[Brainstem & Cranial Nerves, CLSA 2022] 1

2ND SEMESTER MIDTERMS
NEUROANA 11: BRAINSTEM & CRANIAL
NERVES
• Brainstem is in area of cranial nerves and vegetative function
• Can be divided into 3 areas
→ (1) Tectum – top part of the roof (dorsal, posterior)
▪ Midbrain, pons, medulla have tectums
▪ Tectum = roof
→ (2) Tegmentum – floor or lower part (middle part)
▪ Contains cranial nerves, ascending tracts, &
reticular formation
→ (3) Basis – lowest area (most anterior)
▪ Descending tracts carrying motor stimuli
• Know structures that can be found in each area
→ Easier to trace pathways
• Nothing really important in tectum except the colliculi
→ Colliculi – important only as a tool for the medial and
lateral geniculi of the thalamus
→ Medial geniculate body – auditory relay
▪ From ear → cranial nerve → brainstem →
temporal lobe (Heschl’s gyrus)
▪ Lateral geniculate body – visual relay to occipital
lobe
→ Superior colliculus – paired structure in midbrain, receive
direct input from retina, respond to visual stimuli, activate
eye movements
→ Inferior colliculus – principal midbrain nucleus of auditory
pathway, receives input from several brainstem nuclei &
input from auditory cortex
• Anything going into the cortex must pass first through thalamus
→ For anything that enters the cortex, there must be a
thalamic nuclei that relays it (first stop)
• Identify where nuclei are and where axons go and connect
→ Important when looking at cranial nerves
• Nuclei of CN I & II – located in cerebral cortex
→ CN I – located in pre-frontal lobe
→ CN II – located in 1o visual area (BA 17 in occipital lobe)

CN NUCLEI FUNCTION ENTRY / EXIT DYSFUNCTION

CN I Inferior frontal gyrus Sense of smell Cribriform plate Anosmia
Blindness
CN II Occipital lobe Vision/ visual fields Optic foramen
Hemianopia
Ptosis
Oculomotor Innervates levator MR, SR, IR
MR, SR, IR palsy
CN III Edinger Westphal Parasympathetic: constricts pupil Superior orbital fissure Dilated pupil
Nucleus of Perlia Accommodation No accommodation
Interstitial Nucleus of Cajal Vertical gaze center No vertical gaze center
CN IV Lower midbrain Innervates superior oblique Superior orbital fissure No downward outward MVT
V1: Midbrain – mesencephalic Proprioception Superior orbital fissure
Loss of sensation in the face
V2: Pons – motor Mastication Foramen rotundum
CN V
V3: Medulla – chief sensory Tactile sense
Foramen ovale No mastication
Motor: Spinal root Pain & temperature
CN VI Pons Innervates lateral rectus Superior orbital fissure Lateral rectus palsy
Pons: Motor: muscles of expression
Facial palsy
Facial Stapedius
CN VII Stylomastoid foramen
Parasympathetic No lacrimation
Superior salivatory nucleus
Taste: anterior 2/3 of tongue Loss of taste
Pontomedullary:
Position of the head Vertigo
Vestibular
CN VIII Stylomastoid foramen
Heading
Cochlear Deafness
Audition
Medulla: Assists vagus taste: posterior 1/3
CN IX Jugular foramen Poor gag & swallow
Inferior salivatory nucleus PS: saliva
Medulla: Motor: pharynx Dysphagia
Nucleus ambiguus Vocal cords Hoarseness
CN X Jugular foramen
Nucleus tractus solitarius Sensation of pharynx Loss of pharyngeal sensation
Dorsal vagal efferent Sympathetic Loss of parasympathetic function
Medulla
CN XI Innervates SCM/upper trapezius Jugular foramen Paralysis of SCM/upper trapezius
Upper cervical spinal cord
CN XII Medulla Motor: tongue Hypoglossal canal Tongue deviation

