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G. Bales, Ph.D.

/ Clinical Neuroanatomy

COMPREHENSIVE REVIEW & SELF-TEST


CNS NEUROANATOMICAL LESIONS
Syringomyelia

infarct

Posterior spinal a.

stroke
embolus

Anterior spinal a.

ischemia

Brown-Sequard syndrome

aneurysm

Med. medullary syndrome

ilicit drug
inflammation

Lat. medullary syndrome

toxicity

Tonsillar herniation

pharmaceutical

Medial pontine syndrome

malformation

Lateral pontine syndrome

tumor

Locked-in syndrome

metastasis
sclerosis

Cerebellum - Distal PICA

hematoma

Medial midbrain syndrome

hypertension

Lateral midbrain syndrome

mutation

Uncal herniation

autoimmunity

Dorsal midbrain syndrome

infection
prion

Anterior cerebral a.

parasite

Posterior cerebral a.
Middle cerebral a. - superior

blunt trauma
penetrating trauma

Middle cerebral a. - inferior

degeneration

Middle cerebral a. - origin

compression
herniation
demyelination
alien nanobots

Copyrights protected. Internal WesternU use only.

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

SPINAL CORD
Cervical Syringomyelia - C5-C8

ipsi / contra / bilateral

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. ventral white commissure

pain & temperature - upper limb


dermatomes
cape-like distribution

note: VSCT crosses only at lower levels

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

SPINAL CORD
Posterior spinal a. syndrome - cervical
A

DAMAGED

posterior spinal a.

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A-B. fasciculus gracilis &
cuneatus,

touch & conscious proprioception


- upper & lower limbs

C. Lissauer's tract

pain at levels affected

D. dorsal horn

touch at levels affected

some hemiplegia at and below level

motor +/E. lat. CST

- upper &/or lower limbs

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

SPINAL CORD
Anterior spinal a. syndrome - T9

antererior spinal a.

E F

DAMAGED

DEFICIT
DEFICIT(S)
/ SIGN(S)

I / C/ B

sensory
A. fasciculus gracilis

some touch & conscious proprioception - lower


limb

B. ventral white commissure

pain & temperature - at levels affected

C. +/- ALS

pain & temperature - below levels

motor
D. +/- lateral corticospinal fibers

spastic hemiplegia of limbs below

E. anterior corticospinal fibers

spastic hemiplegia of axial muscles below

F. ventral horn

flaccid paralysis of muscles at levels


affected

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

SPINAL CORD
Brown-Sequard syndrome (cord hemisection) - C4
A

B
F

C
G

E
H

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A-B.fasciculus gracilis & cuneatus,

touch & conscious proprioception upper & lower limbs

C. ALS -spinothalamic tracts

pain & temperature below lesion

D-E. spinocerebellar tracts

unconscious proprioception

motor
F. lateral corticospinal fibers + rubrospinal fibers
G. ventral corticospinal fibers

H. ventral horn

spastic hemiplegia of upper & lower


limbs below lesion
spastic hemiplegia, axial mm. below

flaccid paralysis of muscles at level

I
B
I

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MEDULLA OBLONGATA
Medial medullary syndrome (paramedian; Dejerine) - anterior spinal a.

A
paramedian brs.
anterior spinal a.

B
DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. medial lemniscus

touch & conscious proprioception - upper


& lower limbs (hemianesthesia)

B. corticospinal fibers (pyramid)

spastic hemiplegia of upper & lower limbs

C. hypoglossal nucleus

hemilingual muscle palsy; deviation to


lesion side on protrusion

motor

B + C. = "alternating hemiplegia

[ipsi- tongue, contra limbs]

medullary alternating hemiplegia is also called inferior alternating hemiplegia

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

MEDULLA OBLONGATA
Lateral medullary syndrome (Wallenberg) - PICA
B
F
D
G
E

DAMAGED

PICA

A
C

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. spinal trigeminal tract & nucleus

pain and temperature (face)

B. vestibular nuclei

vertigo (spinning), nystagmus, fall to same side

C. ALS

pain and temperature (body)

D. solitary nucleus

loss of taste

motor
E. hypothalamospinal sympathetics

Horner's: miosis, ptosis, anhydrosis

F. ICP - spinocerebellar fibers

ataxia

G. nucleus ambiguus

palatopharyngeal paralysis (dysphagia),


dysarthria, no gag reflex

NOTE : A. + C. is an alternating hemianalgesia


NOTE : cochlear nuclei (AICA) are excluded from from classical Wallenberg

G. Bales, Ph.D. / Clinical Neuroanatomy / NEUROANATOMICAL LESIONS / WU use only.

MEDULLA OBLONGATA
Tonsillar herniation at foramen magnum (bilateral compression)

normal

herniated

compression

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

other
respiratory and cardioregulatory
centers

respiratory and cardiac dysregulation


fatality

NOTE : not preceded by drowsiness-lss of consciousness

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CAUDAL PONS
Paramedian pontine syndrome - (Fovilles; Medial Pontine) basilar a. brs.
D
C
E

paramedian brs.
basilar a.

