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The brainstem has an ectodermal origin and is composed of 4 parts: the diencephalon,
mesencephalon, pons, and medulla oblongata. It serves as the connection between the
cerebral hemispheres with the medulla and the cerebellum and is responsible for basic vital
functions, such as breathing, heartbeat blood pressure, control of consciousness, and
sleep. The brainstem contains both white and gray matter. The gray matter of the brainstem
(neuronal cell bodies) is found in clumps and clusters throughout the brainstem to form the
cranial nerve nuclei, the reticular formation, and pontine nuclei. The white matter consists
of fiber tracts (axons of neuronal cells) passing down from the cerebral cortex—important
for voluntary motor function—and up from peripheral nerves and the spinal cord—where
somatosensory pathways travel—to the highest parts of the brain. The internal structure of
brainstem, although complex, presents a systematical arrangement and is organized in 3
laminae (tectum, tegmentum, and basis), which extend its entire length. The motor pathway
runs down through the basis, which is located at the most anterior part. The cranial nerve
nuclei are settled into the middle layer (the tegmentum), just in front of the 4th ventricle and
are placed, from medial to lateral, on the basis of their function: somatic motor, visceral
motor, visceral sensory, and somatic sensory. All the somatosensory tracts run upward to
the thalamus crossing the tegmentum in front of the cranial nerve nuclei. The tectum,
formed by the quadrigeminal plate and the medullary velum, contains no cranial nuclei, no
tracts and no reticular formation. The knowledge of precise anatomical localization of a
lesion affecting the brainstem is crucial in neurological diagnosis and, on this basis, is
essential to be familiar with the location of the mayor tracts and nuclei appropriately.
Nowadays, current magnetic resonance imaging techniques, although still macroscopic,
allow the fine internal structure of the brainstem to be viewed directly and make it possible
to locate the main intrinsic structures that justify the symptoms of the patient. In this article
we discuss the anatomy of the brainstem and highlight the features and landmarks that are
important in interpreting magnetic resonance imaging.
Semin Ultrasound CT MRI 31:196-219 © 2010 Elsevier Inc. All rights reserved.
196 0887-2171/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1053/j.sult.2010.03.006
Anatomy of the brainstem 197
period becomes expanded into 3 vesicles that demarcate the pouches. The cavities of these diverticula are the rudiments
territory for cerebral hemispheres and brainstem. These consti- of the lateral ventricles. The anterior part of the forebrain,
tute the 3 primary cerebral vesicles and correspond, respec- including the rudiments of the cerebral hemispheres, is
tively, to the future forebrain (prosencephalon), midbrain (mes- called telencephalon, and its posterior portion is termed di-
encephalon), and hindbrain (rhombencephalon). encephalon. The cavity of the diencephalon is the rudiment
The midbrain or mesencephalon is the only one that does not of the 3rd ventricle.
undergo any further segmentation. The first (forebrain) and Simultaneously, the rhombencephalon is segmented into
third (hindbrain) divide once more into a series of 5 vesicles that 2 structures: the anterior one, named metencephalon, con-
become the major portions of the CNS within the skull. sisting of the pons, cerebellum, and the intermediate part of
The forebrain grows forward and the cerebral hemispheres the 4th ventricle; and the myelencephalon, which comprises
originate as diverticula, which rapidly expand to form 2 large the medulla oblongata and the lower part of the 4th ventricle.
Figure 3 Sequential diagrammatic picture of embryologic development of the central nervous system. During week 2,
the embryo is a bilaminar disk, consisting of ectoderm and endoderm. The cells of the ectoderm migrate to the median
plane of the dorsum of the embryonic disk and form a linear band called the primitive streak. Cells from the primitive
streak proliferate and migrate down toward the endoderm (to form the embryonic mesoderm) and cranially toward
the prechordal plate as part of the notocordal process, which will develop the notocord. The notocord induces the
overlying ectoderm to form the neural plate that will eventually give rise to the CNS. The neural plate grows along the
notochord axis and beyond. Then, it forms a median longitudinal neural groove with neural folds on either side. At
the top of each fold are the cells that will make up the neural crest. The neural folds move inward and fuse to form the
neural tube. As the tube pinches off, the areas of neural crest cells on either side separate and form a flat mass to each
side of the neural tube. These neural crest cells will become ganglia of spinal, autonomic and cranial nerves. Finally, the
neural tube submerges beneath the ectoderm to become a separate structure. The brain is developed from the anterior
end of the neural tube, which at an early period becomes expanded into 3 vesicles that demarcate the territory for
cerebral hemispheres and brainstem. (Color version of figure is available online.)
