Brainstem Lesions

Lecturer: Alvin B. Vibar, MD, FPSA

Transcriber: Alexis Tiglao

Brainstem Functional Lesions

• Important in localizing lesions or injuries
• Damaged area is manifested by somatosensory or motor
dysfunction or both
o BODY & EXTREMITIES = OPPOSITE side of the
lesion
o FACE = SAME SIDE of the lesion
o CRANIAL NERVE = same side of lesion
• Level of damages can usually be determined by CRANIAL
NERVE malfunction
• Supratentorial lesion
o SENSORY and MOTOR loss will be manifested on
the SAME SIDE of the body
o LESION is on the OPPOSITE side
o RIGHT cerebral lesion = SENSORY and MOTOR The Rule of 4’s:
losses on the LEFT side
• 4 structures in midline and begin with ‘M’
• Brainstem lesion o Medial medullary lesion = expect involvement of
o Alternating Hemiplegia MEDIAL LEMNISCUS
o Weakness on one side of the body and weakness
• 4 structures to the side and begin with ‘S’
of a cranial nerve on the opposite side
o Lateral medullary lesion = expect involvement of
o Lesion on RIGHT side
SPINOTHALAMIC
§ Motor losses in BODY on LEFT side
• 4 motor nuclei in midline and are divisors of 12 (3, 4, 6,
§ Motor losses of FACE on RIGHT side
12)
o Medial medullary lesion = CN 12
o Lateral medullary lesion = CNs 9, 10, 11
o Medial pontine lesion = CN 6
o Lateral pontine = CNs 5, 7, 8
• Groups of 4 CNs (above pons, pons, medulla)

• Remember (*remember more)

o Midbrain
§ Oculomotor (III)*, Trochlear (IV)*
§ Eye movements
o Pons
§ Trigeminal (V), Abducent (VI), Facial
(VII)*, Vestibulocochlear (VIII)
§ Facial expressions
o Medulla
§ Glossopharyngeal (IX)*, Vagus (X)*,
Accessory (XI), Hypoglossal (XII) MIDLINE STRUCTURES DEFICIT
§ Pharynx and larynx movements, tongue Motor Pathway Contralateral weakness in
movements, taste, blood pressure (Corticospinal Tract) body (paralysis)
Medial Lemniscus Contralateral proprioception/
vibration loss (sensory loss)
Medial Longitudinal Ipsilateral internuclear
Fasciculus opthalmoplegia
Motor Nucleus and Nerve Ipsilateral CN function loss

*Medial Longitudinal Fasciculus – serves as the linkage between

CNs 3, 4, 6 and 8
*Cranial Nerve deficits are always on the same side

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LATERAL STRUCTURES
Spinocerebellar Pathway
Spinothalamic Tract
Sensory Nucleus of CN V
Sympathetic Pathway
o Eye is extorted
DEFICIT § SO is not functioning so IO is unopposed
Ipsilateral ataxia o Head tilted away – compensatory mechanism
Contralateral pain/ o Hypertropia
temperature sensory loss o Causes: Vasculitis (DM, HTN), Trauma,
Ipsilateral pain/ temperature Congenital, Tumor
loss in face • Involving CN 6
(More info)

4 CNs ABOVE PONS DEFICIT

Olfactory CN I Not in midbrain
Optic CN II Not in midbrain
Oculomotor CN III Eye turned out and down
Trochlear CN IV Eye unable to look down when
looking towards nose
(extorted) o Lateral rectus is affected
o Eye is adducted
4 CNs AT THE LEVEL OF DEFICIT § LR is not functioning so MR is
PONS unopposed
Trigeminal CN V Ipsilateral facial sensory loss
(sensory to the face) Brainstem Segments (Review)
Abducens CN VI Ipsilateral eye abduction Medulla
weakness (adducted) UPPER MEDULLA
Facial CN VII Ipsilateral facial weakness • Medial:
(motor to the face) o Medial lemniscus
Auditory CN VIII Ipsilateral deafness o Motor pathway (corticospinal tract)
o Motor nucleus of CN 12: hypoglossal
4 CNs AT THE LEVEL OF THE DEFICIT o Medial longitudinal fasciculus
MEDULLA o Pyramid
Glossopharyngeal CN IX Ipsilateral pharyngeal sensory
loss (no gag reflex)
Vagus X Ipsilateral palatal weakness
Spinal Accessory CN XI Ipsilateral shoulder weakness
Hypoglossal CN XII Ipsilateral weakness of tongue
*All cranial nerve lesions are manifested on the same side