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. medial lemniscus

touch & conscious proprioception

B. corticospinal tract

hemiplegia of upper & lower limbs

C. abducens nucleus and/or fibers

lateral rectus paralysis

motor

D. facial nerve fibers


E. PPRF (paramedian pontine
reticular formation
B + C = middle alternating hemiplegia
NOTE: eyes look at the hemiplegia

facial paralysis

conjugate gaze paralysis to side of lesion

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CAUDAL PONS
Basolateral pontine lesion (Millard-Gubler syndrome)

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
B. corticospinal tract

hemiplegia of upper & lower limbs

C. abducens intrabulbar fibers

lateral rectus paralysis

D. facial nerve fibers

NOTE: eye looks at the hemiplegic side

facial paralysis

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PONS
Lateral pontine syndrome (Marie-Foix)
F

C
A

G
AICA
basilar - long
circumferential aa.

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A . ALS

hemianalgesia limbs & trunk

B. ventral trigeminothalamic tract

face analgesia

C. trigeminal chief sensory nucleus

face anesthesia

D. +/- medial lemniscus

lower limb hemianesthesia

motor
E. trigeminal motor nucleus

masticatory paresis/paralysis

F. MCP, SCP

limb ataxias

G. corticospinal fibers

limb paresis/paralysis

autonomic
G. hypothalamospinal sympathetics

Horner's syndrome

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PONS
Locked in syndrome "pseudocoma"
basilar artery thrombosis (BAT) - bats under the bridge (like in Austen ,TX)

imagine bilateral

DAMAGED

basilar a.: paramedian &


short circumferential brs.

DEFICIT(S) / SIGN(S)

I / C/ B

motor
corticospinal fibers

quadriplegia

corticonuclear fibers +/- : III, IV, V,


VI, VII, IX, X

can include: masticatory palsy, gaze


palsys, laryngeal palsy (aphonia; mute),
facial palsy, dysphagia (can't initiate
swallowing)

Jean Bauby, a 42-year-old father of two, and editor-in-chief of Elle magazine in Paris, suffered a
massive stroke [1995] which left him paralysed and speechless, but able to move one muscle: his
left eyelid. Yet his mind remained as active and alert as ever. By signalling with his eyelid, he
'dictated' 'The Diving Bell and the Butterfly' (Knopf, New York, 1997), blinking to indicate each
individual letter as an alphabet with letters placed according to the frequency of its use in the
French language was repeatedly read to him. Trapped inside his own body, his dispatches are
poignant and often wryly humorous. Bauby tells us about his life in a hospital overlooking the
English Channel, the flights of fancy that sustain him, the meals he can only eat in his imagination.
This story was depicted in the film "The Diving Bell & the Butterfly" in 1997.

NOTE: patient has normal awake consciousness with all cognitive abilities and can feel, but has
most to nearly all voluntary muscles paralysed; usually some eyelid control remains (dont know
why)

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CEREBELLUM
Distal PICA - spino- and vestibulocerebellum

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
posterior spinocerebellum,
vestibulocerebellum (nodulus)

vestibular problems: nystagmus, spinning,


falling to same side; truncal ataxia

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CAUDAL MIDBRAIN
Caudal Paramedian Midbrain Syndrome

paramedian brs. of terminal


basilar a.

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
A trochlear nuc. or fibers; MLF

superior oblique paralysis + internuclear


ophthalmoplegia

B. superior cerebellar decussation

ataxia

C. minimal CST involvement

minor hemiplegia

- no alternating hemiplegia syndrome involving IV

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CAUDAL MIDBRAIN
Caudal Paramedian Midbrain Syndrome

A
B

paramedian brs. of terminal


basilar a.

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
A trochlear nuc. or fibers; MLF

superior oblique paralysis + internuclear


ophthalmoplegia

B. superior cerebellar decussation

ataxia

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ROSTRAL MIDBRAIN
Paramedian midbrain syndrome (Claude's syndrome)

B
A

paramedian brs. of terminal basilar a.