Anatomy of the brainstem 199
Figure 7 Posterior view of the medulla oblongata and floor of the 4th
Figure 5 Coronal inversion-recovery (IR) T1-weighted magnetic reso- ventricle in a gross specimen. Posterior median sulcus (arrow); gracile tu-
nance scan shows a clear discrimination between gray-white matters in bercle (white arrowhead); cuneate tubercle (black arrowhead); inferior cer-
cerebral hemispheres and basal ganglia. This differentiation is scarce in the ebellar peduncles (open arrows); hypoglossal eminence (black asterisk);
brainstem but we can identify some superficial structures, which correlates facial colliculus (black dotted circle); and area acustica (green dotted form).
with those viewed at the gross specimen. P, pons; Py, pyramid; O, olive; Median sulcus (thick arrow). Medial eminence (me); area cinerea (white
and thick arrow, anterior median fissure. Note the cisternal portions of 4th, arrow); striae medullare (thin arrow). (Color version of figure is available
5th, 7th, and 8th cranial nerves (arrows from up to down). online.)
200 M.Á. Fernández-Gil et al
dal tract cross the midline and sweep dorsally and laterally
into the lateral funiculus to form the lateral corticospinal tract
in the spinal cord. The fascicles that cross the midline are
called the decussation of the pyramids. A smaller number of
corticospinal axons in the pyramids remain on the same side
and continue into the spinal cord as the medial corticospinal
tract, located in the ventral funiculus (Figs. 4 and 5). Imme-
diately and posteriorly to the pyramids are 2 rounded and
elongated elevations, the olives, which are shaped by the
underlying inferior olivary nuclei (Figs. 4 and 5).
Between the pyramids and the olives there is a groove, the
preolivary groove, where emerge the rootlets of the hypoglos-
sal nerve (12th cranial nerve). Posterior to the olives is the
postolivary groove, where appear the roots of the glossopha-
ryngeal and vagus nerves and the cranial roots of the acces-
sory nerve (9th, 10th, 11th cranial nerves, respectively; Figs.
4 and 6). Posterior to the olives are the inferior cerebellar
peduncles, which connect the medulla to the cerebellum
(Fig. 7).
The posterior surface of the medulla oblongata is di-
Figure 8 3-T high-resolution axial PD-weighted image shows the pyra-
vided in 2 parts: the lower half, whose surface is continu-
midal pathway (arrowhead), medial lemniscus (arrow), olivary bulging
(asterisk), and inferior cerebellar peduncles (open arrow). ous with the posterior aspect of the spinal cord and where
the posterior median sulcus can be found, and the supe-
rior half, which forms the lower part of the floor of the 4th
approximately, at the level of the foramen magnum (Fig. 1). ventricle. On each side of the median sulcus there are and
On its anterior surface is the anterior median fissure, which 2 elongated swellings, the gracile tubercle, produced by
runs continuously inferior to the anterior median fissure of the underlying gracile nucleus, and lateral to this, the
the spinal cord. On each side of the median fissure there is a cuneate tubercle, produced by the underlying cunate nu-
swelling called the pyramids that are composed of axons cleus (Fig. 7).5-7
from the precentral gyrus of the cerebral cortex that are des- Coronal images through the medulla oblongata clearly
tined to innervate the spinal cord gray matter, the corticospi- may depict the anterior structures as pyramids and olives,
nal or pyramidal tracts. The distal regions of the pyramids which can be demonstrated, as well, in axial sections
become thin, and at that point some fascicles of the pyrami- where cisternal portions of the lower cranial nerve com-
Figure 9 Cranial nerve nuclei. (A) Scheme of the cranial nerve nuclei within the brainstem. Note the location and the direction of
their axons. (B) dorsal view scheme of the brainstem and cranial nerve nuclei location. Quadrigeminal plate (asterisks); lateral and
medial geniculate bodies (arrows). The nuclei of the cranial nerve 3rd to 12th lie in the brainstem, just in front of the floor of the 4th
ventricle and the sylvian aqueduct. Four are located in the medulla oblongata (9th, 10th, 11th, 12th); 4 in the pons (5th, 6th, 7th,
8th) and 4 above the pons (3rd, 4th lay in the midbrain). The 1st (olfactory) and the 2nd (optic) are above the brainstem. The 4
motor nuclei that are in the midline of the brainstem are those that divides equally into 12 that is 3, 4, 6, and 12. They emerge
through the anterior midline surface, except the 4th, which exits from the dorsal part of the midbrain after its decussation in the
superior medullary velum. Although 5, 7, and 9 cranial nerve nuclei have motor function, they also have sensory components and
they do not divide evenly into 12. Thus, they are not pure motor and, on this basis, they are not located medially. The 8th cranial
nerve nucleus (entirely sensory) and 11th (pure motor, which does not divide equally into 12), are located laterally.20 Salivatory and
lacrimal nuclei (s). (Color version of figure is available online.)
