Rule of 4 summary The blood supply of the brain stem paramedian branches and long circumferential branches (AICA,

A, PICA, SCA). Occlusion of the paramedian branches results in medial/paramedian brainstem syndromes and occlusion of the circumferential branches results in lateral brainstem syndromes. Occlusion of vertebral artery can result in lateral brainstem syndromes too. Rules: (applies to the medulla and pons, only the midline structures applies to the midbrain) 1. There are 4 structures in the midline beginning with M a. Motor pathway (corticospinal tract) b. Medial lemniscus c. Medial longitudinal fasciculus (ipsilateral internuclear opthalmoplegia failure of adduction of ipsilateral eye towards the nose and nystagmus in the opposite eye as it looks laterally) d. Motor nuclei and nerve ipsilateral CN3,4,6,12 loss 2. There are 4 structures to the side beginning with S a. Spinocerebellar pathways (ipsilateral ataxia of arms and legs) b. Spinothalamic pathway c. Sensory nucleus of the 5th CN ipsilateral alteration of pain and temperature on the face. d. Sympathetic pathway ipsilateral horners syndrome 3. There are 4 cranial nerves in the medulla, 4 in the pons and 4 above the pons a. 4 in the medulla CN9,10,11,12 b. 4 in the pons CN5,6,7,8(auditory) c. Above the pons 1,2,3,4 4. The 4 motor nuclie that are in the midline are those that divide equally into 12 (except 1 and 2) i.e. CN 3,4,6,12 (5,7,9,11 are in the lateral brainstem)

Brainstem stroke syndromes Webers syndrome (paramedian anterior midbrain) CN3 palsy (pupil sparing) + contralateral hemiparesis Benedikt syndrome (paramedian midbrain) Webers syndrome + red nucleus CN3 palsy + contralateral hemiparesis + contralateral hyperkinesis, ataxia, intention tremor. Claudes syndrome Cerebellar ataxia (superior cerebellar peduncle) + crossed CNIII palsy Fovilles syndrome (paramedian pontine) PPRF + CNVI,VII, corticospinal tract, medial lemniscus, medial longitudinal fasciculus

Millard-Gubler syndrome (paramedian pontine) CN6 + CN7 + contralateral hemiplegia Wallenberg syndrome (lateral medullary) Lateral medullary spinal trigeminal tract + inferior cerebellar peduncle + descending sympathetic tract + ventral spinocerebellar tract + lateral and ventral spinothalamic tract + solitary nucleus + cuneate and gracile nucleus + vestibular nuclei + CN9,10