Cerebellum and

Brain stem
Dr Asim Shrestha
SRCC Ped Neuro fellow
Mumbai
Topics
• Cerebellum
• Brainstem
Cerebellum
• “latin meaning” the little brain
• In adults the weight ratio
between cerebellum and
cerebrum is
1:10,Infants 1:20
• covered by tentorium cerebelli
and is connected to brain stem
by three cerebellar peduncles
• A narrow band down the centre is called the vermis
• It controls most of the cerebellar functions
• Cerebellar Tonsil
- inferior part of the posterior lobe
- may be displaced down through the foramen magnum in
conditions of severe raised ICP or in congenital malformations
Intracerebellar Nuclei
• Four masses of gray matter are
embedded in the white matter of the
cerebellum on each side of the midline
• From lateral to medial, these nuclei
are:

1. Dentate nucleus
2. Emboliform nucleus
3. Globose nucleus
4. Fastigial nucleus
Functions
• Vestibulocerebellum/Flocculono
dular lobe: has a reciprocal
connections with vestibular and
reticular nuclei control of
body equilibrium and eye
movement
• Spinocerebellar lobe/anterior lobe:
has reciprocal connections with the
spinal cord and plays a role in
control of muscle tone as well as
axial and limb movements e.g
walking, swimming
• Cerebrocerebellar/posterior lobe:
has reciprocal connections with the
cerebral cortex and plays a role in
planning and control of movements;
and regulation of discrete
movements
Histology and Connectivity
• cerebellar cortex is divided into three
layers 
1. innermost layer, the granule cell layer
2. middle layer, Purkinje cell layer,
which is only 1-cell thick
3. outer layer, the molecular layer(made
of the axons of granule cells and the
dendrites of Purkinje cells)
4. Interneurons: Golgi cell, the basket
cell, and stellate cell
• Purkinje cells- apical dendrites form a large fan of finely branched
processes; arranged in parallel; sole source of output from the
cerebellar cortex; make inhibitory connections onto the cerebellar
nuclei
Connectivity
1. Mossy fibers originate in
the pontine nuclei, the spinal cord,
the brainstem reticular formation,
and the vestibular nuclei
-each fiber innervates hundreds of
granule cells; make excitatory
synapses with Purkinje cells 
2. Climbing fibers originate
exclusively in the inferior olive and
make excitatory projections onto
the cerebellar nuclei and onto
the Purkinje cells
Afferents and efferents
• Afferents from brain, spinal cord, vestibular nuclei, small bundles
(from tectum and red nucleus)

• Efferents via: Cerebello/Dentato-thalamic, Cerebello/Dentato-rubral,

Cerebello/fastigial-vestibular, Cerebello/fastigial- reticular
Cerebellar Connections
Contd..
Summary of pathways
Cerebellar dysfunction/Signs
• Hypotonia
- diminished resistance to passive movements of joints
- attributable to loss of cerebellar influence on the simple stretch reflex

• Gait alteration and postural changes

- assumes a wide base when he or she stands and is often stiff legged to
compensate for loss of muscle tone
- staggers toward the affected side
- head is often rotated and flexed, and the shoulder on the side of the lesion is
lower than on the normal side
• Disturbances of Voluntary Movement (Ataxia), Tremor
• Dysdiadochokinesia
• Disturbances of Reflexes- Movement produced by tendon reflexes
tends to continue for a longer period of time than normal e.g
pendular jerk
• Nystagmus
• Dysarthria- incoordination of the muscles of the larynx; speech tends
to be explosive, and the syllables often are slurred
Cerebellar syndromes
1. Vermis syndrome
- Common cause: medulloblastoma of the vermis
- Involvement of the flocculonodular lobe signs and symptoms related to the
vestibular system
- muscle incoordination involves the head and trunk and not the limbs

2. Cerebellar Hemisphere Syndrome

- Usu due to tumour
- symptoms and signs are usually unilateral and involve muscles on the side of
the diseased cerebellar hemisphere
- movements of the limbs, especially the arms, are disturbed
- swaying and falling to the side of the lesion often occur
- dysarthria and nystagmus are also common findings
BRAINSTEM
• caudal portion of the brain that connects the
diencephalon to the spinal cord and the cerebellum
• mediates sensory and motor pathways between the
spinal cord and the brain and contains nuclei of the
cranial nerves, the ascending reticular activating
system (ARAS), and the autonomic nuclei

