BRAINSTEM – Dra.

Matheus
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Occupies posterior cranial fossa Stalk like in shape Connects spinal cord with forebrain (3) broad functions o Conduit for ascending & descending tracts o Contains important reflex centers  Control of respiratory & cardiovascular s.  Control of consciousness o Contains nucleui of CN‟s 3-12 Has transverse SUBdivision o Midbrain o Pons o Medulla oblongata Longitudinal SUBdivisions o TECTUM – the roof o BASIS – anterior o TEGMENTUM – central portion

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Cerebella afferent & efferent pathways Central tegmental tract (interconnects tegmentum, diecephalon, & basal forebrain gray matter) Profuse unnamed pathways in the reticular formation

LOWER MEDULLA (Level of decussation of pyramids) consists:

1. 2. 3. 4.

MEDULLA OBLONGATA

Gross appearance Junction b/w medulla & spinal cord Originated at anterior/posterior roots of C1 spinal nerves (level of foramen magnum) Clonical shaped EXTERNAL STRUCTURES
ANTERIOR MEDIAN FISSURE: at midline

Pyramidal tracts: 80-90% decussate forming the lateral corticospinal tract Nucleus of spinal tract of trigeminal nerve Fasciculi gracilis & cuneatus – ascend behind central gray matter Nuclei gracillis & cuneatus – appear as dorsal extension of central gray matter Decussation of lemnisci – located posterior to pyramids ..MEDIAL lemnisci – fromed from internal arcuate fibers (came from nuclei gracilis & cuneatus) Lateral/anterior spinothalamic tracts, Spinotectal tracts & Spinal lemniscus Spinocerebellar, Rubrospinal & Vestibulospinal tract Inferior olivary nucleus – like a crumpled bag ..Sends fibers to cerebellum – called olivocerebellar fibers ..Spino olivary tract Nucleus ambiguous – contain large motor neurons with in reticular formation ..Fibers join CN‟s 9,10,11 ..Supply voluntary skeletal muscle Central gray matter ..Beneath floor of 4th ventricle ..Structures here (from medial to lateral) 1. Hypoglossal nucleus 2. Dorsal nucleus of vagus 3. Nucleus of tactus solitarius (come from CNs 7,9,10) 4. Medial & Inferior vestibular nuclei Medial longitudinal fasciculus ..Form connections b/w CNs 3, 4, 6 ..Receives input from vestibular nuclei, cerebellum, proprioceptive fibers from cervical region ..Can find here: cerebellar peduncle – located poterolateral

LOWER MEDULLA (Level of decussation of lemnisci) consists:

1. 2. 3. 1. 2.

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Contains PYRAMIDS  a swelling on each side of fissure  Inferiorly, fibers cross over called decussation of the pyramids

UPPER MEDULLA (level of the olives)

LATERAL SURFACE

TECTUM (roof)

1. 2. 3.

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Def: plate of brainstem dorsal/posterior to the aqueduct Components: o Midbrain level - Quadrigeminal plate o Pontine level - Superior medullary velum o Medullary level - Inferior medullary velum  Tela Choroida & Choroid plexus Consists of descending (motor) cortical motor tracts (2) types: o PYRAMIDAL tracts  Corticospinal t.  from cortex to spinal cord  Corticobulbar t. cortex to head area o CORTICOPONTINE tract  from the cerebral cortex to the pontine nuclei Def: plate of neurons & tracts b/w tectum & basis Complicated part of the brainstem: contains both gray & white matter Tegmental GRAY matter consists: o Motor sensory nuclei of CN 3-12 (except 4) o Reticular formation – loosely arranged reticular bodies o Supplementary motor & sensory nuclei Tegmental WHITE matter consists: o All LONG sensory tracts (ascends from spinal cord or cranial nerve nuclei to cerebellum, brainstem & thalamus o Medial longitudinal fasciculus

contains: ANTEROLATERAL sulcus  b/w pyramids & olives - Rootlets of hypoglossal nerve CN12 emerge here OLIVES  oval elevations of posterolateral to pyramids - Elevations is due to inferior olivary nuclei POSTEROLATERAL sulcus  b/w olives & inferior cerebellar peduncles (restiform body) - Restiform bodies – connects medulla to cerebellum - In its sulcus arise the roots of CN‟s 9,10,11 Posterior median sulcus  from spinal cord to obex OBEX – a central canal that opens & expands to form 4th ventricle GRACILE Tubercle – elongated swelling on each side of sulcus ..Swelling is due to gracile nucleus CUNEATE Tubercle – elongated swelling lateral to gracile tubercle ..Swelling due to cuneate nucleas

