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BRAINSTEM STROKE
SYNDROMES
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Discussion will contain
Basic neuro-anatomy of the rainstem from aclinician!s "ers"ecti#e
Details of the loo$ su""ly of the rainstem
%arious syn$romes cause$ y stro&e in#ol#in'the rainstem #essels
RULE OF FOUR ( a very simple way to
rememer #arious rainstem lesions)
*linical case e+am"les
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Located between the cerebrumand the spinal cord
Provides a pathway fortracts running between higher and lowerneural centers.
Consists of the midbrain, pons,andmedulla oblongata.
Brainstem
Midbrain
Pons
Medullaobongata
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Midbrain
Pons
Medulla
oblongata
%entral surface of rain stem
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Mi$rainCerebral
peduncles
,onsBasis pontis
Me$ulla
Ventral Lateral View
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,osterior circulation
Vertebral artery branchesPosterior inferior cerebellar Medulla, lower cerebellum
Basilar artery branches
Anterior inferior cerebellar Lower and middle pons, anteriorcerebellum
Superior cerebellar pper pons, lower midbrain, uppercerebellum
Posterior cerebral Medial occipital and temporal
cortex and subjacent white matter,
posterior corpus callosum, uppermidbrain
!halamoperforate branches !halamus
!halamogeniculate branches !halamus
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Brain stem arteries - anterior view
1 Posterior !erebral artery" #uperior !erebellar artery$ Pontine bran!%es o& t%e basilar artery' (nterior in&erior !erebellar artery) *nternal auditory artery+ Vertebral artery, Posterior in&erior !erebellar a- (nterior spinal artery
. /asilar artery
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MID-BRAIN STOKE
SYNDROMES
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Mi$rain
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Shortest brain stem,not more than
"cm in length,lies in the posterior cranial#ossa.#or descriptive purpose,divided into
$orsal tectum and right and left cerebral
Peduncles.%ach cerebral peduncles divide further
into ventral crus cerebri and a dorsal!egmentum by a pigmented lamina
& Substantia nigra'Cerebral peduncles contains(
)$escending fibers that go to thecerebellum via the pons
)$escending pyramidal tracts*unning through the midbrain is thehollow cereral a.ue$uct whichconnects the +rdandthventricles of the
brain.
Mi$rainCrus cerebri
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Basis "e$unculiSustantia ni'ra
*rus cereri
-cerebral peduncle
*ereral a.ue$uct
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Basis Te'mentum
Tectum
Ventral 0orsal Organiation
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!he roof of the a/ueduct - the tectumcontains the corpora /uadrigemina
" superior colliculi that control refle0movements of the eyes, head andnec1 in response to visual stimuli" inferior colliculi that control refle0movements of the head, nec1, andtrun1 in response to auditory stimuli
*or"ora .ua$re'emina
Superior colliculi larger and dar1er
than inferior colliculi,the difference
2n colour due to superficial neurons in
Superior colliculi
Superior and inferior colliculi
seperated by cruciform sulcus
#uperior!olli!uli
*n&erior
!olli!uli
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*nternal stru!tureansverse section of midbrainmmon to oth at inferior an$ su"erior colliculus/
2rus !erebri 3or basis pedun!uli4() Consists of fibres descending from cerebral corte0.
) 2ts medial one)si0th is occupied by coticopontine
fibres from frontal lobe,lateral one)si0th fibres
from temporal,occipital and parietal lobes,theintermediate two third by corticospinal and cortico)
nuclear fibres.
#ubstantia nigra () Present immediately behind and medial to basis
pedunculi.
) 2t appears dar1 as neuron within it contain pigment.
