Brainstem Lesions Guide

Lessons on Brainstem Lesions
Dr. Dennis Bravo
Case A 58 y/o was referred to you because of recent onset of left hemiparesis, left-sided loss of propioception and right-sided tongue deviation. What CNS structures are affected? Explain the symptoms with regards to structures affected. Where is the lesion?
review of Brainstem Structure
Brainstem Anatomy
Midbrain Pons Medulla
Brainstem Anatomy
Midbrain Pons Medulla
Rules of 4*
1. 4 structures in midline and begin with M 2. 4 motor nuclei in midline and are those that
are divisors of 12 (3,4,6,12) 3. 4 structures to the side (lateral) and begin with S 4. 4 CN in medulla, 4 in pons and 4 above pons
*Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
4 Structures in midline and begin with M
4 Structures to the side and begin with S
1 3
4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)
RULE of FOUR*
4 CN in medulla 4 CN in pons 4 CN above pons
2 4
2 4
RULE #1
4 Medial Structures
Motor pathway Medial leminiscus Medial longitudinal

fasciculus Motor nucleus and nerve
RULE #2
4 Medial Motor Nucleus
CN divides number 12 CN 3, 4, 6, 12 are midline 3, 4, 6, 12 nucleus are midline 5, 7, 9, 11 lateral
RULE #3
4 Side Structures
Spinocerebellar pathway Spinothalamic pathway Sensory nucleus of CN5 Sympathetic pathway
4 Medulla Cranial RULE #4 Nerves
Glossopharyngeal (CN9) Vagus (CN10) Spinal accessory (CN11) Hypoglossal (CN12)
RULE #4
4 Pons Cranial Nerves
Trigeminal (CN5) Abducent (CN6) Facial (CN7) Auditory (CN8)
4 Cranial Nerves Above Pons RULE #4
Olfactory (CN1) Optic (CN2) Occulomotor (CN3) Trochlear (CN4)
ne s li e id ur M ct tru S Motor pathway
DE
FIC I
(Corticospinal tract) Medial lemniscus Medial longditudinal fasciculus Motor nucleus and nerve
Contalateral weakness
More Info
DE
FIC I
Contralateral propioception/ vibration loss
More Info
DE
FIC I
Ipsilateral internuclear ophthalmoplegia
More Info
DE
FIC I
Ipsilateral internuclear ophthalmoplegia Ipsilateral CN function loss
al er es at ur L ct tru S Spinocerebellar
DE
FIC I
pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway
Ipsilateral ataxia
More Info
DE
FIC I
Ipsilateral ataxia
Contralateral pain/temp sensory loss
More Info
DE
FIC I
Ipsilateral ataxia
Ipsilateral pain/ temp loss in face
More Info
DE
FIC I
Ipsilateral ataxia
Ipsilateral pain/ temp loss in face Ipsilateral Horners syndrome
More Info
CN lla 4 u ed M
DE
FIC I
Glossopharyngeal CN9 Vagus CN10
Ipsilateral pharyngeal sensory loss
Spinal accessory CN11
Hypoglossal CN12
CN lla 4 u ed M
DE
FIC I
Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness
More Info
Hypoglossal CN12
CN lla 4 u ed M
DE
FIC I
Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness Ipsilateral shoulder weakness
Hypoglossal CN12
CN lla 4 u ed M
DE
FIC I
Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness Ipsilateral shoulder weakness Ipsilateral weakness of tongue
Hypoglossal CN12
More Info
CN 4 ns Po
DE
FIC I
Trigeminal CN5
Ipsilateral facial sensory loss
More Info
Abducent CN6
Facial CN7
Auditory CN8
CN 4 ns Po
DE
FIC I
Trigeminal CN5
Ipsilateral facial sensory loss Ipsilateral eye abduction weakness
Abducent CN6
More Info
Facial CN7
Auditory CN8
CN 4 ns Po
DE
FIC I
Trigeminal CN5
Ipsilateral facial sensory loss Ipsilateral eye abduction weakness Ipsilateral facial weakness
Abducent CN6
Facial CN7
More Info
Auditory CN8
CN 4 ns Po
DE
FIC I
Trigeminal CN5
Ipsilateral facial sensory loss Ipsilateral eye abduction weakness Ipsilateral facial weakness Ipsilateral deafness
Abducent CN6
Facial CN7
Auditory CN8
CN ons 4 P ve bo A
DE
FIC I
Olfactory CN1
Not in midbrain
Optic CN2
Not in midbrain Eye turned out and down
Occulomotor CN3
More Info
Trochlear CN4
CN ons 4 P ve bo A
DE
FIC I
Olfactory CN1
Not in midbrain
Optic CN2
Not in midbrain Eye turned out and down