Figure 12 (A) Axial anatomic section tinged with Mulligan’s method through the mid-pons. The central pons is
located between the middle cerebellar peduncles (mcp), just in the entry zone of the 5th cranial nerve (white
arrows). White matter tracts are well depicted in dark brown color: the corticospinal tracts (cst) at the middle of
the basis pontis are well seen. The medial lemniscus shows a horizontal disposition and serves as the limit between
the tegmentum (posteriorly) and basis (anteriorly). Scp: superior cerebellar peduncle. Pontine nuclei are colored
in blue and occupy the great part of the basis pontis (arrowheads). IV, 4th ventricle; median longitudinal
fasciculus (black arrow); median eminence: asterisk. (B) Axial 3-T high-resolution PD-weighted image. The
magnetic resonance appearance of the brainstem structures correlates exquisitely with the anatomic slice. The
inferior extension of the wings of the ambient cisterns can produce 2 high-intensity areas on either side of the 4th
ventricle and superior cerebellar peduncles (open arrow). (Color version of figure is available online.)
Figure 14 View into the anterior sector of cerebellopontine angle and axial
anatomic section through the middle of the pons. Cca, cavernous carotid
artery; ps, pituitary stalk; ON, optic nerve; ba, basilar artery. Cisternal por-
tions of 5th, 6th, 7th, 8th, and 12th cranial nerves. Note the motor branch
of the 5th cranial nerve (thin arrow) accompanying the thicker sensory root
Figure 13 Anteriorviewoftheponsandmedullaoblongatagrossspecimen. (arrowhead) and reaching the brainstem just in the junction between the
There are many transverse fibers (pontocerebellar tract) crossing the sur- pons and the middle cerebral peduncle (mcp). Entrance to the Meckel’s
face of the pons (arrows) to arrive at the cerebellum through the middle cave (curved arrow). Cst, Corticospinal tracts; ML, medial lemniscus; scp,
cerebellar peduncle (mcp). The basilar groove may be appreciated in the superior cerebellar peduncles; IV, superior portion of the 4th ventricle; roof
middle (asterisk). Note the decussation of pyramidal tract at the inferior of the 4th ventricle formed by the superior medullary velum (smv); locus
end of the pyramids (curved arrow). (Color version of figure is available caeruleus (black arrow). White arrows: deep portions of the Ambiens cis-
online.) tern. (Color version of figure is available online.)
Anatomy of the brainstem 203
Figure 16 (A) Sagittal turbo spin echo (TSE) T2-weighted and (B) sagittal SET1-weighted images through the brainstem clearly
depict the midline structures such us hypothalamus (asterisk), infundibulum (arrow) and pineal gland (white arrow), quadrigem-
inal plate (open arrow), superior medullary velum (arrowhead). Note the CSF fluid void passing through the aqueduct and Monro
foramina (thick arrows). P, pons; dotted line; hypothalamic sulcus.
204 M.Á. Fernández-Gil et al
The sensory nucleus of both nerves is the nucleus of the The Pons
tractus solitarius. Sensations of taste travel through the pe-
ripheral axons of glossopharyngeal and the vagus nerve. They The pons is located between the midbrain cranially and the
enter the brainstem together and form the tractus solitarius, medulla oblongata caudally. It received its name because of
whose fibers terminate at the nucleus solitarius. Afferent im- the appearance it presents on the anterior surface, which is
pulses from the carotid sinus, a baroreceptor situated at the similar to a bridge connecting the right and left cerebellar
bifurcation of the common carotid artery, also travel with the
glossopharyngeal nerve and end in the nucleus of the tractus
solitarius. They are connected with the dorsal motor nucleus
of the vagus nerve. On this basis, the carotid sinus reflex
involves glossopharyngeal and vagus nerves, which assist in
the regulation of arterial blood pressure.8 The glossopharyn-
geal and vagus nerves exit the medulla oblongata as a series of
rootlets in a groove between the olive and inferior cerebellar
peduncle called the retro-olivary or posterior lateral sulcus
(Figs. 4, 6, 9, 10, and 15).
Figure 19 TSE T2-weighted axial high-resolution image at the level of the pons. The cisternal portions of the 6th (open
arrow), 7th (arrow), and 8th (arrowhead). At the IAC the 2 portions of the vestibulocochlear nerve may be seen: the
posterior nerve runs toward the semicircular channels and the anterior 1 toward the cochlea. Both portions fuse at the
CPA cistern to form the bundle of the vestibulocochlear nerve. Note the bulging of the genu of the facial nerve on
the floor of the 4th ventricle forming the facial colliculi (asterisk).
