BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr.

Dennis Ivan Bravo

Basic Course Audit Anatomy-FEUNRMF
Localizing & Analyzing Brainstem Lesions
by: Dr. Dennis Ivan Bravo
CASE: A 58 year-old man was referred to you because of
recent onset of
1. Left hemiparesis
2. Left-sided loss of proprioception
3. Right-sided tongue deviation
• What CNS structure/s is/are affected?

• Explain the symptoms based on structures affected?

• Where is the lesion localized?

LEARNING OBJECTIVES
You are expected to
1. Localize brainstem lesion based on patient’s signs
and symptoms.
2. Explain signs/symptoms of brainstem lesions
based on neurologic structures affected.

LECTURE OUTLINE
• Review of brainstem structures: The Rule of Four
• Functions and deficits of brainstem structures
• Cases: Localizing brainstem lesion

REVIEW OF BRAINSTEM STRUCTURES

FUNCTIONS OF BRAINSTEM STRUCTURES

AND THEIR CORRESPONDING SIGNS/ SYMPTOMS
IN CASES OF DEFICIT

Reference: PPT from HSB Department Page 1 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
MOTOR PATHWAY: CONTRALATERAL WEAKNESS

MEDIAL LEMNISCUS: CONTRALATERAL PRORIOCEPTION/ VIBRATION SENSE LOSS

Reference: PPT from HSB Department Page 2 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
MEDIAL LONGITUDINAL FASCICULUS: IPSILATERAL INTERNUCLEAR OPHTHALMOPLEGIA

SPINOTHALAMIC: CONTRALATERAL PAIN/SENSORY LOSS

Reference: PPT from HSB Department Page 3 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
4 CN in MEDULLA SIGN/SYMPTOM of
DEFICIT
CN 9 Ipsilateral pharyngeal
Glossopharyngeal sensory loss
CN 10 Contralateral palatal
Vagus weakness
CN 11 Ipsilateral Shoulder
Spinal accessory Weakness
CN 12 Ipsilateral weakness of
Hypoglossal tongue

4 CN in PONS SIGN/SYMPTOM of
DEFICIT
CN 5 Ipsilateral facial sensory
Trigeminal loss
CN 6 Ipsilateral eye abduction
Abducent weakness
CN 7 Ipsilateral facial
Facial weakness
CN 8 Ipsilateral deafness
Auditory

Reference: PPT from HSB Department Page 4 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo

4 CN ABOVE PONS SIGN/SYMPTOM of RECAP!!

DEFICIT
CN 1 not in midbrain
Olfactory
CN 2 Not in midbrain
Optic
CN 3 Eye turned out and down
Occulomotor
CN 4 Eye unable to look
Trochlear towards nose tip

Reference: PPT from HSB Department Page 5 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo

RULE OF FOUR*

APPLICATION: Let’s put your knowledge to use.

Make yourself useful. Flex those brain muscles

RULE OF FOUR
 “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 anatomy and brainstem
vascular syndromes for the non-neurologist. Internal
Medicine Journal 2005: 35: 263-266

Reference: PPT from HSB Department Page 6 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
CASE 1: MEDIAL MEDULLARY SYNDROME CASE 2: LATERAL MEDULLARY SYNDROME
A 58 year-old man was referred to you because of A 75 year-old woman was referred to you because
recent onset of of recent onset of
1. Left hemiparesis 1. Uvula deviated to the right
2. Left-sided loss of proprioception 2. Left-sided meiosis, anhydrosis, partial ptosis
3. Right-sided tongue deviation 3. Left-sided ataxia

In Lateral Medullary Syndrome (Wallenberg

Syndrome), there are associated analgesia and
thermoanalgesia of the ipsilateral face.
• Why?

• What brainstem structure is affected?

Reference: PPT from HSB Department Page 7 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
CASE 3 CASE 5: WEBER’S SYNDROME
A 75 year-old woman was referred to you because A 70 year-old male was referred to you because of
of recent onset of sudden onset of
1. Diminution of hearing, right 1. Ophthalmoplegia- left eye turned down and
2. Left-sided body loss of pain and temperature out
sense 2. Loss of pupillary light reflex (direct and
3. Meiosis, anhydrosis, partial ptosis, right face consensual), left eye
3. Paralysis of arms and legs, right

CASE 4: MILLARD-GUBLER SYNDROME, RIGHT

A 10 year-old girl was referred to you because of
gradual onset of
1. Facial weakness, right
2. Medial deviation of right eye
3. Body weakness, left CASE 6: BENEDIKT’S SYNDROME
A 73 year-old female was referred to you because of
sudden onset of
1. Ophthalmoplegia- left eye turned down and
out
2. Propioception loss of body, right
3. Involuntary tremor and movement

Reference: PPT from HSB Department Page 8 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo
CASE 5 CASE 6
WEBER’S BENEDIKT’S
SYNDROME SYNDROME
CN3 CN3
Corticospinal tract Medial lemniscus
Corticobulbar tract Red nucleus
Medial Midbrain Medial midbrain (core)
(more anterior)

REVIEW!!!

Reference: PPT from HSB Department Page 9 of 10

BCA-Human Structural Biology- Localizing & Analyzing Brainstem Lesions by: Dr. Dennis Ivan Bravo

END OF TRANS

Reference: PPT from HSB Department Page 10 of 10