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BRAINSTEM LESIONS
Dennis Ivan Bravo, MD
Rule of Four
1.

4 Medial structures
Motor pathways
Medial lemniscus
Medial longitudinal fasciculus
Motor nucleus and nerve

2.

4 medial motor nucleus

CN 3, 4, 6, 12 divisor of 12 is medial
3, 4, 6 12 nucleus are medial
5, 7, 9 ,11 are lateral

3.

4 side structures
Spinocerebellar pathway
Spinothalamic pathway
Sensory nucleus of CN 5
Sympathetic pathway

4.

4 Medulla Cranial nerves

Glossopharyngeal CN 9
Vagus CN 10
Spinal Accessory CN 11
Hypoglossal CN 12
4 Pons Cranial Nerves
Trigeminal CN 5
Abducens CN 6
Facial CN 7
Auditory CN 8
4 Cranial Nerves above Pons
Olfactory CN 1
Optic CN 2
Oculomotor CN 3
Trochlear CN 4

Example
Inability to raise the soft palate, which is innervated by CN 10 is
caused by a lesion on the same cranial nerve in the medulla, not
in pons nor in midbrain because of the location of CN 10.
Use the tracts to decide if the lesion is medial or lateral:

If any of the manifestations carried by these tracts are impaired,

then position on the brainstem can be identified.
Ascending and descending tracts that pass through the
brainstem
Tract
Corticospinal
Dorsal column/ Medial
lemniscus

Function
Descending motor
somatosensory and conscious
proprioception

Medial longitudinal
fasciculus
Spinothalamic
Spinocerebellar
Sympathetic pathway

Side to side movement of the eye

pain and temperature
unconscious proprioception
Sympathetic functions

MIDLINE STRUCTURES
Pathways and tracts pass through the entire length of the
brainstem and can be likened to meridians of longitude where as
cranial nerves can be regarded as parallels of latitude.
If there is a lesion an you know that there is a particular nerve
that is affected and a particular pathway is affected, locaitng the
exact place of the lesion can be determined. Site of lesion will be
the intersection of the tracts (longitude) and the cranial nerves
(latitude).

CORTICOSPINAL TRACT

Voluntary motor control

Lesion would cause CONTRALATERAL PARALYSIS

Primary motor area in cerebral cortex(Brodmann area 4)

Brainstem
90% cross over to contralateral side at lower medulla
Anterior horn cell of spinal cord
Nerve fibers
Skeletal muscles

MEDIAL LEMNISCUS TRACT

Sensory tract of vibration, position sense,

proprioception and crude touch.
CONTRALATERAL proprioception loss

Posterior horn cell

Dorsal column of spinal cord

MICRO B BRAINSTEM LESIONS (DR. BRAVO)

Fasciculus cuneatus (upper body

proprioception)
Fasciculus gracilis (lower body

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proprioception)
Cross over to contralateral side
Ascends to the brainstem (known as Medial Lemniscus)
Thalamus
Primary somatosensory area of cerebral cortex (Brodmann area
3 1 2)

MEDIAL LONGITUDINAL FASCICULUS TRACT

Coordinates the side to side eye movement causing both

eyes to move in the same direction
Lesion would cause IPSILATERAL Internuclear
opthalmoplegia

Lateral funiculus of spinal cord

Brainstem
Thalamus
Cerebral Cortex (Brodmann Area 3 1 2)

SENSORY NUCLEUS OF TRIGEMINAL

IPSILATERAL pain and temperature loss of the face

Parts of nucleus of CN 5
Mesencephalic nucleus
Principal trigeminal
nucleus
Spinal tract of nucleus of
trigeminal nerve

Stimulus
Proprioception
Light touch;
Discriminative
sensation
Pain and
temperature

Location
Midbrain
Pons
Medulla
oblongata

SYMPATHETIC PATHWAY

Figure 1. The Medial Longitudinal Fasciculus (MLF) tract.

