brainstem. 43.12. On the following diagram, label the thalamus, midbrain, pons, medulla, cerebelluin, and spinal cord. Indicate the level of the tentorial incisure and foramen magnum by drawing a line at the appropriate level and labeling them accordingly.43.13. Place an X on the part of the diagram that acts as a bridge between the forebrain and the cerebellum. Place a Y on the part of the diagram that contains ‘neurons associated with cranial nerve Ill. Place aZon the part of the diagram that is continuous with the spinal cord at the Cental canal 43.14. The of the spinal cord is indicated on the left image. ‘The lower portion of the contains a rostral prolongation of the central canal labeled on the second image. ‘The central canal expands to form the ventricle in the rostral 43.15. The rostral part of the medulla is known as the open part, as it opens to form the floor of the . The fourth ventricle contains and extends between the pons anteriorly and the posteriorly. 43.16. Label the cerebrospinal fluid-filled space in all three images with the correct name, and then label each of the images.Be svieechtwtanen EES 43.17. Moving ___ or superiorly, the fourth ventricle narrows to form the cerebral aqueduct as it passes through the 43.18. A line drawn through the _____filled cerebral aqueduct divides the midbrain into a more _______ roof (tectum) and a more anterior (cerebral peduncle). 43.19. The _____o roof of the midbrain bears four elevations (two pairs; a superior and inferior pair)—the corpora quadrigemina—formed by the —___ and ___collicul Fostral meduta 43.20. Continuity between the spinal cord and caudal does.not end with the presence of a CSFfilled —__ . In fact, many of the surface landmarks also remain, For example, the found as a deep groove along the anterior aspect of the spinal cord continues along the anterior aspect of the ____.. Label the groove on the diagram, 43.21. Draw an arrow to indicate the location of the anterior median fissure. The P on the right diagram indicates the location of the pyramids (descending tracts), and the O indicates the location of the olives (also part of the motor system). Cranial nerve and the emerges between the in the preolivary sulcus. LA spinal cord level Rostral medula,ee we OU FEN PEU PPP PPR PG FR PU PP PUPS FPR PPO PP Pe FPP PPA PPP | 43.22. The becomes very shallow over the pons and contains the artery. The artery takes its name as it Passes over the anterior-most portion of the pons, the basilar portion. The base of the pons is formed by transversally oriented fibers that form the cerebellar peduncles laterally, 43.23. More superiorly, the shallow basilar sulcus is. deepened over the anterior aspect of the to form the interpeduncular fossa; as the name indicates, this fossa separates the cerebral 43.24. On the appropriate diagram(s), label the central canal, 4th ventricle, cerebral aqueduct, basilar sulcus, cerebral peduncles, basilar pons, olive, pyramids, anterior ‘median fissure, and interpeduncular fossa,SPAUFPUFPAPOU RPL FPA PPDPPPPPPU PP FRFPPPPPPP TPP PU PPP PPP PP @w iuieacivemanen BEY 43.25. Match the structure on the left with the appropriate level/region on the right. Cerebral peduncle: —_____ midbrain Middle cerebellar peduncle: pons Ol medulla NxM: spinal cord Pyramid: Basilar artery: Anterior median fissut Fourth ventricle: Central canal: Interpeduncular fossa: 43.26. The posterior median sulcus of the spinal cord can also be seen associated with the _____ aspect of the brainstem. It appears on the floor of the ____ ventricle, dividing it into two halves. 43.27. During development, neural folds come together to form a C$Filled —_______.. The regions more posterior to the newly formed canal are __, while the areas are located anteriorly in the spinal cord. In the brainstem; this process is incomplete. The folds do not fuse to form a central canal; rather, they remain open and form the _____ ventricle on the aspect of the and 43.28. Asa result of the lack of movement of the sensory areas to a____ location as in the spinal cord, the sensory areas are located more _____ along the floor of the ___ venti areas remain more medially located on either side of the posterior _____sulcus. 43.29. Along the floor of the fourth ventricle, evidence of the line dividing the of small depressions called fovea. On the following diagram, place an Mon and _____ areas—the sulcus limitans—is seen in the form the motor areas and an $ on the sensory areas. Label the posterior median sulcus and the location of the sulcus limitans on the image. Posterior surface of tie bransiomPAYA Intrinsic Anatomy of the Brainstem 44,1. A.useful way to study the brainstem is via cross sections. You saw many cross sections of the brainstem in the preceding chapter. Each level of the brainstem, the medulla, pons, and midbrain, has ‘one or more “representative” cross sections. In each representative cross section, intrinsic structures can be identified. One representative cross section for each level appears below. Based on your knowl- edge of the external anatomy of the brainstem, label each of the three levels. 