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BRAINSTEM STROKE

SYNDROMES

Discussion will contain


Basic neuro-anatomy of the brainstem from a
clinicians perspective
Details of the blood supply of the brainstem
Various syndromes caused by stroke involving
the brainstem vessels
RULE OF FOUR = a very simple way to
remember various brainstem lesions.
Clinical case examples

Brainstem

Located between the cerebrum


and the spinal cord
Provides a pathway for
tracts running between higher and lower
neural centers.

Consists of the midbrain, pons,


and medulla oblongata.

Midbrain
Pons

Medulla
obongata

Ventral surface of brain stem

Midbrain

Pons

Medulla
oblongata

Ventral Lateral View

Midbrain
Cerebral
peduncles

Pons
Basis pontis

Medulla

Posterior circulation
Vertebral artery branches
Posterior inferior cerebellar

Medulla, lower cerebellum

Basilar artery branches


Anterior inferior cerebellar

Lower and middle pons, anterior


cerebellum

Superior cerebellar

Upper pons, lower midbrain, upper


cerebellum

Posterior cerebral

Medial occipital and temporal


cortex and subjacent white matter,
posterior corpus callosum, upper
midbrain

Thalamoperforate branches

Thalamus

Thalamogeniculate branches

Thalamus

Brain stem arteries - anterior view

1. Posterior cerebral artery


2. Superior cerebellar artery
3. Pontine branches of the basilar artery
4. Anterior inferior cerebellar artery
5. Internal auditory artery
6. Vertebral artery
7. Posterior inferior cerebellar a.
8. Anterior spinal artery
9. Basilar artery

MID-BRAIN STOKE
SYNDROMES

Midbrain

Midbrain
Crus cerebri
Shortest brain stem,not more than
2cm in length,lies in the posterior cranial
Fossa.
For descriptive purpose,divided into
Dorsal tectum and right and left cerebral
Peduncles.
Each cerebral peduncles divide further
into ventral crus cerebri and a dorsal
Tegmentum by a pigmented lamina
Substantia nigra

Cerebral peduncles contains:


-Descending fibers that go to the
cerebellum via the pons
-Descending pyramidal tracts
Running through the midbrain is the
hollow cerebral aqueduct which
connects the 3rd and 4th ventricles of the

brain.

Cerebral aqueduct

Substantia nigra

Crus cerebri
(cerebral peduncle)

Basis pedunculi

Ventral Dorsal Organization

Tectum

Basis

Tegmentum

The roof of the aqueduct ( the tectum)


contains the corpora quadrigemina

2 superior colliculi that control reflex


movements of the eyes, head and
neck in response to visual stimuli
2 inferior colliculi that control reflex
movements of the head, neck, and
trunk in response to auditory stimuli

Superior
colliculi
Inferior
colliculi

Corpora quadregemina
Superior and inferior colliculi
seperated by cruciform sulcus
Superior colliculi larger and darker
than inferior colliculi,the difference
In colour due to superficial neurons in
Superior colliculi

Internal structure

ransverse section of midbrain

ommon to both at inferior and superior colliculus:

Crus cerebri (or basis pedunculi):


- Consists of fibres descending from cerebral cortex.
- Its medial one-sixth is occupied by coticopontine
fibres from frontal lobe,lateral one-sixth fibres
from temporal,occipital and parietal lobes,the
intermediate two third by corticospinal and corticonuclear fibres.

Substantia nigra

:
- Present immediately behind and medial to basis
pedunculi.
- It appears dark as neuron within it contain pigment.
( neuromelanin )

Medial midbrain syndrome

(paramedian branches
of upper basilar and proximal posterior cerebral arteries)

ON SIDE OF LESION
Eye "down and out"
secondary to unopposed
action of fourth and sixth
cranial nerves, with
dilated and unresponsive
pupil: Third nerve fibers

ON OPPOSITE SIDE
Paralysis of face, arm,
and leg: Corticobulbar
and corticospinal tract
descending in crus
cerebri