• 4 major functions
1. provides passage to various ascending and
descending tracts that connect the spinal cord to
the different parts of the forebrain
2. contains important autonomic reflex centres
(vital centres) associated with the control of
respiration, heart rate and blood pressure
3. contains reticular activating system(RAS) which
controls consciousness
4. contains important nuclei of the last ten cranial
nerves (i.e. IIIrd to XIIth)
Midbrain
Midbrain- Internal structure
• superior colliculus - forms part of the visual reflexes, connected to
lateral geniculate body, receives afferent fibers from optic nerve,
visual cortex, spinotectal tract
- The efferent fibers form the tectospinal and tectobulbar tracts, which
are responsible for the reflex movements of the eyes, head, and neck
in response to visual stimuli

• pretectal nucleus - situated close to the lateral part of the superior

colliculus, afferent pathway for the light reflex relay here, pass to the
Edinger-Westphal nucleus, then pass to the oculomotor nerve
• oculomotor nucleus - The nucleus of the oculomotor nerve is divisible into a
number of cell groups, several groups of large motor neurons and smaller
preganglionic parasympathetic neurons (the Edinger– Westphal nucleus)
- fibres of the oculomotor nucleus pass anteriorly through the red nucleus to
emerge on the medial side of the crus cerebri in the interpeduncular fossa

• Reticular formation- mediates level of consciousness

• Subtantia nigra- dark appearance due to melanin in dopaminergic neurons
 At Inferior colliculus

Central Gey matter: nucleus of trochlear nerve, mesencephalic nucleus of

trigeminal nerve.
White matter: decussation of the superior cerebellar peduncles, lemnisci,
MLF, tectospinal, rubrosipnal
Midbrain- Clinical correlation
• Weber’s syndrome
- lesion affecting the cerebral
peduncle and the fascicle of cranial
nerve III
- Contralateral hemiplegia (including
the lower face) due to corticospinal
and corticobulbar tract involvement
- Ipsilateral oculomotor paresis,
including parasympathetic cranial
nerve III paresis
IPSILATERAL CRANIAL NERVE PALSY, contralateral hemiplegia
CN 3 and 4: Midbrain
CN 6 and 7: Pons
CN 9 to 12: Medulla
PONS
• lies in the posterior cranial fossa
on the clivus (formed by the
fusion of basi-sphenoid and basi-
occiput) anterior to the
cerebellum
• consists of grey and white
matter containing number of
nuclei and fibre tracts
respectively
Medial longitudinal fasciculus(MLF)

• heavily myelinated composite tract,

lying near the midline
• originates from the vestibular nuclei
in the rostral medulla
• interconnects the third, fourth, and
sixth cranial nerve nuclei to each
other and to the vestibular nuclei
• allowing synergistic or coordinated
movements of the two eyes and
adjustments of eye position in
response to movements of the head
Pontine nuclei
• small masses of nerve cells in basilar
part
• corticopontine fibers of the crus
cerebri of the midbrain terminate in
the pontine nuclei, axons of these
cells give origin to the transverse
fibers of the pons cross the
midline enter the middle cerebellar
peduncle and are distributed to the
cerebellar hemisphere
• This connection forms the main
pathway linking the cerebral cortex to
the cerebellum
Pontine respiratory centre
• influence the depth of
inspiration and the frequency of
breathing
• Apneusis, a prolonged
inspiratory effort interrupted by
brief periods of expiration, is
seen with some pontine lesions
PONS-Clinical correlation
• Pontocerebellar angle syndrome-  located in
the pontocerebellar angle include VIIth and
VIIIth cranial nerves, flocculus of cerebellum
and choroid plexus of fourth ventricle
- acoustic neuroma

