Brain stem

R.Arulmoli
Learning outcomes

Enumerate the parts of brainstem.

Describe the external & internal features of midbrain,
pons and medulla oblongata.
Illustrate the transverse sections of midbrain, pons and
medulla oblongata at different levels.
Explain the clinical importance of the different parts of
brain stem.
Brainstem

Stem like extension of the brain which connects the

cerebrum above and spinal cord below.
Brainstem has centres which are necessary for survival
(breathing, digestion, heart rate, blood pressure) and for
arousal (being awake and alert).
Most of the cranial nerve nuclei are located in the
brainstem.
The brainstem is the pathway for all fiber tracts passing up
and down from peripheral nerves and spinal cord to the
highest parts of the brain.
Brainstem

Parts:

Midbrain
Pons
Medulla
oblongata
Brainstem
Midbrain - Mesencephalon
Midbrain
Midbrain
Midbrain - smallest region of the brain stem,
connecting pons to the cerebrum.
Serves as the nerve pathway of the cerebral
hemispheres and contains auditory and
visual reflex centers.
It is superior to the pons and contains the
nuclei of cranial nerves III (oculomotor) and
IV (trochlear).
Divided into tectum (posterior to aqueduct)
& cerebral peduncles (anterior to aqueduct).
Tectum of the midbrain consists of four
projections called colliculus. There are two
superior colliculi and two inferior colliculi.
Cerebral peduncle has crus cerebri,
substantia nigra & tegmentum.
Midbrain-tectum-colliculi
Midbrain

Tectum:
Superior colliculus:
Involved in visual reflexes, receive input from eyes, skin
and cerebrum. Superior colliculus regulates the reflexive
movement of the eyes and head in response to different
stimuli.
Inferior colliculus:
Involved in hearing, integral portion of the auditory
pathways in the CNS.
Midbrain
Cerebral peduncles:
Comprise tegmentum, substantia nigra &
crus cerebri.
Substantia nigra, dark grey to black in
color. It has interconnections with basal
ganglia of the cerebrum and involved in
coordinating movement and muscle tone.
Crus cerebri, portion of the mid brain
anterior to the substantia nigra,consists of
descending tracts from the cerebrum to the
spinal cord and constitute one of the major
CNS motor pathways pyramidal tract.
Red nuclei are present in upper part of
midbrain which shows pinkish color in fresh
brain specimens, due to abundant blood
supply.Has inhibitory effect on muscle
tone.
Midbrain - Internal structure-Upper part
Grey matter:
Oculomotor nerve nucleus,
mesencephalic nucleus of
the trigeminal nerve are
present.
Superior colliculus receives
afferents from the retina &
various other centers.
Efferents to spinal cord as
tectospinal tract.
Pretectal nucleus lies deep to
the superolateral part of the
superior colliculus. Part of
pathway for light reflex and
consensual reflex.
Midbrain - Internal structure-Upper part
Grey matter:
Red nucleus is about 0.5 cm
in the diameter.
- Afferent- from the superior
cerebellar peduncle,globus
pallidus,subthalamic nucleus
& cerebral cortex.
- Efferent- to spinal cord,
reticular formation,thalamus,
olivary nucleus, subthalamic
nucleus it has inhibitory
influence on muscle tone.
Substantia nigra is a lamina
of grey matter made up of
highly pigmented neurons.
Midbrain Transverse section-Upper part
Midbrain - Internal structure-Upper part
White matter :
Crus cerebri Contains
-Corticospinal tract in the middle.
-Frontopontine fibres in the medial one sixth.
-Temporopontine, parietopontine & occipitopontine in the
lateral one-sixth.
Decussation of rubrospinal tracts forms ventral tegmental
decussation.
Decussation of the tectospinal & tectobulbar tracts form
dorsal tegmental decussation.
Medial longitudinal bundle-fibres that interconnect nuclei of
3rd,4th,5th and 6th cranial nerves and spinal part of XIth nerve.
Emerging fibres of oculomotor nerve.
Midbrain - Internal structure-Upper part
White matter :
Tegmentum contains ascending tracts: MTS
- Medial lemniscus crossed fibres of cuneate and
gracile nuclei to thalamus.
- Trigeminal lemniscus fibres arising from spinal
nucleus of trigeminal nerve to thalamus.
- Spinal lemniscus lateral spinothalamic tract to
thalamus.
Midbrain Transverse section-Upper part
Midbrain - Internal structure-Lower part

Grey matter:

Trochlear nerve nucleus in

the ventromedial part,
Mesencephalic nucleus of
trigeminal nerve in the
lateral part.
Inferior colliculus receives
afferents from the lateral
lemniscus & gives efferents
to medial geniculate body.
Substantia nigra a lamina
of grey matter with highly
pigmented nerve cells.
Concerned with muscle
tone.
Midbrain - Internal structure-Lower part
White matter :
Crus cerebri Contains
-Corticospinal tract in the middle.
-Frontopontine fibres in the medial one sixth.
-Temporopontine, parietopontine & occipitopontine in the
lateral one-sixth.