- neuromelanin
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Me$ial mi$rain syn$rome 0"arame$ian ranchesof u""er asilar an$ "ro+imal "osterior cereral arteries1
ON SIDE O2 3ESION
Eye 4$own an$ out4secon$ary to uno""ose$action of fourth an$ si+thcranial ner#es5 with
$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbers
ON O,,OSITE SIDE
,aralysis of face5 arm5
an$ le'/ Corticobulbarand corticospinal tractdescending in cruscerebri
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3ateral mi$rain syn$rome 0syn$rome of small "enetratin' arteries arisin' from"osterior cereral artery1
On si$e of lesion
Eye 4$own an$ out4secon$ary to uno""ose$action of fourth an$ si+thcranial ner#es5 with
$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbersand/or third nervenucleus
On si$e o""osite lesion
6emiata+ia5hy"er&inesias5 tremor/Red nucleus,dentatorubrothalamicpathway
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Mi$ rain syn$romes
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Me$ial mi$rain syn$rome 0"arame$ian ranchesof u""er asilar an$ "ro+imal "osterior cereral arteries1
ON SIDE O2 3ESION
Eye 4$own an$ out4secon$ary to uno""ose$action of fourth an$ si+thcranial ner#es5 with
$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbers
ON O,,OSITE SIDE
,aralysis of face5 arm5
an$ le'/ Corticobulbarand corticospinal tractdescending in cruscerebri
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,ontine syn$romes
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,ons
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,ons
!he pons shows a conve0 anterior surface with prominent transversely running fibres.
!hese fibres collect to form bundles,the
middle cerebellar peduncles.
!he anterior surface of pons is mar1ed in the
midline by a shallow groove,the sulcus
basilaris which lodges the basilar artery.
,ons
s
Sulcus basilaris
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Subdivided into ventral and dorsal part
3entral part of the pons contains
Pontine nuclei:
*ecieves corticopontine fibres from frontal,
temporal,parietal and occipital lobes of
cerebrum
!he efferent fibres form the transverse fibresof pons.
Vertically running corticospinal and
corticopontine fibres.
ransversely running fibres arising in
pontine nuclei
Pontine nuclei
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!he dorsal part of the pons may be regarded as
continuation of the part of the medulla behind the
pyramids.
Superiorly continous with the tegmentum of the
midbrain.
4ccupied predominately by reticular formation
Posterior surface help to form floor of fourth
ventricle
The dorsal part is bounded laterally by inferior
cerebellar peduncle in the lower part of the pons
and superior cerebellar peduncle in upper part.
Dorsal "art of "ons
DORSA3 ,ART
Midpons
!pper pons
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Me$ial inferior "ontine syn$rome 0occlusion of "arame$ian ranch of asilar artery1
On si$e of lesion
,aralysis of con7u'ate 'a8e tosi$e of lesion 0"reser#ation ofcon#er'ence1/ Center orconjugate lateral gaze(R!"
Nysta'mus/ #estibular nucleus
Ata+ia of lims an$ 'ait/ 3i&ely
middle cerebellar peduncle Di"lo"ia on lateral 'a8e/
$bducens nerve
On si$e o""osite lesion
,aralysis of face5 arm5 an$ le'/Corticobulbar and corticospinal
tract in lower pons Im"aire$ tactile an$
"ro"rioce"ti#e sense o#er one-half of the o$y/ %ediallemniscus
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3ateral inferior "ontine syn$rome 0occlusion of anterior inferior cereellar artery1
On side o& lesion
6ori8ontal an$ #ertical nysta'mus5#erti'o5 nausea5 #omitin'5 oscillo"sia/#estibular nerve or nucleus
2acial "aralysis/ &eventh nerve
,aralysis of con7u'ate 'a8e to si$e oflesion/ Center or conjugate lateral gaze
Deafness5 tinnitus/$uditory nerve orcochlear nucleus
Ata+ia/ %iddle cerebellar peduncle andcerebellar hemisphere
Im"aire$ sensation o#er face/
'escending tract and nucleus fth nerve
On side opposite lesion
Im"aire$ "ain an$ thermal sense o#erone-half the o$y 0may inclu$e face1/&pinothalamic tract