Lateral midbrain syndrome

(syndrome of small penetrating arteries arising from


posterior cerebral artery)

On side of lesion
Eye "down and out"
secondary to unopposed
action of fourth and sixth
cranial nerves, with
dilated and unresponsive
pupil: Third nerve fibers
and/or third nerve
nucleus
On side opposite lesion
Hemiataxia,
hyperkinesias, tremor:
Red nucleus,
dentatorubrothalamic
pathway

Mid brain syndromes

Medial midbrain syndrome

(paramedian branches
of upper basilar and proximal posterior cerebral arteries)

ON SIDE OF LESION
Eye "down and out"
secondary to unopposed
action of fourth and sixth
cranial nerves, with
dilated and unresponsive
pupil: Third nerve fibers

ON OPPOSITE SIDE
Paralysis of face, arm,
and leg: Corticobulbar
and corticospinal tract
descending in crus
cerebri

Pontine syndromes

Pons

Pons
The pons shows a convex anterior surface
with prominent transversely running fibres.
These fibres collect to form bundles,the
middle cerebellar peduncles.
Pons

The anterior surface of pons is marked in the


midline by a shallow groove,the sulcus
basilaris which lodges the basilar artery.

s
Sulcus basilaris

Subdivided into ventral and dorsal part


Ventral part of the pons contains
Pontine nuclei:
Recieves corticopontine fibres from frontal,
temporal,parietal and occipital lobes of
cerebrum
The efferent fibres form the transverse fibres
of pons.
Vertically running corticospinal and
corticopontine fibres.
Transversely running fibres arising in
pontine nuclei

Pontine nuclei

Dorsal part of pons

Midpons

The dorsal part of the pons may be regarded as


continuation of the part of the medulla behind the
pyramids.
Superiorly continous with the tegmentum of the
midbrain.

DORSAL PART

Occupied predominately by reticular formation


Posterior surface help to form floor of fourth
ventricle
The dorsal part is bounded laterally by inferior
cerebellar peduncle in the lower part of the pons
and superior cerebellar peduncle in upper part.

Upper pons

Medial inferior pontine syndrome

(occlusion of paramedian branch of basilar artery)

On side of lesion
Paralysis of conjugate gaze to
side of lesion (preservation of
convergence): Center for
conjugate lateral gaze(PPRF)
Nystagmus: Vestibular nucleus
Ataxia of limbs and gait: Likely
middle cerebellar peduncle
Diplopia on lateral gaze:
Abducens nerve
On side opposite lesion
Paralysis of face, arm, and leg:
Corticobulbar and corticospinal
tract in lower pons
Impaired tactile and
proprioceptive sense over onehalf of the body: Medial
lemniscus

Lateral inferior pontine syndrome

(occlusion of anterior inferior cerebellar artery)

On side of lesion
Horizontal and vertical nystagmus,
vertigo, nausea, vomiting, oscillopsia:
Vestibular nerve or nucleus
Facial paralysis: Seventh nerve
Paralysis of conjugate gaze to side of
lesion: Center for conjugate lateral gaze
Deafness, tinnitus: Auditory nerve or
cochlear nucleus
Ataxia: Middle cerebellar peduncle and
cerebellar hemisphere
Impaired sensation over face:
Descending tract and nucleus fifth nerve
On side opposite lesion
Impaired pain and thermal sense over
one-half the body (may include face):
Spinothalamic tract

Medial midpontine syndrome


(paramedian branch of midbasilar artery)
On side of lesion
Ataxia of limbs and gait
(more prominent in
bilateral involvement):
Pontine nuclei
On side opposite lesion
Paralysis of face, arm, and
leg: Corticobulbar and
corticospinal tract
Variable impaired touch
and proprioception when
lesion extends posteriorly:
Medial lemniscus

Lateral midpontine syndrome

(short

circumferential artery)

On side of lesion
Ataxia of limbs: Middle
cerebellar peduncle
Paralysis of muscles of
mastication: Motor fibers
or nucleus of fifth nerve
Impaired sensation over
side of face: Sensory fibers
or nucleus of fifth nerve
On side opposite lesion
Impaired pain and thermal
sense on limbs and trunk:
Spinothalamic tract