Eye unable to look down when looking towards nose
Occulomotor CN3
Trochlear CN4
More Info
Lets put your knowledge to use...
Always remember
Pathways and tracts pass through the entire length of the brainstem and can be likened to meridians of longitude whereas the various cranial nerves can be regarded as parallels of latitude. If you establish where the meridians of longitude and parallels of latitude intersect then you have established the site of the lesion.
Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
Case
58 year old woman Left hemiparesis Left-sided loss of propioception Right-sided tongue deviation
Case
Structure
58 year old woman Left hemiparesis Left-sided loss of propioception Right-sided tongue deviation
Motor (CS tract, R) Medial

lemniscus, R CN12, R
Structure

Location
Structure
Medial Medial Medulla

Location
Structure
Medial Medial Medulla

Medial medullary syndrome (R)

Vertebral artery, medullary branch (R)
Case
58 year old woman Left-sided meiosis, anhydrosis, ptosis Left-sided ataxia Uvula deviated to right
Case
Structure
58 year old woman Left-sided meiosis, anhydrosis, ptosis Left-sided ataxia Uvula deviated to right
Sympathetic
tract, Left
Spinocerebellar CN10, Left
Structure
Sympathetic
tract, Left
Location
Structure
Side, Left Side, Left Medulla
Sympathetic
tract, Left
Location
Structure
Side, Left Side, Left Medulla

Lateral medullary syndrome (L)
Sympathetic
tract, Left

Posterior inferior cerebellar artery (L)
Assignment In lateral medullary syndrome (Wallenberg syndrome), there are associated analgesia and thermoanalgesia of the ipsilateral face. Why? What brainstem structure is affected?
Case 10 y/o girl with the ff symptoms Left-sided weakness

Right eye deviates medially
Structure
Righ-sided facial weakness

Structure
Motor (CS tract, R)

Structure
Motor (CS tract, R)

LR weakness, CN6 Right

Structure
Motor (CS tract, R)

CN7, Right
Location
Structure
Motor (CS tract, R)

CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)

CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)

Pons
CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)

Pons
Pons
CN7, Right
Location
Structure
Medial structure
Motor (CS tract, R)

Pons
Pons
Medial Pons
CN7, Right
Pons tumor
Location
Structure
Medial structure
Motor (CS tract, R)

Pons
Pons
Medial Pons
CN7, Right
Millard-Gubler Syndrome Pons tumor
Assignment What is astrocytoma? Where is it usually located? Who are most often affected?
Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reex, left eye
Structure
Paralysis of right arm and leg
Case
Structure
CN3, Left
Case
Structure
CN3, Left CN3, Left
Case
Structure
CN3, Left CN3, Left

Motor, CS tract, Left
Location
Structure
CN3, Left CN3, Left

Location
Structure
Midbrain
CN3, Left CN3, Left

Location
Structure
Midbrain Midbrain
CN3, Left CN3, Left

Location
Structure
Midbrain Midbrain Medial, Left
CN3, Left CN3, Left

Location
Structure
Midbrain Midbrain Medial, Left

Medial Midbrain
CN3, Left CN3, Left

Webers Syndrome
Case
Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss
Structure
Involuntary movement
Case
Structure
CN3, Left
Case
Structure
CN3, Left
Medial Lemniscus, Left
Case
Structure
CN3, Left
Red nucleus, Left
Location
Structure
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left Medial, Left
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left Medial, Left Medial, Left
CN3, Left
Red nucleus, Left
Location
Structure
Midbrain, Left Medial, Left Medial, Left