206 M.Á. Fernández-Gil et al
Figure 21 (A, B) 3T Axial high-resolution PD-weighted images through the midbrain. It is recognized by the “mouse
ears.” White matter tracts appear as dark structures: Corticospinal tracts (arrowheads), medial lemniscus (open arrow),
and medial longitudinal fasciculus (arrow). The white fibers of the superior cerebellar peduncles (scp) have decussated
and run superiorly to reach the red nucleus (asterisk).
Anatomy of the brainstem 207
central gyri. The output from these neurons is carried via the
corticobulbar tracts, which roam along the genu of the inter-
nal capsule. This component is the supranuclear contribu-
tion to the facial nerve function. Keeping this in mind, we
must consider that there is a difference in the transmission of
neural orders to the upper face and lower face: the cortico
nuclear fibers that supply the muscles of the upper part of the
face partially decussate and consequently, originate in both
cerebral hemispheres, whereas the fibers that supply the
muscles of the lower part of the face decussate completely,
Figure 24 (A) Coronal fluid attenuation inversion recovery and (B) coronal SE T2-weighted sequences show the
rhomboid shape of the 4th ventricle. In that plane we can see the superior (arrows), medial (asterisk), and inferior
(arrowhead) cerebellar peduncles, which constitute the lateral boundaries.
giving innervation from the opposite cerebral hemisphere. The vestibular nerve is the nerve of equilibrium. It arises
The knowledge of this pathway help in the clinical examina- from bipolar cells in the vestibular ganglion, ganglion of
tion and location of a facial lesion because a supranuclear Scarpa, which is situated in the upper part of the outer end of
facial palsy would have a corresponding contralateral central the internal auditory meatus. The cochlear nerve is the nerve
lesion, and would likely spare the upper face.12 However, of hearing and conducts nerve impulses concerned with
another involuntary pathway exists; it is separated and con- sound from the organ of Corti in the cochlea. Both vestibular
trols mimetic or emotional changes in facial expression. This and cochlear nerve leave the internal auditory canal at the
other pathway forms part of the reticular formation. porus acusticus and link to form the vestibulocochlear nerve
The sensory nucleus is the upper part of the nucleus of the bundle (8th), which course the CPA cistern with the facial
tractus solitarius (solitarius nucleus or gustatory nucleus) nerve (7th; Figs. 15 and 19).13,14
and lies poserolateral and close to motor nucleus of the 7th. It The vestibulocochlear nerve enters the anterolateral brain-
is the end point for axons originating in the geniculate gan- stem at the pontomedullary junction. Vestibular nerve-fibers
glion of the petrous bone. This axons form the sensory root, terminate in the vestibular nuclear complex (Fig. 17A). The
also called nervus intermedius (pars intermedii of Wrisberg). vestibular complex consists of 4 nuclei (lateral, superior, me-
The parasympathetic nuclei are the superior salivatory and dial, and inferior) and is located along the lateral floor of the
lacrimal nuclei, which lie posterolateral to the main motor 4th ventricle in the lower pons (Figs. 7 and 9). Axons from
nucleus, just slightly superior to the gustatory nucleus, at the these nuclei go along 3 roads: (1) to cerebellum via the ves-
inferior pons. They give rise to the motor parasympathetic tibulocerebellar tract to aid in coordination, (2) descend un-
fibers supplying the submandibular, sublingual and lacrimal
glands (Fig. 9).
The sensory root is composed of both a sensory compo-
nent and a parasympathetic motor component. The end
function of the sensory root is (1) to provide taste function to
the anterior two-thirds of the tongue, (2) to allow sensory
control of lacrimation, and (3) to control the stapedial reflex.
Associated with this functionality is the control of the output
of the sublingual and submandibular glands.
The 2 roots of the facial nerve (motor and sensory) emerge
at the lower border of the pons in the recess between the olive
and the inferior peduncle. The motor part is more medial and
the sensory part is lateral to the former. Immediately poste-
rior to the lateral side of the sensory part is the 8th nerve
(Figs. 15 and 19).
Vestibulocochlear Nerve Nuclei
The vestibulocochlear nerve consists of 2 distinct parts, the
vestibular nerve and the cochlear nerve. They are concerned Figure 25 Coronal cut of a brain specimen tinged with Mulligan’s
with the transmission of afferent information from the inter- method. Some brainstem structures may be identified: cn, caudate
nal ear to the CNS related to balance and hearing. Both are nucleus; lv, lateral ventricle; ic, internal capsule; th, thalamus; bg,
sensory in function and course together until they reach their basal ganglia; sn, substantia nigra; ec, external capsule. (Color ver-
respective nuclei in the brainstem. sion of figure is available online.)