IPSILATERAL Horners Syndrome

Horner Syndrome
o Interruption in the Sympathetic functions of the bidy
thus Parasympathetic functions predominate
o Triad of manifestation: Miosis, Anhydrosis, Ptosis
o Miosis constriction of the pupil
o Anhydrosis decreased sweating of the face of
the ipsilateral side
o Ptosis drooping eyelid of the ipsilateral side

Higher center send out fibers that innervate the nucleus of CN 6

to innervate the lateral rectus. CN 6 will also send fibers that
cross over to the contralateral side and form the medial
longitudinal fasciculus, innervating the contralateral nucleus of
CN 3 which will allow contraction of the medial rectus.
Internuclear opthalmoplegia
o Paralysis of the lateral rectus
o Communication between CN 3 and CN 6 nucleus is
interrupted.

MOTOR NUCLEUS AND NERVE

Figure 2. Horner Syndrome. Pupilloconstriction on the

ipsilateral side of the lesion.
Location
Midbrain

Cranial Nerve
3 Oculomotor

Site of
Lesion
ipsilateral

4 Trochlear

Ipsilateral

5 Trigeminal

Ipsilateral

6 Abducens

Ipsilateral

7 Facial

Ipsilateral

8 Vestibulocochlear
9 Glossopharyngeal

ipsilateral
Ipsilateral

10 Vagus

ipsilateral

11 Accessory

ipsilateral

12 Hypoglossal

ipsilateral

Motor nucleus and nerve lesion

IPSILATERAL CN functional loss

LATERAL STRUCTURES

Pons

SPINOCEREBELLAR TRACT

Unconscious proprioception
Damage to this tract will cause IPSILATERAL ataxia
Helps maintain balance
Sends out fibers going to cerebellum

SPINOTHALAMIC TRACT

CONTRALATERAL pain and temperature sensation

Posterior horn cell of spinal cord

Send out fibers to contralateral side
MICRO B BRAINSTEM LESIONS (DR. BRAVO)

Medulla
oblongata

Deficit
Eye turned out
and down
Unable to look
down
when
looking
towards nose
Facial sensory
loss
Eye abduction
weakness
Facial
weakness
deafness
Pharyngeal
sensory loss
Palatal
weakness
Shoulder
weakness
Weakness
of
tongue

CASTILLO, N.P. 2013 1-A

Hypoglossal
nucleus
Tractus solitarius
Medial lemniscus
corticospinal
Figure 3. Deviation of the uvula to the right side caused by a
lesion on the left vagus nerve.
Levator uvulae
Innervated by CN 10
Has a tendency to pull away from each other and
thereby elevating the uvula.
Weaker side will lose capability to pull and therefore
the uvula deviates opposite to the lesion and towards
the stronger side.
Summary of the different tracts
Pathway
Corticospinal
Medial
Lemniscus
Spinocerebellar
Spinothalamic
Sympathetic

Function

Site of
Lesion

Deficit

Motor
proprioception

contralateral
contralateral

Unconscious
proprioception
Pain &
temperature

ipsilateral

Paralysis
Proprioception
loss
Ataxia

Sympathetic
functions

ipsilateral

contralateral

Loss of pain
and temp
sensation
Horner
Syndrome

Cases
58 year old was refered to the doctor because of a recent onset of
left hemiparesis, left-sided loss of proprioception, right sided
tongue deviation. What seen structures are affected and explain
the symptoms with regards to the structures affected? Where is
the lesion?
Manifestations
Left Hemiparesis
Left sided loss of
proprioception
R sided tongue
deviation

Structures affected
Corticospinal R
Medial lemniscus
R
CN 12, R

Location
Medial
Medial
Medulla

MEDIAL MEDULLARY SYNDROME

Occlusion of the medullary branch of the vertebral
artery
Tongue deviation
When tongue is protruded outside, the muscles tend to
push each other in front
Deviation towards the side of lesion happens due to the
inability of the muscles on that side to push the tongue
forward.