Medial Midbrain
CN3, Left
Red nucleus, Left
Benedikts Syndrome
Webers Syndrome
Benedikts Syndrome
CN3 Motor, CS tract Corticobulbar tract Medial midbrain
CN3
Medial Lemniscus
Red nucleus Medial midbrain
Webers
Benedikts
Parinauds syndrome Posterior midbrain Superior colliculi Center for upward gaze Inability to look up (Dolls eye) Argylle-Robertson pupil
Any questions?
The End
RETURN
Brain stem
10%
90%
RETURN LESION
Brain stem
10%
90%
RETURN LESION
Brain stem
10%
90%
Contralateral paralysis
Return
Return LESION
Return LESION
Contralateral sensory loss
Return
Return
Return
Return
LESION
Return
LESION
Ipsilateral ataxia
Return
LESION
Brain Stem Contralateral sensory loss

Pain & temperature
Return
Return
LESION
Return
LESION
Ipsilateral facial sensory loss
Horners Syndrome
Meiosis Ptosis Anhydrosis

Return
Deviated to the right
Return
Vagus Levator uvalae
Vagus
Return
Vagus
Lesion
Deviated to the right
Return
Vagus
Lesion
Deviated to the right Uvula deviates OPPOSITEthe lesion Return
Tongue deviates OPPOSITE the lesion Deviated to the LEFT
Return
Return
Return
Facial weakness
Return
Cranial Nerve 3 EOM except lateral rectus & superior oblique Down and out Ptosis Absent pupillary light reex
Return
Return

Brainstem Lesions Guide

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Lessons on Brainstem Lesions

Dr. Dennis Bravo

review of Brainstem Structure

Midbrain Pons Medulla

Midbrain Pons Medulla

4 Structures in midline and begin with M

4 Structures to the side and begin with S

4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)

4 CN in medulla 4 CN in pons 4 CN above pons

4 Structures in midline and begin with M

4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)

4 Structures to the side and begin with S

4 CN in medulla 4 CN in pons 4 CN above pons

4 Structures in midline and begin with M

4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)

4 Structures to the side and begin with S

4 CN in medulla 4 CN in pons 4 CN above pons

4 Structures in midline and begin with M

4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)

4 Structures to the side and begin with S

4 CN in medulla 4 CN in pons 4 CN above pons

4 Structures in midline and begin with M

4 Motor nuclei in midline and are divisors of 12 ( 3, 4, 6, 12)

4 Structures to the side and begin with S

4 CN in medulla 4 CN in pons 4 CN above pons

Motor pathway Medial leminiscus Medial longitudinal

4 Medial Motor Nucleus

CN divides number 12 CN 3, 4, 6, 12 are midline 3, 4, 6, 12 nucleus are midline 5, 7, 9, 11 lateral

Spinocerebellar pathway Spinothalamic pathway Sensory nucleus of CN5 Sympathetic pathway

4 Medulla Cranial RULE #4 Nerves

Glossopharyngeal (CN9) Vagus (CN10) Spinal accessory (CN11) Hypoglossal (CN12)

4 Pons Cranial Nerves

Trigeminal (CN5) Abducent (CN6) Facial (CN7) Auditory (CN8)

4 Cranial Nerves Above Pons RULE #4

Olfactory (CN1) Optic (CN2) Occulomotor (CN3) Trochlear (CN4)

ne s li e id ur M ct tru S Motor pathway

ne s li e id ur M ct tru S Motor pathway

ne s li e id ur M ct tru S Motor pathway

Ipsilateral internuclear ophthalmoplegia

ne s li e id ur M ct tru S Motor pathway

Ipsilateral internuclear ophthalmoplegia Ipsilateral CN function loss

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

Ipsilateral pain/ temp loss in face

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

Ipsilateral pain/ temp loss in face Ipsilateral Horners syndrome

Glossopharyngeal CN9 Vagus CN10

Ipsilateral pharyngeal sensory loss

Spinal accessory CN11

Glossopharyngeal CN9 Vagus CN10

Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness

Glossopharyngeal CN9 Vagus CN10

Spinal accessory CN11

Glossopharyngeal CN9 Vagus CN10

Spinal accessory CN11

Ipsilateral facial sensory loss

Ipsilateral facial sensory loss Ipsilateral eye abduction weakness

Not in midbrain Eye turned out and down

Not in midbrain Eye turned out and down

Lets put your knowledge to use...

Motor (CS tract, R) Medial