BRAINSTEM LESIONS

Lesion - structural alterations of the tissue or organ --> functional dysfunctions --> manifestations --> syndrome - set of manifestations which occur together

Causes of lesions Atherosclerosis, herniation, trauma, tumor

Brainstem lesion Vascular - blood supply Herniation - fixed structures of the cranial vault --> manifestations (structures of the brainstem - locations) Cranial nuclei and nerves Ascending fiber tracts Descending fiber tracts

Figure. Cross section of brain Horizontal subdivision of brainstem Tectum, roof Quadrigemina Tegmentum: midbrain to medulla; contains all cranial nerve nuclei

Pontine, inferior olivary, quadrigemina, red nucleus, substancia nigra - not part of tegmentum but affected ??

Tracts: ascending and descending

Spinothalamic, posterior column, trigeminal (prominent ascending) Manifestation: Corticospinal, corticobulbar, cortico (prominent descending) Manifestation: paralysis, ataxia

Oculomotor... Oculomotor nuclei, edinger-westphal Trochlear... Trochlear Trigeminal... Main sensory, spinal (descending), mesencephalic, motor (masticatory) Abducens... Abducens Facial... Facial, superior salivatory, gustatory (solitary)* Vestibulocochlear... Cochlear (2nuclei), vestibular (4nuclei) Glossopharyngeus... Ambiguus, inferiors salivatory, solitary* Vagus... Dorsal motor

Under rhomboid fossa--> tegmentum--> nuclei

Purely motor are adjacent to median sulcus CN III, IV, VI, XI, XII Purely sensory are adjacent to lateral sulcus CN VIII (I & II are not part of the brainstem) Mixed are adjacent to medial sulcus (paramedian sulcus) CN V, VII, IX, X

Trigeminal nerve is more adjacent to median sulcus than lateral

Three internal longitudinal divisions oft he brainstem Tectum Tegmentum

Basis

Figure.Components of cranial and spinal nerves

Lower moror neurons are found in the spinal cord, medulla, pons, and midbrain LMNs send axons into the cranial nerves, terminating on skeletal muscles, to allow for voluntary movement Figure. Netter

Figure. Tectum, tegmentum, basis

External features of the medulla oblongata Divisons: anterior, lateral, posterior medulla

Posterior medulla Gracile and cuneate

Internal anatomy Caudal medulla

Structures Ascending pathways Continue to the medulla Origin. Spinal cord .anterolateral system .anterior and posterior spinocerebellar tracts

.posterior column system - gracile and cuneate fasciculi

Spinomesencephalic and spinothalamic tracts continue to the thalamus

Posterior column system Axons synapse on the medulla. Gracile and cuneate nuclei but the tactile and vibratory components continue rostrally via medial lemniscus

Spinocerebellar tracts Posterior tract... Axons enter the cerebellum via restiform body ICP Anterior tract... AXONS ENTER THE CEREBELLUM THROUGH SCP

Spinoolivary and spinovestibular tracts terminate medulla Spinoreticular tract terminate medulla

DESCENDING PATHWAYS Traverses the medulla en route to the spinal cord Corticospinal tract Origin cerebral cortex Rubrospinal tract and tectospinal tract Origin midbrain Reticulospinal and vestibulospinal tracts Origin pons Medulla contributes fibers to these two Medial longitudinal fasciculus At this level contains only descending fibers

Caudal medulla - level of the motor decussation Posterior medulla Motor decussation - pyramidal decussation gracile and cuneate nuclei and fasciculi posterior to the decussation Spinal trigeminal tract lateral Spinal trigeminal nucleus, pars caudalis internal to the spinal trigeminal tract...terminates spinal trigeminal nucleus

Caudal medulla - level of the sensory decussation Gracile and cuneate fasciculi Gracile and cuneate nuclei --> axons swing anteromedially - internal arcuate --> cross the midline rostral to the motor decussation -> sensory decussation

Above the level of the obex, the fibers have already decussated Area postrema... Location wall of the 4th ventricle Spinothalamic... Decussates at the spinal cord

Midmedullary level - hypoglossal nerve,

Reticular nuclei All of the cells that are interspersed among the more compact and named structures of the brainstem Raphe Bilaterally symmetrical cell groups in the brainstem located directly adjacent to the midline

Medial medullary reticular area Caudal medullary level - central nucleus of the medulla Rostral - gigantocellular reticular nucleus extends into the pons

Lateral medullary reticular area Lateral reticular nucleus Parvocellular nucleus Ventrolateral reticular area - control of heart rate and respiration

Raphe nuclei Nucleus raphe pallidus Nucleus raphe obscuris Nucleus raphe magnus - begins rostral medulla, extends pons, inhibition of pain in the posterior horn spinal cord

Vascular supply

Anterior spinal artery supply the medial structures of the medulla at all levels including the pyramid, medial lemniscus, hypoglossal nucleus and roots

Occlusion of the penetrating branches to one side of the medial medulla Medial medullary syndrome ... Deferine syndrome

Occlusion of the main anterior spinal artery Bilateral deficit... Reflecting both damaged to both pyramids, both medial lemnisci, both hypoglossal nuclei or exiting roots

No loss of pain and temperature sensations

Posterior spinal artery Supply the posterior medulla caudal to the obex Major structures Posterior column nuclei, gracile and cuneate nuclei Spinal trigeminal tract and nucleus

Posterior inferior cerebellar artery Supply the entire posterolateral medulla Structures Anterolateral system Spinal trigeminal tract and nucleus vestibular nuclei Solitary tract and nucleus ambiguus Sensory and motor deficits Lateral medullary syndrome - PICA syndrome or wallenberg syndrome Loss of pain and temperature, nystagmus, vertigo, half no gustatory sense, dysphagia, hoarseness

Medial medullary syndrome Contralateral hemipareais Contralateral loss of proprioceptiona nd vibratory senses on the body Deviation of the tongue to the ipsilateral side when protrude

Vascular lesion of the posterior spinal artery Rare

Ipsilateral loss of proprioception and vibratory senses Ipsilateral loss of pain and temperature from the face

Lateral medullary syndrome - wallenberg syndrome Contralateral loss of pain and temperature sensations from the body Ipsilateral loss of pain and temperature sensations from the face

External features of the pons Divided Pontine tegmentum posterior part Basilar pons anterior part

Basilar pons Massive bundles of transversely oriented fibers Anteriorly and laterally Enter the cerebellum as MCP Trigeminal nerve root exit marks the transition Anterior basilar pons Posterior MCP emerge V - exit laterally Medial to lateral sequence in the inferior pontine sulcus VI, VII, VIII VII two roots SVE fibers

SVA, GVE, GSA fibers (intermediate nerve)

How do you differentiate between an upper vs lower medulla lesion? Lower medulla, no manifestations Upper medulla, medial lemniscus .above obex contralateral .lower obex ipsilateral at gracile and cuneate nuclei

Pons? Only lateral rectus paralysis No two point discrimination Paralysis

Midbrain, pons, medulla Paralysis present

Herniation syndrome to the midbrain What happens if midbrain is hit? Patient is awake, reticular and cerebellum are intact

Uncal herniation Tentorium cerebelli High pressure, uncus is squished Midbrain is squished in turn

Herniation in the foramen magnum Medulla affected Ventrolateral reticular formation affected Cardiorespiratory arrest