MICRO B BRAINSTEM LESIONS (DR. BRAVO)

Figure 4. Tracts and structures affected by the medial medullary

syndrome highlighted in red.
Case 2
Manifestations
Left sided miosis,
anhydrosis, ptosis
Left sided ataxia
Uvula deviated to the
right

Structures affected
Sympathetic L

Location
Side

Spinocerebellar L
CN X, L (particularly
the nucleus
ambiguus)

Side
Medulla

LATERAL MEDULLARY SYNDROME or WALLENBERG

SYNDROME
Occlusion of the posterior inferior cerebellar artery
Associated with analgesia and thermoanalgesia of the
ipsilateral face pain and temperature loss in the face
o Involvement of the spinal tract nucleus of
trigeminal or spinothalamic nuclei of
trigeminal
Case 3
50 year old man
Manifestations
Structures affected
Location
Left sided loss of pain Spinothalamic R
Side
and temperature
Right Dimunition in
CN VIII R
Pons
hearing
Horner syndrome
Sympathetic
Side
(MAP)
LATERAL PONTINE SYNDROME
Occlusion of posterior cerebellar artery
Case 4
10 year old girl
Manifestations
Left sided weakness
Right eye deviates
medially
Right sided facial
weakness

Structures affected
Corticospinal R
CN 6 (Lateral rectus)
R
CN 7 R

Location
Medial
Pons
Pons

MEDIAL PONTINE SYNDROME / MILLARD-GUBLER

SYNDROME
Pons tumor usually an astrocytoma
o Tumor arising from the astrocytes
o Located in the medial pons
o Children are usually affected
Chronic and progressive

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Case 5
70 year old male hypertensive suddenly developed
Manifestations
Structures affected
Location
Left sided ipsilateral CN 3 L
Midbrain, L
ophthalmoplegia
Loss of pupillary light
CN 3 L
Midbrain, L
reflex, left eye
Paralysis of right arm
Corticospinal L
Medial, L
and leg
Ophthalmoplegia
The eye is down and out
CN 3 Oculomotor damage

Figure 6. Parinaud Syndrome (shaded area) of the posterior

midbrain where it primarily affects the superior colliculi involved
in the visual pathway

Pupillary light reflex

CN 2 and 3

LOCKED IN SYNDROME
Lesion is located at the basal aspect of pons
Paralysis of all the voluntary muscles except for eye
movement
Conscious but can only move eyes
Paralysis of the corticobulbar and corticospinal
Reticular fibers are unaffected
o Keeps us awake
o Acts as sensor in filtering sensory input
o Filters out the passage of other information
o Allows passage of infrequent or important
stimuli to reach cerebral cortex

MEDIAL MIDBRAIN SYNDROME/ WEBERS SYNDROME

Case 6
Manifestations
Left sided ipsilateral
ophthalmoplegia
Right sided
proprioception loss
Involuntary
movement

Structures affected
CN 3 L

Location
Midbrain, L

Medial Lemniscus
L
Red nucleus L

Medial, L
Medial, L

Red nucleus pathway for the involuntary movement

BENEDIKTS SYNDROME
Webers Syndrome
CN 3
Corticospinal
Corticobulbar
Medial midbrain

Benedikts Syndrome
CN3
Medial Lemniscus
Red nucleus
Medial midbrain

Webers syndrome affects more of the motor function where as

the Benedikts syndrome involves the sensory tracts.

Syndrome
Medial Medullary Syndrome
Lateral Medullary or
Wallenberg Syndrome
Medial Pontine or MillardGubler Syndrome
Lateral Pontine Syndrome
Medial Midbrain or Webers
Syndrome
Benedikts Syndrome
Posterior Midbrain or
Parinauds Syndrome
Locked in Syndrome

Etiology
Medullary branch of the
vertebral artery occlusion
Posterior Inferior Cerebellar
Artery occlusion
aastrocytoma
Posterior cerebellar artery
occlusion
CN3, and motor tracts
CN3, Medial Lemniscus and
Red nucleus
Superior colliculi
Paralysis of corticobulbar and
corticospinal

Figure 5. Comparison of the affected areas in Webers (shaded

area) and Benedikts Syndrome (pink box). Note that both
involves CN 3.
PARINAUDS SYNDROME
Posterior midbrain is affected especially the superior
colliculi which is the center for upward gaze.
There is inability to look up Dolls eye
Argylle- Robertson pupil
o Prostitutes pupil
o Secondary to tertiary syphilis infection
o Pupil accommodates but do not react to light
MICRO B BRAINSTEM LESIONS (DR. BRAVO)

CASTILLO, N.P. 2013 1-A