Anatomy of the brainstem 209
crossed to the spinal cord forming the vestibulospinal tract, menturn. From this both stations they run cranially form-
and (3) to join the nucleus of the cranial nerves III, IV, VI via ing the lateral lemniscus. Most neurons from the dorsal
the medial longitudinal fasciculus providing conjugate gaze cochlear nucleus tend to extend directly to the contralat-
and conjugate eye reflexes.15 eral lateral lemniscus and only a few auditory fibers ascend
The fibers of the cochlear nerve enters the brainstem at in the ipsilateral lateral lemniscus (Fig. 32).
the lower border of the pons on the lateral side of the
emerging facial nerve and are separated from it by the
vestibular nerve. When enters the pons the nerve bifur-
The Midbrain
cates to synapse with the secondary neurons which are The midbrain connects the pons to the diencephalon. It com-
situated in the dorsal cochlear and ventral cochlear nu- municates with the cerebellum via the superior cerebellar
cleus, located on the surface of the inferior cerebellar pe- peduncles (Figs. 1 and 20). On the anterior surface of the
duncle, lateral to the restiform body. The dorsal cochlear midbrain there is a deep depression in the midline, the inter-
nucleus process high-frequency sound input (outer fibers peduncular fossa, which is bounded on either side by the
from the cochlear base). The ventral nucleus senses low- crus cerebri (Fig. 20). Many small blood vessels perforate the
frequency sound (Fig. 17A).16 floor of the interpeduncular fossa, and this region is termed
Some axons of the ventral cochlear nucleus synapse the posterior perforated substance (Fig. 15). The part situ-
with the ipsilateral superior olivary nucleus and others ated posterior to the cerebral aqueduct is the tectum and on
cross the midline to form the trapezoid body, the major its surface there are 4 colliculi (corpora quadrigemina; Figs. 9
acoustic pathway decussation, located in the pontine teg- and 16). These are rounded eminences that are divided into
Figure 26 (A) Axial IR T1-weighted image through the midbrain-diencephalon. The posterior margin of the thalami (PV,
pulvinar) hang over the superior colliculi (Sc). (B) Axial IR T1-weighted image through the diencephalon. The 3rd
ventricle and the structures, which surround it, form the diencephalon. The thalami are at both sides of the 3rd
ventricle (arrowheads) and the internal capsule separates (arrows) them from the basal ganglia (Bg). (C) Axial DP-
weighted and (D) axial T2-weighted images show the corticospinal tracts that run downward through the posterior
limb of the internal capsule (arrow). On T2-weighted images the corticospinal pathway is seen as 2 high intensity dots
positioned at the posterior limb of the internal capsule (thick arrow).
210 M.Á. Fernández-Gil et al
From these nuclei, the fibers pass forward through the sinus between the oculomotor nerve cranially and the oph-
tegmentum, the MLF, the red nucleus, and the medial part of thalmic division of the trigeminal nerve (V1) caudally.
the substantia nigra, and emerge from the oculomotor sulcus
on the medial side of the cerebral peduncle to enter the in-
terpeduncular cistern (Figs. 9 and 23A). The 3rd nerve (with The 4th Ventricle
accompanying parasympathetic fibers) passes ventrally be- The 4th ventricle, or cavity of the hindbrain or rhomben-
tween the posterior cerebral and superior cerebellar arteries, cephalon, is situated in front of the cerebellum and behind
inferior to the posterior communicating artery and medial to the pons and upper half of the medulla oblongata It is lined
the free edge of the tentorium to enter the roof of the cavern- by ciliated epithelium, and is continuous below with the
ous sinus.9 The oculomotor nerve innervates all the extraoc- central canal of the medulla oblongata. Above, it communi-
ular muscles except the lateral rectus and the superior cates, through the cerebral aqueduct, with the cavity of the
oblique muscle and provides parasympathetic innervation to 3rd ventricle (Figs. 1 and 16). It possesses a roof or dorsal
the constrictor pupillae and ciliary muscles via the ciliary wall, a floor or ventral wall, and lateral boundaries.
ganglion.