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BASIS

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POSTERIOR SURFACE contains:

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TEGMENTUM (tegmen “covering”)

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INTERNAL STRUCTURES Considered at 2 levels: LOWER medulla (caudal half) consists: o Level of decussation of pyramids o Level of decussation of lemnisci UPPER medulla (rostal half) consists: o Level of olives o Level just inferior to the pons

PONS
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Anterior to cerebellum Connects medulla to midbrain 1 inch (2.5 cm) long Anteriorly, seen as a bridge connecting the R & L cerebellar hemispheres Convex, with many travsverse fibers o Fibers from the middle cerebellar peduncle

ANTERIOR SURFACE contains:

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Basilar groove – shallow groove in the midline o Basilar groove is for basilar artery Abducens nerve (CN6) – in the groove b/w pons & medulla

1. 2. 3. 4. 5. 6.

LATERAL SURFACE contains:

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Middle cerebellar peduncle (Brachium pontis) o MCP – where CN 5 can be found o Brachium pontis – connects pontine nuclei to cerebellum 2. Pontocerebellar angle o Formed by rostral medulla, caudal pons & adjacent cerebellum o Attached here: CNs 7 & 8 Note: o Brachium Respiformis  Connects cerebellum to medulla  Located in cerebellar peduncle o Superior cerebellar peduncle  midbrain to cerebellum
POSTERIOR SURFACE of the PONS contains:

Medial lemniscus – with spinal & lateral lemnisci o lateral lemniscus – carries auditory fibers to inferior colliculus of midbrain Trapezoid body o made up of fibers from trapezoid body & cochlear nuclei – for auditory relay station Nerve fiber of facial nucleus wind around abducens nucleus – forming facial colliculus Medial longitudinal fasciculus – beneath 4th ventricle at midline o connects vestibulocochlear nuclei with nuclei controlling extraoccular muscle (CN 3,4,6) Vestibular nuclei o lateral to abducens nucleus & close to inferior cerebellar peduncle Spinal nucleus of trigeminal nerve & tract o lie anteromedial to inferior cerebellar peduncle

MIDBRAIN

Gross appearance Connects pons & cerebellum w/the forebrain 0.8 inch (2 cm) long Transferred by a narrow channel, the cerebral aqueduct, which is filled with CSF EXTERNAL STRUCTURES
ANTERIOR SURFACE consists:

1. 2. 3. 4.

Interpenduncular fossa – deep depression in the midline Crus cerebri – on each side of fossa Posterior perforated substance – small perforations at floor of the fossa Occulomotor nerve – emerge from groove at medial side of crus cerebri consists: Superior Bracium – passes from superior colliculus to lateral geniculate body & optic tract Inferior Brachium – connects inferior coniculus to medial geniculate body Corpora Quadrigemina – has 4 rounded eminences o Superior colliculi – centers for visual reflexes o Inferior colliculi – corners auditory centers Trochlear nerve – emerge below inferior colliculi

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Superior cerebellar peduncle (Brachium conjunctivum) o Limits posterior surface laterally o Main cerebellar efferent pathway Dorsal medial sulcus at midline Medial eminence – an elongated elevation on each side of sulcus o Contains Facial collicular – inferior continuation of eminence Sulcus limitans – lateral to medial eminence o Substantia ferruginea Floor of superior part of sulcus limitans Bluish-gray in color o Area vestibuli Lateral to sulcus limitans (+) vestibular nuclei Internal Structure Studied at 2 levels o Transverse section passing through facial colliculus (caudal part) o Transverse section passing through the trigeminal nuclei (cranial part) Each section is divided into 2 regions: o Anterior basal part o Postertior part – the tegmentum *the 2 part is divided by trapezoid body