• Midbrain has nuclei of CN III, IV, V
→ CN IV – only axon that exits dorsally
→ CN V nuclei found in all parts of the brainstem
• Pons has nuclei of CN V, VI, VII, part of CN VIII
→ CN VI – longest one, under the brain
▪ When brain is heavy with edema, brain will
press on this cranial nerve
• Medulla oblongata has nuclei of CN V, IX, X, XI, XII, part of VIII
→ CN XI – only one with spinal cord nuclei
• All nuclei are in tegmentum of brainstem except CN I & II
• When structure is supratentorial, effects are contralateral
• When structure is infratentorial, effects are ipsilateral
CN I: OLFACTORY NERVE ---------------------------------------------------------------------
• Tip of nasopharynx is only one compartment
→ Left and right nostril not in separate nuclei
→ Cannot smell in one nostril, but can smell on other side
– diagnosis is blocked nose
▪ True anosmia affects both sides
• Receptors of olfactory nerve – whatever you smell is picked up
here, goes through cribriform plate → olfactory bulb (both L & R)
• Olfactory bulb is connected to limbic lobe
→ Can influence the way you feel or think about a person
CN II: OPTIC NERVE ----------------------------------------------------------------------------
• Glasses will improve visual acuity but not visual field defects
→ Visual field is what you see on the left, right, temporal
(lateral), nasal (medial)
→ Scotoma – visual field defects
• Quadrantonopsia – affects quarter field of vision
CN III: OCULOMOTOR NERVE ---------------------------------------------------------------
[Brainstem & Cranial Nerves, CLSA 2022] 2
• Retina is at the back of the eye
• Light passing through lens inverts
→ Light from below goes on top and vice versa
→ Light from temporal vision goes to nasal retina
• Closing left eye, open right eye, what nuclei will be used?
→ Both nuclei (nasal retina to left nuclei, temporal to right)
• Trace pathway
→ Visual fields cross retinas
→ Temporal retina stays on ipsilateral side
▪ Form a V that fell down daw
→ Nasal retina crosses to contralateral retina (form an X)
• Left homonymous hemianopsia (cannot see LEFT view)
→ Damage to right occipital lobe
▪ Left nasal retina which receives left temporal
vision crosses to right nucleus
▪ Right temporal retina which receives left nasal
vision goes to right nucleus
• Right homonymous hemianopsia (cannot see RIGHT view)
• Bitemporal hemianopsia – damage in optic chiasma
→ Cannot see in both temporal visual fields
▪ Temporal vision always enters nasal retina
▪ Nasal retinas cross in middle to opposite nuclei
→ Can see in both nasal (central) visual fields
→ Tunnel vision
• Optic radiation – part of it is in parietal lobe, part in temporal lobe
before going to occipital lobe (think of vision now in quadrants)
→ Parietal radiation stimuli from superior retina
▪ Parietal lobe sees vision inferiorly
▪ Damaged → cannot see inferiorly
→ Temporal radiation stimuli from inferior retina
▪ Temporal lobe sees vision superiorly
▪ Damaged → cannot see superiorly
→ Left temporal lobe lesion → problem in right superior
quadrant view
▪ Right superior quadrantonopsia
• Multiple functions & multiple nuclei
All CN III nuclei located in upper midbrain side by side,
on top of optic foramen
→ Separated at before midbrain but unite once they enter
• (1) Oculomotor nuclei
→ Ptosis – cannot lift eyelid due to lack of innervation of
levator palpebrae superioris
→ Palsy – cannot adduct eye or look inward
• (2) Edinger Westphal nucleus – parasympathetic function
→ CN III, VII, IX, X – CN with parasympathetic function
→ Damage → dilated pupil
• (3) Central nucleus of Perlia – for accommodation
→ One cannot move both eyes outward (laterally)
simultaneously because CN VI has no equivalent for central
nucleus of Perlia
→ You can only move both eyes inward together
• (4) Nucleus of Cajal – Father of Neuroplasticity
→ Right nucleus of Cajal controls right eye
→ Both eyes look up and down at the same time
→ Vertical gaze center coordinates R and L superior rectus
 [Brainstem & Cranial Nerves, CLSA 2022] 3

CN IV: TROCHLEAR NERVE ------------------------------------------------------------------ CN VII: FACIAL NERVE ------------------------------------------------------------------------------