Roof or Dorsal Wall
Trochlear Nerve Nucleus (4th) The upper portion of the roof is formed by the superior
The trochlear nerve is the slimmest of the cranial nerves and cerebellar peduncle and the superior medullary velum. The
the only one to leave the posterior surface of the brainstem. It superior peduncle emerge from the central white substance
is entirely motor and supplies the superior oblique muscle of of the cerebellum, pass upward and forward, forming, at first,
the eyeball allowing turning the eye downward and laterally. the lateral boundaries of the upper part of the cavity. On
The trochlear nucleus is situated in the dorsal midbrain, cau- approaching the inferior colliculi, they converge, and their
dal to the oculomotor complex and dorsal to the MLF, im- medial portions overlap the cavity and form part of its roof.
mersed in the anterior part of the gray matter that surrounds The superior medullary velum, which is a thin white matter
the cerebral aqueduct of the midbrain. The landmark to iden- lamina, fills the angular interval between both superior pe-
tify its location is the level of the inferior colliculus (Figs. 9 duncles (Fig. 9).
and 23B). The lower portion of the roof is formed by the inferior
From its origin it runs downward and backward through medullary velum. This is continued downward and for-
the tegmentum, around the aqueduct, and decussate, with ward from the central white substance of the cerebellum
the nerve of the opposite side, in the superior medullary and ends inferiorly in a thin, concave, somewhat ragged
velum emerging from the surface of the velum, immediately margin. Immediately inferior to the inferior medullary ve-
behind the inferior colliculus. lum, in the midline, there is a thin triangular shaped area
In the subarachnoid space, the nerve turns anteriorly with no nervous matter called Obex, which forms, at the
through the Ambiens cistern and runs between the tentorium same time, the close-up of the posterior median sulcus of
and the midbrain. It passes around the cerebral peduncle the medulla (Fig. 10).
parallel to the 3rd cranial nerve and, just like it, courses In the roof of the 4th ventricle there are 3 openings, ie, 1
between the superior cerebellar artery and posterior cerebral medial and 2 laterals: the medial aperture (foramen Ma-
artery. The nerve enters the lateral dural wall of the cavernous gendi), is situated immediately above the inferior angle of the
Figure 29 (A) Coronal fast spin echo T2-weighted and (B) coronal TSE T1-weighted after gadolinium injection. Both
images clearly demonstrate the corticospinal tracts passing through the internal capsule (arrowheads), pes cerebri in the
midbrain (arrows) and anterior portion of the pons (open arrow).
212 M.Á. Fernández-Gil et al
ventricle (above the Obex); and the lateral apertures (foram- boidal shape and its boundaries (superior medullary velum
ina of Luschka) are found at the extremities of the lateral and cerebellar peduncles). We can also identify in axial
recesses. By means of these 3 openings the ventricle commu- planes the facial colliculi what indicates the level of the 6th
nicates with the subarachnoid cavity owing the cerebrospinal and 7th cranial nerve nuclei (Figs. 19 and 24).
fluid to circulate.
The non-nervous part of the roof is formed by the epithe-
lial lining of the ventricle, which covers the deep surface of
The Diencephalon
the inferior medullary velum and extends on to the floor of The diencephalon, consists of the 3rd ventricle and the structures
the ventricular cavity; it is covered and strengthened by a which bound it. It extends posteriorly to the point where the 3rd
portion of the pia mater, which is named the Tela choroidea
of the 4th ventricle. The Tela choroidea has 2 highly vascular
infections, the choroid plexuses.
ventricle becomes continuous with the cerebral aqueduct and an- the thalami is narrow and rounded and forms de posterior
teriorly as far as the interventricular foramina (Figs. 1 and 16). The boundary of the interventricular foramen (Fig. 16).
diencephalon can be divided into 4 major parts: the epithala- The posterior extremity is expanded, directed backward
mus, the hypothalamus, the subthalamus, and the thalamus. and lateral ward, and overlaps the superior colliculus. Medi-
The epithalamus comprises the trigonum habenulæ, the ally, it presents an angular prominence, the pulvinar, which
pineal body, and the posterior commissure. The hypothala- is continued laterally into an oval swelling, the lateral genic-
mus includes the subthalamic tegmental region and the ulate body. Beneath the pulvinar, but separated from it by the
structures forming the greater part of the floor of the 3rd superior brachium, is a second oval swelling, the medial
ventricle. It is the only area exposed to the surface and con- geniculate body (Figs. 9 and 28), which forms part of the
sists of the corpora mammillaria, tuber cinereum, infundib- auditory pathway. Lateral is the lateral geniculate body,
ulum, hypophysis, and optic chiasma (Figs. 15, 16, and 26). which forms part of the visual pathway.