TRANSVERSE SECTION through CAUDAL PART – Basal Part consists: 1. Pontine Nuclei – small masses of nerve cells o Corticopontine fibers from midbrain terminate in the pontine nuclei (give rise to transverse fibers) o Corticospinal & corticobulbar tracts intersect with these fibers o Transverse pontine fibers enter cerebellum through the middle cerebellar peduncle TRANSVERSE SECTION through CRANIAL PART – Tegmentum consists: 1. Motor nucleus of CN5 – under lateral part of 4th ventricle 2. Principal sensory nucleus of CN 5 – lateral to motor nucleus o Continues inferiorly w/ nucleus of spinal tract 3. Superior cerebellar peduncle – posterolateral to motor nucleus o Joined by anterior spinocerebellar tract 4. Raphe nuclei of reticular formation – lie in midline tegmentum o Important in synthesis of serotonin (important in production of slow wave or NON-REM sleep) 5. Locus ceruleus – lateral to central gray matter o Synthesize NE (indicated in REM, a paradoxical sleep) TRANSVERSE SECTION through CRANIAL PART – Basal Part consists: 1. CorticoSPINAL, CorticoBULBAR & CorticoPONTINE 2. Pontine nuclei

LATERAL SURFACE

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POSTERIOR SURFACE consists:

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INTERNAL STRUCTURES Comprise 2 levels: LOWER midbrain (Transverse section @ the level of the inferior colliculi) UPPER midbrain (Transverse section @ level of the superior colliculi) (2) LATERAL HALVES: Cerebral Peduncles CRUS CEREBRI - anterior part TEGMENTUM - posterior part divided by SUBSTANTIA NIGRA

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*Substantia Nigra – covered by pigmented gray matter

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TRANSVERSE SECTION through the CAUDAL PART - Tegmentum consists:
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LOWER MIDBRAIN (level of inferior colliculi) consists:

Central gray matter Crus Cerebri

Decussation of superior cerebellar peduncle Medial Lemniscus

..Surrounds aqueduct ..Contains descending tracts: a.Corticospinal & Corticobulbar tracts occupy middle 2/3 b.Frontopontine fibers – occupy medial part c.Temporopontine fibers – occupy lateral part ..Central part of tegmentum ..Behind substantia nigra ..Spinal & trigeminal lemnisci are lateral to medial lemniscus ..Lateral lemniscus – behind trigeminal lemniscus ..Near midline ..Lateral to aqueduct ..Part of auditory pathway ..Receives fiber from lateral lemniscus ...Lateral decusation ..Large motor nucleu throughout midbrain ..Made of medium-sized multipolar neurons with melanin granules in their cytoplasm ..Covered with muscle tone ..Lie in central gray matter @ midline ..Fiber pass lat&post to exit midbrain bellow inferior colliculi ..(+) Descending tracts: Corticospinal, Corticobulbar & Corticopontine ..Curved band posterior to substantia nigra ..Forms part of visual reflexes ..Lie in central gray matter near midline ..Rounded mass of gray matter ..Redish d/t vascularity & iron containing pigment in cytoplasm of its neurons ..In tegmentum, lat., & post., tp red nucleus

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? 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 RULE 4: 4 Medulla Cranial Nerves •Glossopharyngeal (CN9) •Vagus (CN10) •Spinal accessory (CN11) •Hypoglossal (CN12) RULE 4: 4 Pons Cranial Nerves •Trigeminal (CN5) •Abducent (CN6) •Facial (CN7) •Auditory (CN8) RULE 4: 4 Cranial Nerves above Pons •Olfactory (CN1) •Optic (CN2) •Occulomotor (CN3) •Trochlear (CN4)

BRAINSTEM LESION – Dr. Bravo

MIDLINE STRUCTURES Motor pathway (Corticospinal tract) Medial Lemniscus Medial longitudinal fasciculus Motor nucleus & nerve LATERAL STRUCTURES Spinocerebellar pathway Spinothalamic Sensory nucleus of CN 5 Sympathetic pathway 4 CN – MEDULLA CN9 CN 10 CN 11 CN 12 4 CN – PONS CN 5 CN 6 CN 7 CN 8 4 CN – ABOVE PONS CN 1 CN 2 CN 3 CN 4