• CN IV – located in lower midbrain, directly below all CN III nuclei • Stapedius – keeps tympanic membrane (eardrum) stable so you don’t
→ Palsy: paralysis accompanied by involuntary tremors hear things too loud (attenuation)
→ Pure motor cranial nerve • Parasympathetic function: lacrimation and saliva production
→ Posterior 1/3 of tongue innervated by glossopharyngeal
• Muscles of facial expression
CN V: TRIGEMINAL NERVE ------------------------------------------------------------------ → Innervates upper and lower face
• Has several nuclei, has both motor and sensory → 5 branches
• Pass through superior orbital fissure – III, IV, VI, V-1 ▪ Temporal branch (forehead)
• Face is divided into 3 parts subserved by branches of CN V ▪ Zygomatic branch (upper eyelid)
→ Opthalmic, maxillary, mandibular branches ▪ Buccal branch (lower eyelid and upper mouth)
→ Separate outside of the brainstem ▪ Mandibular branch (lower mandibular muscles)
→ Before entering, will unite in semilunar ganglion ▪ Cervical branch (platysma)
▪ Then after entering, will divide (to pons, → 2 divisions
midbrain, medulla) according to function ▪ Temporofacial division (upper face, first &
• All senses in upper face will enter opthalmic division second branches)
→ Upper face senses proprioception, temperature and ▪ Cervicofacial (lower face, last 3 branches)
pain, tactile sense
• Midbrain tegmentum: sense if you are smiling even if you don’t
see it (position sense through mesencephalic nucleus)
→ Proprioception – sense raising eyebrow
▪ Pass through right opthalmic branch →
right superior orbital fissure → right
trigeminal ganglion → right midbrain
• Bell’s palsy is CN VII disorder
→ Muscles on one side of the face becomes weak or
paralyzed (droop or become stiff)
→ Chewing is not helpful since mastication is under CN V
▪ Chewing is the only motor function of CN V
→ Use instead bubblegum (because it has blowing)
• Chief nucleus: feeling someone touch your face
→ Kiss on left cheek (tactile) → left maxillary branch →
left foramen rotundum → left trigeminal ganglion →
left pons
▪ At left pons, still cannot feel kiss
▪ Needs to be sent to other regions to be felt
▪ From different nuclei of CN V → thalamus
(ventroposterolateral nucleus of trigeminal)
→ area 3, 1, 2 (1o somatosensory cortex)
▪ Left pons → right VPL → right BA 3,1,2
• Medulla – spinal root for pain and temperature felt on face
→ All of these are in the brainstem
• Important thalamic nuclei to remember
→ Smile – voluntary (must originate from cortex)
→ (1) VPL – general sensation, anything before 3,1,2
→ Facial nucleus in pons has upper and lower division
passes through this thalamic nuclei
▪ Lower area innervates upper face, upper area
→ (2) Ventral anterior nuclei – any from basal ganglia
innervates lower face
▪ Basal ganglia chooses role of each muscle:
▪ Division is eyelid line when eyes are closed
agonist, antagonist, assistant, fixator
▪ Right frontal cortex will innervate left pontine
▪ Before going to BA 6 & 8
nucleus → move left face
→ (3) Ventrolateral nuclei before those from BA 6 & 8
→ Upper part has double innervation from ipsilateral side &
pass to cerebellum
contralateral side (left and right cortex)
→ (4) Medial geniculate body – before any audition goes
→ Lower face can only be stimulated by contralateral cortex
to BA 41 & 42
▪ Damage to cranial nerve as it exits foramen to
→ (5) Lateral geniculate – before vision goes to BA 17 face or in pons – paralysis of whole half
(peripheral facial palsy)
CN VI: ABDUCENS NERVE --------------------------------------------------------------------
→ Clinically, difference is in the eyebrow
• CN VI – pure motor nerve
→ Testing can be through 3 instructions: raise eyebrow (upper
→ Abducts the eye face), close eyes (can be by lower face), smile (lower face)
→ Exits superior orbital fissure