The subthalamic tegmental region is the upward continua- The thalamus is divided into several parts, which contain
tion of the tegmentum; it lies on the ventrolateral aspect of the groups of different thalamic nuclei. The anterior part of the
thalamus. The red nucleus and the substantia nigra are pro- thalamus contains the anterior thalamic nuclei, which receive
longed into its lower part; in front it is continuous with the the mammilothalamic tract from the mammillary nuclei. The
substantia innominata of Meynert. Medially, it is the gray sub- function of the anterior thalamic nuclei is closely associated
stance of the floor of the 3rd ventricle, the corpus subthalami- with of that of the limbic system and is concerned with emo-
cum (nucleus of luys), which is a brownish mass, lenticular in tional tone and the mechanisms of recent memory.
shape on transverse section, and situated on the dorsal aspect of The medial part of the thalamus contains the large dorso-
the fibers of the base of the cerebral peduncle (Fig. 25). medial nucleus and several smaller nuclei. The dorsomedial
The thalamus is the largest part of the diencephalon and nucleus has 2 connections with the whole prefrontal cortex of
serves as a relay station to all the main sensory tracts. It may the frontal lobe of the cerebral hemisphere. It also has similar
be regarded as a large ganglionic mass in which the ascending connections with the hypothalamic nuclei. The medial part
tracts of the tegmentum and a considerable proportion of the of the thalamus is responsible for the integration of a large
fibers of the optic tract end, and from the cells of which variety of sensory information, including somatic visceral
numerous fibers (thalamocortical) take origin, and radiate to and olfactory information and the relation of this information
almost every part of the cerebral cortex. to ones emotional feelings and subjective states.
It consists of 2 large ovoid masses, situated one on either The lateral part is subdivided in dorsal and ventral com-
side of the 3d ventricle (Figs. 25 and 26). The anterior end of ponents. The dorsal stage includes the lateral dorsal nucleus,
Figure 31 Axial PD-weighted high-resolution images performed with a 3-T equipment. The main running tracts, which
cross the brainstem, may be identified. The pyramidal pathway is marked with arrowheads; The lemniscus (ie, medial
lemniscus, spinotrigeminal lemniscus, and spinothalamic pathway) is shown by the arrows. The medial longitudinal
fasciculus is only seen in 5 images as 2 dark dots just in front of the 4th ventricle and located at both side of the midline
(open arrows). (Color version of figure is available online.)
214 M.Á. Fernández-Gil et al
medial lemniscus, vestibular, acoustic and visual pathways, terminate primarily within the medial reticular zone. A 4th
cerebelloreticular pathways. Efferent projections extend region must be added: the intermediate zone, found only
down to the brainstem and spinal cord through reticulobul- in the medulla, is situated between the medial and lateral
bar and reticulospinal tracts. Additional pathways extend to columns. It is involved in autonomic regulation of respi-
the corpus striatum, the cerebellum, the red nucleus, the ration, heart rate, and blood pressure.22,23
substantia nigra, the tectum and the nuclei of thalamus, sub- On the basis of this organization we may say that the RF is “a
thalamus and hypothalamus.21 mess well arranged,” and its functions are accurately distributed.
The RF has a complex organization, but it is not random Thus, caudal to the midpontine level, RF is involved in the
and may be divided, for teaching purposes, into 3 longi- coordination of fine movements, autonomic regulation of respi-
tudinal columns with ill-defined boundaries. This areas ration, heart rate, and blood pressure. Rostral to the midpontine
are distinguished on the basis of the their cytoarchitecture level the RF is involved in arousal, consciousness, and the wak-
but they are also functionally distinct. In addition a 4th ing state. The RF also regulates the preservation of mental estate,
zone is defined in the medulla: (1) the raphe with cells homeostasis-neurovegetative reflexes, postural reflexes, and
lying along the midline. They mediate posture, movement, taste.2 Because of its redundancy, a bilateral lesion or complete
pain, autonomic function and arousal; (2) the paramedi- section of the tegmentum is required to cause dysfunction of the
an-medial zone proyects to the cerebellum and to hypo- RF (Figs. 17, 23, and 27).
thalamus and thalamus (via the central tegmental tract)
and to the spinal cord via the reticulospinal tract. All of
these projections are associated with motor functions; (3)
The Running Tracts
the lateral zone receives multiple sensory inputs from the Several ascending and descending tracts travel the entire brain-
spinal cord, cranial nerves and cerebellum. It is thought to stem. The most important descending one is the motor path-
be an afferent association area and has short axons that way, which is composed by the corticospinal and corticobulbar
tracts. It controls the voluntary skeletal muscle activity of the
body and face. There are several important ascending tracts that
control: the homunculus has a very large face and mouth pyramids. The crossed fibers enter the lateral white column of
because there are many upper motor that innervate these the spinal cord to form the lateral corticospinal tract. The few
parts of the body. This initial somatotropic organization in fibers, which do not cross the midline, descend in the anterior
the cortex continues along the whole route of the pathway white column of the spinal cord as the anterior corticospinal
(Fig. 28). tract. The fibers of these both tracts synapse with the second
When one passes through the midbrain, pons and me- neuron located at the anterior gray column of the medulla.