Diplopia
• Involving CN 3

Midbrain
UPPER MIDBRAIN: LEVEL OF SUPERIOR COLLICULUS
• Medial:
o Red nucleus
o Most of the eye muscles are affected
o Crus cerebri
o Down and out
o Corticospinal tract
§ CN 3 innervates all extraocular muscles
o Oculomotor nerve
except SO and LR
o Medial lemniscus
§ IO is not functioning so SO is unopposed
o Causes: Vasculitis (DM, HTN), Aneurysms
• Involving CN 4

o Trochlear/Superior oblique is affected

[Micro HSB B] Brainstem Lesions 2 of 6

LOWER MIDBRAIN: LEVEL OF INFERIOR COLLICULUS • Ipsilateral
o Deviation of tongue to the ipsilateral side when
protruded: HYPOGLOSSAL NERVE/NUCLEUS
(MOTOR)
• Hypoglossal nerve injury
o Test: Ask patient to stick out tongue
o Symptoms of nerve damage: When paralyzed, the
tongue will point to the damaged side

Pons
• Medial:
o Pontine fibers
o Pontine nucleus
o Trapezoid body
o Medial lemniscus
o Motor nucleus of CN 5
• Lateral:
o Sensory nucleus of CN 5
o Spinothalamic tract LATERAL MEDULLARY SYNDROME (WALLENBERG
SYNDROME)
CASE: A 65 year old patient presents to the ER with the following
symptoms: nausea, vomiting and nystagmus, difficulty swallowing and
hoarseness, absence of gag reflex, ataxia on left side. During
neurological examination: decreased pain and temperature
sensation on the LEFT side of the FACE, decreased pain and
temperature sensation on the RIGHT side of the BODY.

DYSPHAGIA, HOARSENESS and (-) GAG REFLEX – NUCLEUS

AMBIGUUS (CNs 9 and 10)

SENSORY – DECREASED PAIN and TEMPERATURE on RIGHT

Brainstem Lesions
Medulla
MEDIAL MEDULLARY SYNDROME
CASE: A patient was brought to the ER and examination revealed the
following: weakness of the LEFT arm and leg, increased muscle
tone and deep tendon reflexes on the right, diminished vibration and
position sense on the right, dysarthria and deviation of the tongue
to the RIGHT when protruded.
CN 12 – RIGHT HYPOGLOSSAL nerve (medial)
WEAKNESS – LEFT ARM and LEG – CORTICOSPINAL TRACT
(medial)
SENSORY – DIMINISHED VIBRATION and POSITION SENSE on
the LEFT side – MEDIAL LEMNISCUS (medial)
• Occlusion ANTERIOR SPINAL ARTERY
• Contralateral
o Hemiplegia of arm and leg: CORTICOSPINAL
TRACT
o Loss of position & vibratory senses and
discriminative touch: MEDIAL LEMNISCUS
side of the BODY – ANTEROLATERAL SYSTEM
DECREASED PAIN and TEMPERATURE on LEFT side of the FACE
– SPINAL TRIGEMINAL TRACT
• Occlusion of POSTERIOR INFERIOR CEREBELLAR
ARTERY (PICA)
• Deficits:
o Contralateral loss of pain and temperature on
body: ANTEROLATERAL SYSTEM
o Ipsilateral loss of pain and temperature on face:
SPINAL TRIGEMINAL TRACT/NUCLEUS
o Dysphagia, soft palate paralysis, hoarseness,
diminished gag reflex: NUCLEUS AMBIGUUS
(CNs IX and X)
o Ipsilateral HORNER’S SYNDROME (miosis,
ptosis, anhidrosis, flushing of face):
HYPOTHALAMOSPINAL FIBERS (Sympathetic –
Lateral side)
o Ataxia to the ipsilateral side: RESTIFORM BODY
& SPINOCEREBELLAR FIBERS
o Nausea, diplopia, tendency to fall to ipsilateral
side, nystagmus, vertigo: VESTIBULAR NUCLEI