DEFICIT (see diagram) Contralateral weakness Contralateral propioception/ Vibration loss Ipsilateral internuclear opthalmoplegia Ipsilateral CN function loss DEFICIT Ipsilateral ataxia Contralateral pain/ temp sensory loss Ipsilateral pain/ temp loss in face Ipsilateral Horner‟s syndrome DEFICIT Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness Ipsilateral shoulder weakness Ipsilateral weakness of tongue DEFICIT Ipsilateral facial sensory loss Ipsilateral eye abduction weakness Ipsilateral facial weakness Ipsilateral deafness DEFICIT Not in midbrain Not in midbrain Eye turned out & down Eye unable to look down when looking toward nose

Medial longitudinal fasciculus Mesenteric nuclei of CN 5 Nucleus of Inferior colliculus Reticular formation Substantia Nigra

Trochlear nucleus

LOWER MIDBRAIN (level of superior colliculi) consists:

Crus cerebri Medial, Spinal & Trigeminal lemnisci Nucleus of superior colliculus Oculomotor nucleus Red nucleus Reticular formation

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.” EXAMPLE: CASE 1: •58 year old woman •Left hemiparesis •Left-sided loss of propioception •Right-sided tongue deviation LOCATION: >Medial >Medial >Medulla

*look for: cranial nerve nuclei in brainstem

STRUCTURE damaged: >Motor (CS tract, R) >Medial lemniscus, R >CN 12, R STRUCTURE: >Motor (CS tract, R) >Medial lemniscus, R >CN 12, R

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Dx: Medial medullary syndrome CASE 2: •58 year old woman •Left sided meiosis, anhydrosis, ptosis •Left-sided ataxia •Uvula deviated to the right LOCATION: >Side, Left >Side, Left >Medulla Dx: Lateral medullary syndrome (L)

Affected: Vertebral artery, medullary brach (R) STRUCTURE damaged: >Sympathetic tract, L >Spinocerebellar >CN10, L STRUCTURE: >Sympathetic tract, L >Spinocerebellar >CN10, L

Dx: Medial Midbrain CASE 5: •70 year old male hypertensive suddenly developed: •Left-sided ipsilateral opthalmoplegia •Right-sided propioception loss •Involuntary movement LOCATION: >Midbrain >Medial, Left >Medial, Left Dx: Medial Midbrain Weber’s syndrome • CN 3 • Motor, CS tract • Corticobulbar tract • Medial midbrain

Affected: Weber‟s syndrome STRUCTURE damaged: >CN 3, Left >Medial lemniscus, Left >Red nucleus, Left STRUCTURE: >CN 3, Left >Medial lemniscus, Left >Red nucleus, Left Affected: Benedikt‟s syndrome Benedikt’s syndrome • CN 3 • Medial lemniscus • Red nucleus • Medial midbrain

Affected: Posterior inferior cerebellar artery (L) In lateral medullary syndrome (Wallenberg syndrome), there are associated analgesia and thermoanalgesia of the ipsilateral face. Why? What brainstem structure is affected? CASE 3: •10 year old girl w/ the ff: •Left sided weakness •R eye deviates medially •R sided facial weakness LOCATION: >Medial structure >Pons >Pons Dx: Medial pons What is astrocytoma? Where is it usually located? Who are most often affected? CASE 4: •70 year old male hypertensive suddenly developed: •Left-sided ipsilateral opthalmoplegia •Loss of pupilary light reflex, Left eye •Paralysis of Right arm & leg LOCATION: >Midbrain >Midbrain >Medial, Left
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STRUCTURE damaged:: >Motor (CS tract, R) >LR weakness, CN6 R >CN 7, R STRUCTURE: >Motor (CS tract, R) >LR weakness, CN6 R >CN 7, R Affected: Pons tumor (Millard-Gubler SYndrome

Parinaud’s syndrome •Posterior midbrain •Superior colliculi •Center for upward gaze •Inability to look up (Doll‟s eye) •Argylle-Robertson pupil Manifestations:  No pupillary light reflex  With accomodation

STRUCTURE damaged: >CN 3, Left >CN 3, Left >Motor, CS tract, Left STRUCTURE: >CN 3, Left >CN 3, Left >Motor, CS tract, Left