dulla oblongata some of the axons (corticomesencephalic, The clinical appearance of a lesion affecting the corticospi-
corticopontine, and corticobulbar tracts) cross the midline nal tract depends on the level of injury. Usually it manifests as
to terminate at the motor cranial nuclei of the contralateral an upper motor neuron defect, which results in contralateral
side. Lesions involving the corticobulbar tracts before they hemiparesis accompanied by spastic paralysis, hyper-re-
have decussated within the brainstem will result in a con- flexia, and Babinski sign. If all cranial nerves are affected,
tralateral loss of motor function in the face; lesions involv- then, the lesion is above the midbrain. If the lesion is located
ing the motor nuclei themselves or exiting motor compo- in the brainstem, it will cause lower motor neuron distur-
nents of the appropriate cranial nerves will result in an bance on the level where the lesion is and long tract signs
ipsilateral hemiparesis. The greater part of these descend- below the lesion (ipsilateral cranial nerve dysfunction and
ing fibers, however, extends downward to the spinal cord contralateral hemiparesis).19,24-27
to form the corticospinal tract. The corticospinal tract may be identified on magnetic res-
At the junction of the medulla oblongata and the spinal cord, onance imaging as 2 well-defined bilaterally symmetric
most of the fibers cross the midline at the decussation of the round or oval foci increased intensity in the posterior internal
Figure 36 Axial 3-T high-resolution images through the pontomedullary junction, pons, upper pons, and midbrain
showing the medial longitudinal fasciculus (arrows). It may be seen as 2 paired dark spots just near the floor of the 4th
ventricle. It extends from the upper medulla to the midbrain connecting the 8th, 6th, 4th, and 3rd cranial nerve nuclei
with the reticular formation.
218 M.Á. Fernández-Gil et al
capsule. These normal focal hyperintense areas are 3 to 4 mm (of the spines) and temperature of the face go through the
in diameter, have homogeneous internal architecture and are “spinotrigeminal tract.”
without any mass effect. The high intensity indicates that the The other main sensations, proprioception and touch, are
corticospinal fibers, at this level, have lower axonal and my- transported by the lemniscus. The medial lemniscus carries
elin densities compared with the surrounding posterior cap- the information from the body and, of course, trigeminal
sular fibers, which are tightly packed myelinated with small- lemniscus transfers the sensations from the face.19,25,26,29
caliber axons (Figs. 26, 29, and 30). Because of the complexity of the brainstem organization
Normal hyperintense foci are observed usually in the ros- and its many connections, we are going to simplify the anat-
tral midbrain on T2-weighted images, but they could not be omy into those which the radiologist must know: the spino-
followed below the caudal midbrain because the corticospi- thalamic, spinotrigeminal, medial lemniscus, trigeminal lem-
nal tracts separate into several bundles in the pons and the niscus, longitudinal medial fasciculus, and lateral lemniscus.
density of the large axons decreases.28 At the pons these fibers These 6 tracts are represented and explained in detail in Figs.
may be identified in axial PD-weighted images as transversal 32-36. The main somatosensory pathways are summarized
foci of dark gray color (Figs. 30 and 31). in the Table 2.
For teaching purposes, we are going to consider that all the 1. Cerebellar and basal ganglia lesions result in motor
different ascending pathways, which are in charge of conduit problems.
the sensations, consist of 3 neurons. The first neuron has its 2. Basal ganglia disorders are specifically characterized by
cell body in the posterior root ganglion of the spinal nerve. A meaningless, unintentional, and unexpected move-
peripheral process connects with a sensory receptor ending, ments.
whereas a central process enters the spinal cord through the 3. The presence of cranial nerve involvement signifies that
posterior root to synapses on the second neuron. The second the lesion lies above the level of the foramen magnum.
neuron gives rise to an axon that cross the midline (de- 4. The presence of a radicular pain along an extremity
cussates) and ascends to a higher level of the CNS, where it suggests that the lesion lies below the level of the fora-
synapse with the 3rd neuron. The 3rd neuron is usually men magnum.
located in the thalamus and give rise to projection fibers that 5. The presence of a cranial nerve defect on 1 side and
pass to a sensory region of the cerebral cortex. On this basis, defects of motor or sensory modalities in the contralat-
the tracts passing through the brainstem are the decussated eral extremities confirms that the lesion lies at the level
axons of the second neuron. of the brainstem and not in the cerebral cortex or inter-
Many of the neurons in the ascending pathways branch nal capsule.
into the RF, which, in turn, activates the cerebral cortex, 6. Lesions of the cerebral cortex and internal capsule both
maintaining wakefulness. The main sensations that are con- result in contralateral sensory and motor deficits.29
veyed by the coming tracts are pain and temperature on the
one hand and proprioception and touch on the other. References
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