44.2, The medulla is often represented with several cross sections from top to bottom, a al ‘medulla section, a middle section, and a al section, Based on your understanding that the medulla has the most in common with the spinal cord and the rostral medulla has the east in common, label each of the three sections below. PUPP PPG PP PPR PE, UPL UPL PPG PPP PPP PP PP PP PPP PPP PPP PPP, PU PPP | —_—PA PFT PLP PPP PPP PPP FPP PPP PP PPP PHP PTR, OKA PMA, 44.3. Cross sections through the medulla are easy to identify, ‘The caudal medulla exhibits large pyramids (descending or bers) on its anterior aspect, while still possessing a CSF-filled canal, as seen in the spinal cord. Label these two structures on the diagram. ‘44,4. In the middle of the medulla, the central canal expands and moves ____ to form the 4th ventricle, and a large midline fiber bundle, the medial lemniscus, becomes evident. ‘The medial lemniscus is made of crossed secondary fibers carrying fine touch, conscious proprioception, and vibratory sense from the ____lateral side of the body. These modalities were carried in the _________ columns in the spinal cord. Label the 4th ventricle and medial lemnisci on the diagram. 44,5, The _____ medulla also exhibits the 4th ventricle and medial lemniscus; in addition, a prominent fiber bundle connecting it to the cerebellum appears on the lateral aspects— the inferior cerebellar peduncle. Label the 4th ventricle, medial lemniscus, and inferior cerebellar peduncle on the diagram, 44.6. The , the middle division of the brainstem, has a unique expansion of its tegmentum (anterior aspect)—the base. ‘The base of the pons is made primarily of many transversally oriented fibers. Label the base and tegmentum of the pons on the following diagram. 44.7. The most striking feature of the midbrain is the presence of two very large fiber masses on the which carry a host of ascending and descending fibers. The 4th Jor aspect—the peduncles, ventricle has shrunk in size to form a CSFilled tube, the cerebral aqueduct. Label the peduncles and the cerebral aqueduct on the diagram. |URSIN PA FFI FPNPPN PPFPPPUPPPPPPPPPPPTPR PP PP PPP PPP PP r iw nc aay aha Bn 44,8. Although not necessarily exclusive to a section, the relatively unique characteristics of each section make identification of regions of the brainstem simple; in other words, certain structures are ‘most prominent or first appear in a particular region and therefore serve as useful landmarks, For each structure listed below, identify whether it is a characteristic of the midbrain, pons, or medulla. Peduncles: ‘Medial longitudinal fasciculus: Inferior cerebellar peduncles: Base: Pyramids: Cerebral aqueduct: 44,9. Extending the length of the brainstem, which includes the ___, _ and from superior to inferior, is the reticular formation. The —______ may be conceptualized as the longitudinal core of the brainstem surrounded by tracts and nuclei in much the same way that a hot dog is surrounded by a bun, SS 44.10, The ___ ______ is composed of an extensive and poorly organized network of cells and fibers, which given its position in the center of the stem, makes it able to recelve and project to a huge number of ascending (___) and descending (. ‘nuclei, Its position allows it to influence such things as consciousness, sleep, musculoskeletal reflexes, ) tracts and nearby and the endocrine and the autonomic nervous systems. 44.11. Surrounding the reticular formation are the __ nerve nuclei and the central pathways of their fibers as well as an extensive network of fibers “passing through” the brainstem towards more superior and inferior targets. Encircle the location of the reticular formation on the following diagrams.44 w Intrinsic Anatomy of the Brainstem EM 44.12. Within the _____, the caudal-most part of the brainstem, many characteristics of the _____ cord are still evident. Most of the _______ horns of the spinal cord (the motor aspect) move posteriorly towards the central portion of the medulla, while the _____ horns (sensation for the body) move laterally to become associated with the trigeminal system, which mediates ______ for the head. Label the encircled regions on the section to indicate if they are more llkely motor areas or sensory areas. 44,13. The ___ columns, composed of the fasciculus gracilis and cuneatus, fee respective nuclei, the nucleus _____ and nucleus ___in the medulla. 44.14, Closer to the midline in the upper sections of the medulla, there appears a pair of medial . The ____lemniscus of each side contains ___ary fibers mediating imb). the dorsal column modalities from the nucleus gracilis (lower limb) and cuneatus ( 44.15. Label the encircled arcuate fibers leaving the nucleus gracilis and ___ as they cross to form the ___lateral Label the nucleus gracilis and cuneatus. 