Decussation of superior cerebellar peduncles.

Medial longitudinal bundle-fibres that interconnect nuclei of

3rd,4th,5th and 6th cranial nerves and spinal part of XIth nerve.
Emerging fibres of trochlear nerve.
Midbrain - Internal structure- Lower part
White matter :
Tegmentum contains ascending tracts: MTSL
- Medial lemniscus crossed fibres of cuneate and
gracile nuclei to thalamus.
- Trigeminal lemniscus fibres arising from spinal
nucleus of trigeminal nerve to thalamus.
- Spinal lemniscus Lateral spinothalamic tract to
thalamus.
- Lateral lemniscus Auditory fibres arising from auditory
nuclei to medial geniculate body.
Midbrain Transverse section-Lower part
Midbrain Transverse section
Midbrain-Functions

Nerve pathway of cerebral hemispheres.

Auditory and visual reflex centers.
2 cranial nerve nuclei are situated:
-III - Oculomotor (supplies muscles of eye
movement), [motor].
-IV - Trochlear (Superior oblique muscle of
the eye), [motor].
Pons - Metencephalon
Pons

The pons is a bridge-like

structure which links
different parts of the brain
and serves as a relay
station from the medulla to
the higher cortical
structures of the brain.
It contains the respiratory
center.
Pons External structure
Anterior surface:
Convex,transversely running
fibres, middle cerebellar
peduncle.
The V nerve emerges from the
anterior surface.
Shallow groove in the middle,
sulcus basilaris lodges the
basilar artery.
At ponto-medullary junction
emerges VI, VII, VIII nerves.
Posterior aspect:
Forms the upper part of the floor
of the fourth ventricle.
Pons Posterior aspect
Pons - Internal features

The pons is divisible into a ventral part and a dorsal part.

Ventral (basilar) part contains pontine nuclei,
transverse and vertical fibres.
- Pontine nuclei are scattered groups of cells
seperated by nerve fibres.
- Transverse fibres are pontocerebellar fibres,cross
the midline to enter the opposite middle cerebellar
peduncle.
- Vertical fibres are corticospinal,corticonuclear &
some corticopontine fibres.Corticonuclear fibres end
in the motor nuclei of cranial nerves mainly of
opposite side.
Pons-Transverse section-upper part
Pons - Internal features-Upper part
Dorsal part (Tegmentum):
Grey matter :
Motor & sensory nuclei of trigeminal nerve.
White matter : MTSL
Contains medial lemniscus, trigeminal lemniscus, spinal
lemniscus,lateral lemniscus and medial longitudinal bundle.
1. Medial lemniscus crossed fibres of cuneate and gracile nuclei.
2. Spinal lemniscus - lateral spinothalamic tract.
3. Trigeminal lemniscus contains fibres arising in the spinal
nucleus of the trigeminal nerve to the thalamus.
4. Lateral lemniscus is a part of the auditory pathway.
5. Medial longitudinal bundle is made up of fibres that interconnect
the nuclei of the cranial nerves III,IV,VI,VIII & spinal part of the
accessory nerve coordinates movements of head & neck in
response to VIII cranial nerve stimulation.
Pons-Transverse section-upper part
Pons - Internal features-Lower part
Dorsal part (Tegmentum):

Grey matter : White matter :

Abducent nucleus. Trapezoid body

transverse band of fibres.
Facial nucleus.
Medial lemniscus.
Vestibular & cochlear
Lateral spinothalamic
nuclei lie in relation to the tract.
inferior cerebellar
peduncle. Inferior cerebellar
peduncle.
Spinal nucleus of
trigeminal nerve. Fibres of the facial nerve
follow a peculiar course.
Salivatory & lacrimatory
nuclei.
Pons-Transverse section-Lower part
Pons-Transverse section-Lower part
Pons - functions

Respiratory center.
Cranial nerve nuclei:
V - Trigeminal (skin of face, tongue, teeth; muscle of
mastication), [motor and sensory].
VI - Abducent (Lateral rectus muscle of eye),
[motor].
VII - Facial (Muscles of expression), [motor and
sensory].
VIII - Vestibulocochlear, [sensory].
Medulla oblongata - Myelencephalon
Medulla oblongata