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Me$ial mi$"ontine syn$rome0"arame$ian ranch of mi$asilar artery1
On side o& lesion
Ata+ia of lims an$ 'ait0more "rominent inilateral in#ol#ement1/
ontine nuclei On side opposite lesion
,aralysis of face5 arm5 an$le'/ Corticobulbar and
corticospinal tract %ariale im"aire$ touch
an$ "ro"rioce"tion whenlesion e+ten$s "osteriorly/
%edial lemniscus
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3ateral mi$"ontine syn$rome 0shortcircumferential artery1
On side o& lesion
Ata+ia of lims/ %iddlecerebellar peduncle
,aralysis of muscles of
mastication/ %otor fbersor nucleus o fth nerve
Im"aire$ sensation o#ersi$e of face/ &ensory fbersor nucleus o fth nerve
On side opposite lesion
Im"aire$ "ain an$ thermalsense on lims an$ trun&/&pinothalamic tract
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Me$ial su"erior "ontine syn$rome 0"arame$ian ranchesof u""er asilar artery1
On side o& lesion
*ereellar ata+ia 0"roaly1/&uperior and/or middlecerebellar peduncle
Internuclear o"hthalmo"le'ia/%edial longitudinal asciculus
Myoclonic syn$rome5 of "alate5"haryn+5 #ocal cor$s5res"iratory a""aratus5 face5oculomotor a""aratus5 etc)/ central tegmental bundle)
On side opposite lesion
,aralysis of face5 arm5 an$ le'/Corticobulbar and corticospinaltract
Rarely touch5 #iration5 an$"osition are a9ecte$0arm:le'1/
%edial lemniscus
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Rt internuclearo"hthalmo"le'ia
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One an$ a half syn$rome
RT 3T
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3ateral su"erior "ontine syn$rome 0syn$rome of su"erior cereellar artery1
On side o& lesion
Ata+ia of lims an$ 'ait5 fallin' to si$eof lesion/ %iddle and superiorcerebellar peduncles, superior suraceo cerebellum, dentate nucleus
Di88iness5 nausea5 #omitin'; hori8ontalnysta'mus/ #estibular nucleus
,aresis of con7u'ate 'a8e 0i"silateral1/
ontine contralateral gaze Miosis5 "tosis5 $ecrease$ sweatin'
o#er face 06orner
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MED=33A
OB3ON>ATA
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Medulla is broad above ,5oins with pons narrow below, continous with spinal cord
Length is about +cm, width is about "cm
at its upper end
Surfaces shows series of fissuresAnterior median fissurePosterior median fissure
Medulla oblongata
Most inferior region of the brain stem.
Becomes the spinal cord at the level ofthe foramen magnum.
E5ternal stru!ture o& medulla
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%entral surface of me$ulla olon'ata contains,yrami$ele#ation etween anterior me$ian
an$ anterolateral sulcus2orme$ $ue to $ecussation of corticos"inal ?res)
,yrami$
Oli#e
Oli#eO#al swellin' etween anterolate "osterolateral sulcus5half an inc lon',ro$uce$ y lar'e mass of 'ray
matter calle$ inferior oli#ary nucleus
E5ternal sur&a!e o& medulla
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Anterior me$ian ?ssure
,yrami$
Anterolateral ?ssure
Oli#e
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Medial medullary syndrome 0occlusion of #erteral artery or of ranch of #erteral orlower asilar artery1
On side o& lesion
,aralysis with atro"hy ofone-half half the ton'ue/*psilateral twelth nerve
On side opposite lesion ,aralysis of arm an$ le'5
s"arin' face; im"aire$tactile an$
"ro"rioce"ti#e senseo#er one-half the o$y/Contralateral pyramidaltract and medial
lemniscus
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3ateral me$ullary syn$rome 0occlusion of any of ?#e #essels maye res"onsile@#erteral5 "osterior inferior cereellar5 su"erior5 mi$$le5 or inferior lateral me$ullary arteries1
On side o& lesion
,ain5 numness5 im"aire$ sensation o#erone-half the face/ 'escending tract andnucleus fth nerve
Ata+ia of lims5 fallin' to si$e of lesion/+ncertainrestiorm body, cerebellarhemisphere, cerebellar fbers,spinocerebellar tract ("
Nysta'mus5 $i"lo"ia5 oscillo"sia5 #erti'o5nausea5 #omitin'/ #estibular nucleus
6orner