• Pontine hemorrhage-
- pin-point pupil: due to involvement of ocular
sympathetic fibres
-Hyperpyrexia, due to severe damage to pons,
the body is cut off from heat regulating centres
in the hypothalamus.
– Deep coma, due to involvement of reticular
formation.
– Bilateral paralysis of face and limbs, due to
involvement of facial nerve nuclei and
corticospinal fibres
• Tumours of the pons
- astrocytoma of the pons is the most common tumour of the
brainstem
- signs and symptoms depend on the area affected
Locked in syndrome
• Bilateral ventral pontine lesions
• Quadriplegia due to bilateral
corticospinal tract involvement
• Aphonia due to involvement of the
corticobulbar fibers innervating the
lower cranial nerve nuclei
• reticular formation is not injured,
the patient is fully awake
• supranuclear ocular motor pathways
lie dorsally and are therefore spared;
therefore, vertical eye movements
and blinking are intact
MEDULLA

• shaped like a truncated cone

(bulb-like) hence its alternative
name ‘bulb’
• contains vital centres: (a) cardiac
centre, (b) vasomotor centre,
and (c) respiratory centre
• provides attachment to last four
cranial nerves
• central canal of the spinal cord
continues upward into the lower
half of the medulla; in the upper
half of the medulla, it expands as
the cavity of the fourth ventricle

• This divides the medulla into a

closed part, which contains the
central canal, and an open part,
which contains the caudal half of
the fourth ventricle
• Area postrema- vomitting centre
in medulla; has dopamine
receptors hence nausea is the
side effect of anti-parkinsonian
drugs
Fig: Decussation of pyramidal
(corticospinal) tracts in the lower
part of medulla
Vagus nerve nuclei
• consists of four nuclei located in
the medulla oblongata
• three main nuclei are the dorsal
motor(DMN), nucleus ambiguus,
and the solitary nucleus. The
fourth nucleus has a minor input
from the spinal trigeminal
nucleus, which receives the main
input from the trigeminal nerve
• historically called
the pneumogastric nerve
• DMN of vagus
- general visceral efferent nucleus and is
the largest parasympathetic nucleus in
the brain stem
- controls the non-striated muscle of the
viscera of the thorax (heart, bronchi,
lungs and oesophagus) and abdomen
(stomach, liver, pancreas, spleen, small
intestine and proximal part of the colon)
• NTS
- extends throughout the length of the
medulla composed of general visceral
afferents from the vagus and
glossopharyngeal nerves
- The nucleus and its central connections
with the reticular formation subserve
the reflex control of cardiovascular and
respiratory functions
- If stimulation of the oropharynx occurs, other than during swallowing, the gag reflex may
be initiated.
Vagus nerve stimulation in
intractable epilepsy
LATERAL MEDULLARY(WALLENBERG)
SYNDROME
• Most often secondary to
intracranial vertebral artery or
PICA occlusion
• Ipsilateral facial hypalgesia and
thermoanesthesia - trigeminal
spinal nucleus and tract
involvement
• Contralateral trunk and extremity
hypalgesia and thermoanesthesia -
spinothalamic tract
• Ipsilateral palatal, pharyngeal, and
vocal cord paralysis, dysphagia and
dysarthria nucleus ambiguus
Contd..
• Ipsilateral Horner syndrome
descending sympathetic fibers

• Vertigo, nausea, and vomiting

vestibular nuclei

• Ipsilateral cerebellar signs and

symptoms cerebellar
peduncle and cerebellum
Signs that help to localize brainstem
lesions
Reticular Formation
• Resembles a net (reticular) that is made up
of nerve cells and nerve fibers, located deep
in the tegmentum
• extends up through the axis of the CNS from
the spinal cord to the cerebrum
• receives input from most of the sensory
systems
• has efferent fibers that descend and
influence nerve cells at all levels of the CNS
• integrator in the CNS
• monoaminergic groups of cells are located in
well-defined areas throughout the reticular
formation
• Types- Ascending RAS, Descending RAS
Neurotransmitter system
• Networks of NT systems project to
widespread areas of the CNS
• influence the level of consciousness,
wakefulness and sleep
• play a role in pain processing,
motivation, emotion, reward, and
addiction
• most important NT systems include
those involving dopamine (DA),
norepinephrine [NE], and serotonin
(5-HT) - aminergic systems
Conclusion
• Cerebellum- functions, intracerebellar nuclei, afferents and efferents
• Brainstem- cranial nerve and and other nuceli, ascending and
descending fibres
• Brainstem syndromes
• Reticular activating system- consciousness/wakefulness
• Neurotransmitter system- dopamine, norepinephrine, serotonin
THANK YOU