The medulla oblongata functions primarily as a relay

station for the crossing of motor tracts between the
spinal cord and the brain.
It also contains the respiratory, vasomotor and cardiac
centers.
Controls reflex activities such as coughing, gagging,
swallowing and vomiting
Medulla oblongata External structure
Piriform in shape wider at the upper end and measure about 3 cm in
length, lower part contains the central canal.
Upper part is open and forms the caudal part of the floor of the fourth
ventricle. Divided into right & left halves by the anterior & posterior
median fissures.
Each half is divided into anterior, posterior & lateral regions by the
anterolateral & posterolateral sulci.
External features-
- Anterior median fissure
- Pyramid
- Olive
- Inferior cerebellar peduncle
- Cuneate tubercle
- Gracile tubercle
- Posterior median sulcus
Medulla oblongata anterior view
Medulla oblongata posterior view
Medulla oblongata External structure

Pyramid is made up of
corticospinal fibres.In
the lower part of medulla
right and left pyramids
cross in the midline
forming pyramidal
decussation.
70-90% of cortico spinal
fibers decussate(cross
over) across the anterior
median fissure as lateral
cortico-spinal tract.
Cortico-spinal fibers
which do not decussate
form anterior cortico-
spinal tract.
Medulla oblongata External structure
Medulla shows an oval elevation in
the lateral region of upper
part,olive,produced by inferior
olivary nucleus.
Rootlets of hypoglossal nerve
emerge between the pyramid and
olive.
Rootlets of 9,10 and cranial part of
accessory nerves emerge behind
the olive.
Inferior cerebellar peduncle,
connecting the medulla to the
cerebellum.
Cuneate and gracile tubercles
produced by nucleus cuneatus and
gracilis.
Medulla oblongata Internal structure

Lower part: Pyramidal decussation

Grey matter:
White matter:
Decussating pyramidal
fibres separate anterior
horn from the central grey
matter the separated part
forms the spinal nucleus of
the accessory nerve.
Central grey matter pushed
backwards.
Nucleus gracilis & cuneatus
are continuous with the
central grey matter.
Pyramids anteriorly.
Decussation of the
pyramidal tracts the fibres
of the pyramid run
backwards & laterally to
reach the lateral white
column of the spinal cord.
Fasciculus gracilis &
fasciculus occupy the
posterior white column.
Medulla oblongata-Lower part- Pyramidal decussation
Medulla oblongata- Internal structure

Middle part: Sensory decussation

Grey matter: White matter:
Nucleus gracilis & nucleus Internal arcuate fibres
cuneatus are much larger & medial lemniscus.
are separated from the
Pyramidal tracts lie
central grey matter. anteriorly.
Accessory cuneate nucleus.
Medial longitudinal bundle.
Nucleus of the spinal tract
of trigeminal nerve. Spinocerebellar & lateral
Lower part of inferior olivary spinothalamic tracts.
nucleus.
Hypoglossal nucleus.
Dorsal nucleus of vagus.
Nucleus of tractus solitarius.
Medulla oblongata middle part- sensory decussation
Medulla oblongata- Internal structure

Upper part: Inferior olivary nucleus

Grey matter:
Hypoglossal nucleus White matter:

Dorsal nucleus of vagus Inferior cerebellar

peduncle.
Nucleus gracilis &
nucleus cuneatus Olivocerebellar fibres

Nucleus of spinal tract of Striae medullares are

trigeminal nerve. seen in the floor of the
fourth ventricle.
Inferior olivary nucleus
Arcuate nucleus.
Medulla oblongata- Internal structure - upper part
Clinical importance - Brainstem
Midbrain
Midbrain ascends posterior cranial fossa through small opening in the
tentorium cerebelli, so vulnerable to traumatic injury.
It is a site for tumors, hemorrhage, or infarcts will produce a wide
variety of symptoms and signs.
Trauma to the Midbrain:
Among the mechanisms of injuries to the midbrain, a sudden lateral
movement of the head could result in the cerebral peduncles impinging
against the sharp rigid free edge of the tentorium cerebelli.
Involvement of the oculomotor nucleus will produce ipsilateral paralysis
of the levator palpebrae superioris; superior, inferior and medial rectus
muscles; and inferior oblique muscle.
Malfunction of the parasympathetic nucleus of the oculomotor nerve
produces a dilated pupil that is insensitive to light and does not
constrict on accommodation.
Involvement of the trochlear nucleus will produce contralateral
paralysis of the superior oblique muscle of the eyeball.
Midbrain