44.16. Further _____, the middle division of the brainstem, the , is seen to possess a se to the __ cerebellar base region. The base contains a mass of crossing fibers that gives peduncle. In addition to the crossing fibers, the base contains cell bodies—the pontine nucle-—and many ____ ing fibers on their way down to the spinal cord.Pret te PPYN BEN BPTI PY NN BPP RP PPS TN vs HPT vm DPPH, OV PVN ON ON ON BOLTON OTN FON BOR POR PLL BTN OA NPL PTL OL NP PPP PY 44 w Intrinsic Anatomy of the Brainstem [EEEY 44.17. Other features of the pons are continuations of structures seen in the medulla, such as the the ascending fibers that began as the columns of the spinal cord and other pathways passing rostrally to terminate in the From the following list of structures, circle all of the choices that are associated with the Posterior or dorsal columns of the spinal cord. Medial lemniscus Pontine nuclei Arcuate fibers Inferior cerebellar peduncle Nucleus gracilis Pyramids Central canal 44,19. In the midbrain, the ventricle narrows to form the cerebral aqueduct. The cerebral aqueduct is surrounded by a mass of gray matter called the periaqueductal gray. The cells of the gray have a prominent role in pain modulation, Shade in the periaqueductal gray and label the cerebral aqueduct on the diagram.PFPA FPA TFT IPU FOG PPP TTR ROTO PROT OPTI fs ry Blood Supply to the Brainstem 45.1. The brainstem blood supply originates in the pair of _____ arteries that ascend through the transverse foramina of the cervical vertebrae (as the name implies). They enter the skull via the , the large foramen that marks the transition from _____ cord to brainstem. 45.2. The paired vertebral arteries merge at the pontomedullary junction to form a single basilar artery, named for its position along the of the pons. The basilar artery terminates by dividing into two posterior cerebral arteries. Label the vertebral, basilar, and posterior cerebral arteries on the diagram, 45.3. The most inferior division of the brainstem, the ____, receives blood from multiple sources, all of which are branches of the vertebral or _____ arteries. 45.4. The primary branches supplying blood to the medulla are the anterior and posterior spinal arteries. The spinal artery is found in the anterior median sulcus, while the pair of _____ spinal arteries is found in the posterior lateral sulct on either side of the posterior median sulcus. Label the anterior and posterior spinal arteries, the anterior and posterior median sulci, and the posterior lateral sulci on the am, coo‘45 m Blood Supply to the Brainstem 45.5. Branches of the spinal arteries penetrate the substance of the medulla, dividing it into vascular zones based on the regions they supply. These _____zones lead to predictable functional loss. when their blood supply is compromised. The following sections illustrate the vascular zones of the ‘medulla; circle and label the vascular zones in each section on the left side. 45.6. In the caudal medulla, there are three vascular zones that are all supplied by branches of the ____ arteries. The branch to the medial vascular zone is particularly small and prone to problems. If the small artery feeding the zone becomes blocked, the _____ and may be compromised, creating a predictable loss of ‘motor function contralateral to the lesion (pyramid), a loss of dorsal column modalities _____lateral to the lesion, and loss of CN XIL, producing deviation of the tongue to the side upon protrusion. Shade in the medial vascular zone on the diagram, and label the structures affected by a loss of blood and a loss of posterior column modalities on the left side of the diagram. lateral 45.7. A blockage of the artery to the paramedian zone, which contalns the problems. . produces 45. Branches of the unpaired ________ artery—pontine arteries—serve as the chief supply to the pons. The blood supply divides the into four vascular zones. The superior cerebellar artery supplies the dorsal ________, which contains the superior cerebellar the mai outflow of the cerebellum; thus, individuals with damage here suffer severe and obvious motor impairment. PUPP PAPC PPP PPP PY PPP PPP PPP PP PPP PPP PPP | 457FTP PFU BP PFU PPUFPU FP POPP PPP PP PPP PPP PPP PPP PPP PY PU PUP 45 m Blood Supply to the Brainstem red 45.9, Shade in the medial vascular zone on the right side of the Image, and label the structure affected by such a lesion on the left side of the image. Will the individual have sensory loss ipsilateral to the lesion? Will the individual have motor loss The medial longitudinal fasciculus is affected by this lesion; this will have an adverse affect contralateral to the lesion? ‘on conjugate eye movements (coordination of the eyes as they attempt to move in concert). 45.10. The midbrain is also divided into four vascular zones. Label them on the right side of the diagram, 45.11. The posterior inferior cerebellar artery is the primary supplier of blood to the paramedian vascular zone. Lesion of this artery has a devastating affect on the cerebral peduncles, which contain descending fibers among other things. Also affected by this lesion are the substantia nigra (motor system) and the oculomotor nerve as it passes through the region. This collection of problems has been named Weber's syndrome. For each of the following structures, indicate whether the prob- lem will be ipsilateral or contralateral for the lesion, Extraocular muscle paralysis: ‘Arm paralysis: Leg paralysis Chronically dilated pupil: Drooping eyelid: ‘Tongue movement: ryFe ee ee ee rr ee ee ee ‘45 m Blood Supply tothe Broinstem 45.12. Label the following arteries on the diagram: Anterior spinal Vertebral Basilar Pontine Superior cerebellar Labyrintiine Posterior cerebral 45.13. The tiny labyrinthine artery, a branch of the _____, constitutes the blood supply to the vestibular system; blockage here causes equilibrium problems and loss of balance. 45.14. For each artery listed, indicate its source—either the vertebral or basilar artery. Pontine: Anterior spinal Superior cerebell Labyrinthine: Posterior spinal: |