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

*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

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

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

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

2 4

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

*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 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

*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 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

*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

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

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
Contralateral propioception/ vibration loss

More Info

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
Contralateral propioception/ vibration loss

Ipsilateral internuclear ophthalmoplegia

More Info

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
Contralateral propioception/ vibration loss

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

al er es at ur L ct tru S Spinocerebellar

DE

FIC I

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

Ipsilateral ataxia
Contralateral pain/temp sensory loss

More Info

al er es at ur L ct tru S Spinocerebellar

DE

FIC I

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

Ipsilateral ataxia
Contralateral pain/temp sensory loss

Ipsilateral pain/ temp loss in face

More Info

al er es at ur L ct tru S Spinocerebellar

DE

FIC I

pathway Spinothalamic Sensory nucleus of CN5 Sympathetic pathway

Ipsilateral ataxia
Contralateral pain/temp sensory loss

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

Glossopharyngeal CN9 Vagus CN10

Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness

More Info
Spinal accessory CN11

Hypoglossal CN12

CN lla 4 u ed M

DE

FIC I

Glossopharyngeal CN9 Vagus CN10

Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness Ipsilateral shoulder weakness

Spinal accessory CN11

Hypoglossal CN12

CN lla 4 u ed M

DE

FIC I

Glossopharyngeal CN9 Vagus CN10

Ipsilateral pharyngeal sensory loss Ipsilateral palatal weakness Ipsilateral shoulder weakness Ipsilateral weakness of tongue

Spinal accessory CN11

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

Motor (CS tract, R) Medial

lemniscus, R CN12, R

Location

Structure

Medial Medial Medulla

Motor (CS tract, R) Medial

lemniscus, R CN12, R

Location

Structure

Medial Medial Medulla

Medial medullary syndrome (R)

Motor (CS tract, R) Medial

lemniscus, R CN12, 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

Spinocerebellar CN10, Left

Location

Structure

Side, Left Side, Left Medulla

Sympathetic
tract, Left

Spinocerebellar CN10, Left

Location

Structure

Side, Left Side, Left Medulla

Lateral medullary syndrome (L)

Sympathetic
tract, Left

Spinocerebellar CN10, 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

Case 10 y/o girl with the ff symptoms Left-sided weakness

Right eye deviates medially

Structure

Motor (CS tract, R)

Righ-sided facial weakness

Case 10 y/o girl with the ff symptoms Left-sided weakness

Right eye deviates medially

Structure

Motor (CS tract, R)

LR weakness, CN6 Right

Righ-sided facial weakness

Case 10 y/o girl with the ff symptoms Left-sided weakness

Right eye deviates medially

Structure

Motor (CS tract, R)

LR weakness, CN6 Right

Righ-sided facial weakness

CN7, Right

Location

Structure

Motor (CS tract, R)

LR weakness, CN6 Right

CN7, Right

Location

Structure

Medial structure

Motor (CS tract, R)

LR weakness, CN6 Right

CN7, Right

Location

Structure

Medial structure

Motor (CS tract, R)

LR weakness, CN6 Right

Pons

CN7, Right

Location

Structure

Medial structure

Motor (CS tract, R)

LR weakness, CN6 Right

Pons

Pons

CN7, Right

Location

Structure

Medial structure

Motor (CS tract, R)

LR weakness, CN6 Right

Pons

Pons
Medial Pons

CN7, Right

Pons tumor

Location

Structure

Medial structure

Motor (CS tract, R)

LR weakness, CN6 Right

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
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reex, left eye

Structure

CN3, Left

Paralysis of right arm and leg

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reex, left eye

Structure

CN3, Left CN3, Left

Paralysis of right arm and leg

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reex, left eye

Structure

CN3, Left CN3, Left

Motor, CS tract, Left

Paralysis of right arm and leg

Location

Structure

CN3, Left CN3, Left

Motor, CS tract, Left

Location

Structure

Midbrain

CN3, Left CN3, Left

Motor, CS tract, Left

Location

Structure

Midbrain Midbrain

CN3, Left CN3, Left

Motor, CS tract, Left

Location

Structure

Midbrain Midbrain Medial, Left

CN3, Left CN3, Left

Motor, CS tract, Left

Location

Structure

Midbrain Midbrain Medial, Left

Medial Midbrain

CN3, Left CN3, Left

Motor, CS tract, Left

Webers Syndrome

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss

Structure

Involuntary movement

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss

Structure

CN3, Left

Involuntary movement

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss

Structure

CN3, Left
Medial Lemniscus, Left

Involuntary movement

Case
70 y/o male hypertensive suddenly developed
Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss

Structure

CN3, Left
Medial Lemniscus, Left

Involuntary movement

Red nucleus, Left

Location

Structure

CN3, Left
Medial Lemniscus, Left

Red nucleus, Left

Location

Structure

Midbrain, Left

CN3, Left
Medial Lemniscus, Left

Red nucleus, Left

Location

Structure

Midbrain, Left Medial, Left

CN3, Left
Medial Lemniscus, Left

Red nucleus, Left

Location

Structure

Midbrain, Left Medial, Left Medial, Left

CN3, Left
Medial Lemniscus, Left

Red nucleus, Left

Location

Structure

Midbrain, Left Medial, Left Medial, Left

Medial Midbrain

CN3, Left
Medial Lemniscus, 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 Levator uvalae

Vagus

Lesion

Deviated to the right

Return

Vagus Levator uvalae

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