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
A. oculomotor nuc. or fibers; MLF

eye movement paralyses

B. Edinger-Westphal

autonomic eye reflexes (pupillary, ciliary)

ataxias

proximal limb flexors

and
C. superior cerebellar peduncle
decussation

or
D. red nucleus, rubrospinal
decussation

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ROSTRAL MIDBRAIN
Cerebral peduncle syndrome (Webers; midbrain base syndrome)

D
A
B
C

penetrating brs. proximal PCA

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
A. oculomotor fibers

eye movement paralyses (eye down & out)

B. CST

limbs & trunk hemiplegia

C. CNT

hemiplegias (lower VII, X, XII)

D. substantia nigra

parkinsonism

A+B = alternating hemiplegia [ipsi- eye, contra- limb]


midbrain alternating hemiplegia is also called superior alternating hemiplegia

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ROSTRAL MIDBRAIN
Medial midbrain syndrome (Benedikt's syndrome) = Claude's + Weber's

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
oculomotor nuc. or fibers

eye movement paralyses

superior cerebellar peduncle


decussation

cerebro(ponto)cerebellar ataxias (skilled )

+/- red nucleus

proximal limb flexors

CST, CNT

hemiplegia

note: lateral midbrain syndromes are rarely if ever described

midbrain alternating hemiplegia is also called superior alternating hemiplegia

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ROSTRAL MIDBRAIN
Midbrain tegmentum lesion (Nothnagels syndrome)

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
oculomotor nuc. or fibers

eye movement paralyses

superior cerebellar peduncle


decussation

cerebro(ponto)cerebellar ataxias (skilled )

Note: cerebellar fibers mostly crossed by this level.

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ROSTRAL MIDBRAIN
Dorsal midbrain syndrome (Parinaud's) - e.g., pineal tumor
compression

A
B

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
A. pretectal nucs. & post.
commissure

autonomic eye reflexes (consensual)

B. superior colliculus

voluntary saccades & tracking

C. vertical gaze center

initially, conjugate upward gaze paralysis, later


downward

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MIDBRAIN
Uncal herniation (thru tentorial notch) - supratentorial space-filling masses

uncus

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

motor
CN III compression

pupillary dilation; oculomotor weakness

I/ B

crus cerebri compression

weakness of body muscles (hemiparesis)

C/ B

+/- rostral reticular formation

drowsiness-loss of consciousness; respiratory


dysregulation

I/ B

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CEREBRAL CORTEX
Anterior cerebral a. occlusion
C

B A

D
B
A
E

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. posterior paracentral lobule and
superiormost postcentral gyrus

lower limb anesthesia

motor
B. anterior paracentral lobule and
superiormost precentral gyrus

lower limb paralysis

C. micturition center

reduced voluntary inhibition of bladder emptying

B*

D. olfactory tract

anosmia

E. corpus callosum

dissconnection syndromes

other

* i.e., both sides of the bladder empty

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CEREBRAL CORTEX
Posterior cerebral a. occlusion
A
B
C
D
E
F

+/-

+/-

A
A
A
B
C
C

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. medial occipital cortex; +/- pole

homonymous hemianopia +/- macular sparing

I/C

B. thalamus

thalamic syndromes

I/C

C. hippocampal region

memory

NOTE: basilar emboli tend to lodge at its apex; vision is most acute and dbilitating effect

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CEREBRAL CORTEX
Middle cerebral a. - superior division occlusion
D

A
C

A
C
D

B
E

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. central & lower postcentral gyrus

anesthesia of upper limb & face

B. insula + operculum

loss of taste

C. angular gyrus

writing

reading aloud

B?

motor
D. central & lower precentral gyrus

paralysis of upper limb & lower face

E. Broca's area (dominant side)

impaired language expression (aphasia)

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CEREBRAL CORTEX
Middle cerebral a. - inferior division occlusion

+/A
B

DAMAGED

DEFICIT(S) / SIGN(S)

I / C/ B

sensory
A. Wernicke's area (dominant side)

receptive aphasia (impaired comprehension;


speech fluent but nonsensical)

B. Meyer's loop (rostral


geniculocalcarine tract)

upper quadrantanopia

C. +/- occipital pole (variable)

+/- macular vision

B*
ipsi- eye
+ contraeye =
homony
mous

*NOTE not strictly applicable here, but fluent speech requires both side laryngeal muscles, so
in some sense it becomes bilateral

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CEREBRAL CORTEX
Middle cerebral a. - occlusion at its origin
B

A
B

DAMAGED
sensory

DEFICIT(S) / SIGN(S)

I / C/ B

superior div. + inferior div. deficits

motor

A. genu & PLIC

hemiplegia: lower face & upper limb (super.


div.) + lower limb
hemianesthesia: face & upper limb (super. div.)
+ lower limb

B. lenticular nucleus

(masked by paralysis)

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