[Micro HSB B] Brainstem Lesions 3 of 6


• How to test for CN 9 and 10:
o Say “ahhh”
o Affected side:
§ Palatal arch will sag
§ Uvula deviates towards the OPPOSITE
In the picture above, what is injured is the RIGHT VAGUS
(glossopharyngeal is sensory).
Lateral medullary syndrome – Posterior inferior
cerebellar artery – PICA – Dysphagia is the
differentiating symptom. Remember the Pokémon, PIKACHU
PICAchew = PICA – can’t – chew (dysphagia)
LACK OF MOVEMENT and DILATED PUPIL on the RIGHT –
OCULOMOTOR NERVE (CN 3)
LEFT-SIDED WEAKNESS of UPPER and LOWER EXTREMITIES –
CORTICOSPINAL TRACT
• Occlusion of POSTERIOR CEREBRAL ARTERY (PCA)
• Affects OCULOMOTOR and CRUS CEREBRI
• Contralateral spastic hemiplegia (motor weakness on upper
and lower extremities): CORTICOSPINAL TRACT
• Contralateral facial and hypoglossal paralysis:
CORTICOBULBAR FIBERS on the cerebral peduncle
• Contralateral Parkinsonism (rigor and tremor/involuntary
tremors): SUBSTANTIA NIGRA
• Ipsilateral lateral gaze weakness & diplopia:
OCULOMOTOR NERVE/ CN 3 FIBERS (LMN)
o Unable to move eye up, down, or medially on the
ipsilateral side
o Pupillary dilation or wide-fixed pupils: if Edinger-
Westphal nucleus is involved
• OCULOMOTOR NERVE INJURY – down and out

• TROCHLEAR NERVE INJURY - extorted

• Similar to Benedikt’s but more severe contralateral

weakness

MEDIAL MIDBRAIN SYNDROME: BENEDIKT’S SYNDROME

• Stroke of midbrain tegmentum
• Affects the RED NUCLEUS and SUBSTANTIA NIGRA and
fascicular portion of CN 3
MEDULLARY SYNDROMES
• Contralateral proprioception loss: MEDIAL LEMNISCUS
MEDIAL LATERAL
• Occlusion of PCA perforators
CN 12 CNs 9, 10, 11
• Ipsilateral CN 3 palsy and contralateral involuntary
Alternating hemiplegia Alternating hemiplegia
movements and hemiplegia (if it affects the corticospinal
Motor loss Motor loss
tracts)
Medial lemniscus Anterolateral/ Spinothalamic
Sensory loss Sensory loss
WEBER’S BENEDIKT’S
Anterior spinal artery Posterior inferior cerebellar
CN 3 CN 3
artery (PICA)
PCA PCA
Corticospinal Tract Corticospinal tract
Midbrain
Substantia nigra Substantia nigra
Medial midbrain - Ventral Medial midbrain
MEDIAL MIDBRAIN SYNDROME: WEBER’S SYNDROME
Crus cerebri Medial Lemniscus
CASE: A 67 year old man is brought to the ER by his wife. She
Corticobulbar Tract Red nucleus
explains that he fell suddenly, could not get up and complained of
being sick. The examination revealed LEFT sided weakness of the
Sensory loss? BENEDIKT’S – Medial lemniscus
upper and lower extremities, a lack of movement of the RIGHT eye
Weakness? BOTH – Corticospinal tract
and a dilated pupil on the RIGHT.
Involuntary tremors? BOTH – Substantia nigra
CN 3 Palsy? BOTH