Medial superior pontine syndrome

(paramedian branches

of upper basilar artery)

On side of lesion
Cerebellar ataxia (probably):
Superior and/or middle
cerebellar peduncle
Internuclear ophthalmoplegia:
Medial longitudinal fasciculus
Myoclonic syndrome, of palate,
pharynx, vocal cords,
respiratory apparatus, face,
oculomotor apparatus, etc.:
central tegmental bundle.
On side opposite lesion
Paralysis of face, arm, and leg:
Corticobulbar and corticospinal
tract
Rarely touch, vibration, and
position are affected(arm>leg):
Medial lemniscus

Rt internuclear
ophthalmoplegia

One and a half syndrome


RT

LT

Lateral superior pontine syndrome

(syndrome of superior cerebellar artery)

On side of lesion
Ataxia of limbs and gait, falling to side
of lesion: Middle and superior
cerebellar peduncles, superior surface
of cerebellum, dentate nucleus
Dizziness, nausea, vomiting; horizontal
nystagmus: Vestibular nucleus
Paresis of conjugate gaze (ipsilateral):
Pontine contralateral gaze
Miosis, ptosis, decreased sweating
over face (Horner's syndrome):
Descending sympathetic fibers
On side opposite lesion
Impaired pain and thermal sense on
face, limbs, and trunk: Spinothalamic
tract
Impaired touch, vibration, and position
sense, more in leg than arm : Medial
lemniscus (lateral portion)

MEDU
LLA
OBLO
NGATA

External structure of medulla

Most inferior region of the brain stem.


Becomes the spinal cord at the level of
the foramen magnum.
Medulla is broad above ,joins with pons
narrow below, continous with spinal cord
Length is about 3cm, width is about 2cm
at its upper end
Surfaces shows series of fissures
Anterior median fissure
Posterior median fissure

Medulla oblongata

External surface of medulla

Ventral surface of medulla oblongata contains


Pyramid
elevation between anterior median
and anterolateral sulcus
Formed due to decussation of corticospinal
Olive
fibres.
Oval swelling between anterolate
posterolateral sulcus,half an inch
long
Produced by large mass of gray
matter called inferior olivary
nucleus

Olive

Pyramid

Pyramid
Olive

Anterolateral fissure
Anterior median fissure

Medial medullary syndrome

(occlusion of vertebral artery or of branch of vertebral or


lower basilar artery)

On side of lesion
Paralysis with atrophy of
one-half half the tongue:
Ipsilateral twelfth nerve
On side opposite lesion
Paralysis of arm and leg,
sparing face; impaired
tactile and
proprioceptive sense
over one-half the body:
Contralateral pyramidal
tract and medial
lemniscus

Lateral medullary syndrome

(occlusion of any of five vessels may


be responsiblevertebral, posterior inferior cerebellar, superior, middle, or inferior lateral medullary arteries)

On side of lesion
Pain, numbness, impaired sensation over
one-half the face: Descending tract and
nucleus fifth nerve
Ataxia of limbs, falling to side of lesion:
Uncertainrestiform body, cerebellar
hemisphere, cerebellar fibers,
spinocerebellar tract (?)
Nystagmus, diplopia, oscillopsia, vertigo,
nausea, vomiting: Vestibular nucleus
Horner's syndrome (miosis, ptosis, decreased
sweating): Descending sympathetic tract
Dysphagia, hoarseness, paralysis of palate,
paralysis of vocal cord, diminished gag reflex:
Issuing fibers ninth and tenth nerves
Loss of taste: Nucleus and tractus solitarius
Numbness of ipsilateral arm, trunk, or leg:
Cuneate and gracile nuclei
Weakness of lower face: Genuflected upper
motor neuron fibers to ipsilateral facial
nucleus
On side opposite lesion
Impaired pain and thermal sense over half
the body, sometimes face: Spinothalamic