Blockage of the cerebral

aqueduct:
Pons
Tumors, hemorrhage, or infarcts in the pons produce a variety of
symptoms and signs. Tumors of the Pons:
Astrocytoma of the pons occurring in childhood is the most common
tumor of the brainstem.
The symptoms and signs are those of ipsilateral cranial nerve
paralysis and contralateral hemiparesis: weakness of the facial
muscles on the same side (facial nerve nucleus), weakness of the
lateral rectus muscle on one or both sides (abducent nerve
nucleus), nystagmus (vestibular nucleus), weakness of the jaw
muscles (trigeminal nerve nucleus), impairment of hearing (cochlear
nuclei),
Contralateral hemiparesis, quadriparesis (corticospinal fibers),
anesthesia to light touch with the preservation of appreciation of
pain over the skin of the face (principal sensory nucleus of
trigeminal nerve involved, leaving spinal nucleus and tract of
trigeminal intact), and contralateral sensory defects of the trunk and
limbs (medial and spinal lemnisci).
Involvement of the corticopontocerebellar tracts may cause
ipsilateral cerebellar signs and symptoms.
Pons
Pontine hemorrhage:
The pons is supplied by the basilar artery and the anterior, inferior, and
superior cerebellar arteries.
If the hemorrhage occurs from one of those arteries and is unilateral,
there will be facial paralysis on the side of the lesion (involvement of
the facial nerve nucleus and, lower motor neuron palsy) and paralysis
of the limbs on the opposite side (involvement of the corticospinal
fibers as they pass through the pons).
There is often paralysis of conjugate ocular deviation (involvement of
the abducent nerve nucleus and the medial longitudinal fasciculus).
When the hemorrhage is extensive and bilateral, the pupils may be
pinpoint (involvement of the ocular sympathetic fibers); there is
commonly bilateral paralysis of the face and the limbs.
Medulla oblongata

The medulla oblongata contains many cranial nerve nuclei that are concerned
with vital functions (e.g., regulation of heart rate and respiration), but it also
serves as a conduit for the passage of ascending and descending tracts
connecting the spinal cord to the higher centers of the nervous system. These
tracts may become involved in demyelinating diseases, neoplasms, and
vascular disorders.
Raised pressure in the posterior cranial fossa and its effect on the Medulla
oblongata:
The medulla oblongata is situated in the posterior cranial fossa, lying beneath
the tentorium cerebelli and above the foramen magnum.
In tumors of the posterior cranial fossa, the intracranial pressure is raised,
cerebellum and the medulla oblongata tends to be pushed toward the area of
least resistance; there is a downward herniation of the medulla and cerebellar
tonsils through the foramen magnum.
This will produce the symptoms of headache, neck stiffness, and paralysis of
the glossopharyngeal, vagus, accessory, and hypoglossal nerves owing to
traction.
Medulla oblongata
Arnold-Chiari malformation:
Congenital anomaly in which there is a
herniation of the tonsils of the cerebellum
and the medulla oblongata through the
foramen magnum into the vertebral
canal.
This results in the blockage of the exits in
the roof of the fourth ventricle to the
cerebrospinal fluid, causing internal
hydrocephalus.
It is commonly associated with
craniovertebral anomalies or various
forms of spina bifida.
Medulla oblongata
Vascular disorders of the Medulla oblongata:
Lateral medullary syndrome of Wallenberg:
The lateral part of the medulla oblongata is supplied by the posterior inferior
cerebellar artery, which is usually a branch of the vertebral artery.
Thrombosis of either of these arteries, produces the following signs and
symptoms:
- Dysphagia and dysarthria due to paralysis of the ipsilateral palatal and
laryngeal muscles (innervated by the nucleus ambiguus).
- Analgesia and thermoanesthesia on the ipsilateral side of the face
(nucleus and spinal tract of the trigeminal nerve).
- Vertigo, nausea, vomiting, and nystagmus (vestibular nuclei).
- Ipsilateral Horner syndrome (descending sympathetic fibers).
- Ipsilateral cerebellar signs- gait and limb ataxia (cerebellum or inferior
cerebellar peduncle).
- Contralateral loss of sensations of pain and temperature (spinal lemniscus-
spinothalamic tract).
Medulla oblongata

Lateral medullary syndrome of Wallenberg

Medulla oblongata

Medial medullary syndrome:

The medial part of the medulla oblongata is supplied
by the vertebral artery.
Thrombosis of the medullary branch, produces the
following signs and symptoms:
- Contralateral hemiparesis (pyramidal tract).
- Contralateral impaired sensations of position and
movement and tactile discrimination (medial
lemniscus).
- Ipsilateral paralysis of tongue muscles with deviation
to the paralyzed side when the tongue is protruded
(hypoglossal nerve).
Medulla oblongata

Medial medullary syndrome of Wallenberg

Summary
Brain stem

Brain stem includes midbrain,pons & medulla.

Midbrain has superior,inferior colliculi, tegmentum,
substantia nigra,crus cerebri,III & IV nerve nuclei.
Pons has pontine nuclei,transverse & vertical fibres in the
anterior part. V,VI,VII,VIII nerve nuclei in the posterior part.
Medulla shows pyramid,olive,inferior cerebellar
peduncle,cuneate tubercle & gracile tubercle externally.
IX,X,XI,XII nerve nuclei are present inside.
Brain stem-cranial nerve nuclei
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