[Micro HSB B] Brainstem Lesions 4 of 6


DORSAL MIDBRAIN SYNDROME: PARINAUD’S SYNDROME
• Result of pinealoma or germinoma of the pineal region
• NOT VASCULAR in origin
• “Doll’s Eye” – ability to look up is lost
• Affected structures:
o SUPERIOR COLLICULUS (vision)
o Pretectal area
• Deficits:
o Paralysis of upward and downward gaze
o Pupillary disturbances (Pseudo-Argyll Robertson
pupils)
o Absence of convergence (retraction nystagmus on
attempts at upward gaze): cerebral aqueduct
o Compression causes non-communicating
hydrocephalus
§ Unilateral deafness and tinnitus:
COCHLEAR NUCLEUS
o Ataxia: MIDDLE CEREBELLAR PEDUNCLE &
CEREBELLAR HEMISPHERE
• Contralateral:
o Impaired pain and temperature sense over one-
half of the body: SPINOTHALAMIC TRACT
MEDIAL INFERIOR PONTINE SYNDROME
• Occlusion of paramedian branch of BASILAR ARTERY
• Ipsilateral:
o CN 6
§ Diplopia on lateral gaze (adducted)
§ Paralysis of conjugate gaze to the side of
lesion
o Ataxia: MIDDLE CEREBELLAR PEDUNCLE
• Contralateral:
o Paralysis of face, arm, leg: CORTICOSPINAL
TRACTS
o Impaired tactile & proprioceptive sense over one-
half of body: MEDIAL LEMNISCUS

Pons

Remember!
Medial – CN 6
Lateral – CNs 5, 7, 8

LATERAL INFERIOR PONTINE SYNDROME WEAKNESS OF THE FACE IN BELL’S PALSY VS STROKE
CASE: A 71 year old woman consulted her family physician with a
complaint that “food dribble out of my mouth when I eat”. The
examination reveals a weakness around the right eye and opening of
the mouth. She also has loss of pain and temperature sensations on
the opposite side of the body excluding the head.

WEAKNESS AROUND RIGHT EYE and MOUTH – FACIAL NERVE

(CN 7 – orbicularis oculi)

SENSORY – LOSS of PAIN and TEMPERATURE on the OPPOSITE

side of the BODY – ANTEROLATERAL SYSTEM

• ANTERIOR INFERIOR CEREBELLAR ARTERY (AICA)

• Ipsilateral:
o CN 5
§ Impaired sensation over the face
o CN 7
§ Facial paralysis
§ Loss of taste from anterior 2/3 of tongue:
CN 7 Peripheral – lesion is on same side; weakness on one half of
SOLITARY NUCLEUS
the face
o CN 8
Central Stroke – lesion is on opposite side; not entire half of face
§ Horizontal & vertical gaze nystagmus,
with weakness
vertigo, nausea, vomiting: VESTIBULAR
NERVE/NUCLEI

[Micro HSB B] Brainstem Lesions 5 of 6

LATERAL MEDULLARY VS LATERAL PONTINE
LATERAL MEDULLARY LATERAL PONTINE
PICA – Dysphagia AICA – Facial involvement
(differentiating symptom) – (differentiating symptom) –
PICAchew (PICA can’t chew) “fACIAl” = AICA spelled
backwards

REMEMBER…
From superior to inferior:
• PCA occlusion – Weber’s & Benedikt’s
• Basilar artery occlusion – Medial pontine syndrome
• AICA occlusion – Lateral pontine syndrome
• PICA Occlusion – Lateral medullary/Wallenberg’s syndrome
• Anterior spinal artery occlusion – Medial medullary
syndrome

Summary

• PPT (2018)
• Recordings

[Micro HSB B] Brainstem Lesions 6 of 6