▪ If lesion is in brain (supratentorial area) or
in axons of corticobulbar tract (cortex to
brainstem) – upper face can still move , can
still raise eyebrows but smile deviated
(central facial palsy)
▪ Admit the one who can raise eyebrows
▪ May be start of a stroke → next day may be
wholly paralyzed
→ Physically worst looking one (peripheral facial palsy) is
clinically better
▪ Means damage is only in nucleus
▪ If patient cannot raise eyebrows → no need
to be admitted or for CT scan, only take
meds and undergo physical therapy
• Parasympathetic function
→ Axons will always loop around CN VI, go out and divide
→ 1st division: greater petrosal nerve – upper lacrimal
glands (lacrimation)
→ 2nd division: chorda tympani – for taste & saliva
production (under the tongue)
CN VIII: VESTIBULOCOCHLEAR NERVE ---------------------------------------------------
• Separate as 2 distinct functions
• Between pons and medulla (pontomedullary)
• Vestibular and cochlear nuclei are in medulla
Vestibular
• Semicircular canals are just receptors
→ Movement of perilymph & endolymph
• Only nuclei will interpret position of head
• Vestibular nuclei (divided into 4, half in pons, half in medulla)
→ Superior, medial, inferior, lateral
→ 3 connections of vestibular nuclei
▪ (1) Connects to eye cranial nerves (CN III, IV,
VI) via median longitudinal fasciculus (MLF)
▪ (2) Connects to flocculonodular lobe
(cerebellum has 3 lobes) via
vestibulocerebellar tract
▪ (3) Connection to spinal cord
(vestibulospinal tract)
→ CN III, IV, VI → restiform bodies of inferior cerebellar
peduncle → flocculonodular lobe → spinal cord
→ When you are sleepy and your head dips forward,
cerebellum calculates how much muscles need to
move to correct position
→ Spinal cord directs muscles to carry out cerebellum’s
instructions
CN IX: GLOSSOPHARYNGEAL NERVE -----------------------------------------------------
• Sidekick of CN X
• Nucleus responsible for parasympathetic saliva production
→ More saliva produced since it stimulates both parotid
and mandibular glands
→ Damage → only decreased salivary production since
CN VII also contributes
• Responsible for taste in posterior 1/3 of the tongue
• Poor gag and swallow (CN X test according to Snell Anatomy)
→ Gag/pharyngeal reflex test – depress posterior aspect
of tongue using tongue depressor
▪ Response: palatoglossal arch goes up
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▪ If arches go up equally → uvula is straight
→ Paralyzed position cannot lift, so functional side pulls uvula
to one side (same as in vocal muscles)
▪ Points to functional part
▪ If right is damaged, uvula points to the left
CN X: VAGUS NERVE --------------------------------------------------------------------------------
• Longest axon in terms of cranial nerves – down to abdomen
• (1) Nucleus ambiguous – swallowing, vocal cords
→ Dysphagia – difficulty in swallowing
→ Left vocal cord stimulated by left nucleus ambiguus
→ Vocal cord paralysis
▪ Only hoarseness if only 1 side is affected
• (2) Nucleus tractus solitarius – sensory
→ Hyperactive in sore throat (feel pain)
→ Taste from glossopharyngeal passes through this nucleus
• (3) Dorsal vagal efferent
→ Practically innervates all thorax and most of abdomen
(except transverse colon, descending colon)
CN XI: SPINAL ACCESSORY NERVE --------------------------------------------------------------
• Pure motor (makes muscles contract)
• 1st nuclei in medulla, 2nd nuclei in spinal cord
• Turns head and shrugs shoulder
→ Left CN XII controls left sternocleidomastoid → turns head
to right (if cannot turn right, damage is in left nucleus)
→ Right CN XI shrugs right shoulder
CN XII: HYPOGLOSSAL NERVE --------------------------------------------------------------------
• Pure motor nerve in medial medulla
• Genioglossus (main muscle) attached to base of tongue
→ Contracting left genioglossus → base of tongue pulls to left
→ tip goes to right (opposite effect)
→ Left hypoglossal nerve innervates left genioglossus muscle
→ Stimulating right hypoglossus → tongue goes to left (base
pulls to right, tip goes to left)
• If tongue points to the left, damage is in left genioglossus innervated
by left hypoglossal (pointing to area of lesion)
→ Tongue pulls to right because right genioglossus is working
→ Simpler to remember: tongue action pushes
▪ Whatever is not working cannot push so lags
behind while functional side points to it
• Axons coming out of CN XII nuclei divides medulla into medial & lateral
medulla
• Everything lateral to axon called lateral medulla
→ Blood supply: posterior inferior cerebellar artery (PICA)
→ Stroke of PICA (common) – CN nuclei IX, X, affected
▪ Lateral medullary syndrome – dysphagia, loss of
sensation contralaterally
▪ CN XI – not affected so much because it has
spinal branch
▪ Suddenly cannot swallow is a sign of stroke
→ Ascending spinothalamic tract
• Everything medial called medial medulla
→ Anterior spinal artery
→ Only has corticospinal tracts
→ If paralyzed, can lead to quadriplegia