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BRAINSTEM

JOEL P. CARREON M.D.

Brainstem
It is made up of midbrain, pons and medulla
oblongata
Occupies the posterior cranial fossa of the skull
Stalklike in shape
Functions:
1. serves as conduit for ascending tracts and
descending tracts
2. has important reflex centers associated with
respiration, cardiovascular system,
conciousness
3. contains nuclei of CN III to XII

MIDBRAIN

Gross Appearance
2cm (0.8 inch) in
length
Connects the pons
& cerebellum with
the forebrain
Traversed by a
narrow channel,
filled with CSF
cerebral
aqueduct

Posterior Surface
Rounded
eminences
4 Colliculi
(corpora
quadrigemina)

divided into
superior & inferior
pairs by a vertical
& transverse
groove

Posterior Surface
Superior colliculi
centers for visual
reflexes

Inferior colliculi
lower auditory
centers

Posterior Surface
Trochlear nerves
emerge in the
midline below the
inferior colliculi;
small diameter
nerves that wind
around the lateral
aspect of midbrain
& enters lateral wall
of cavernous sinus

Lateral Aspect of Midbrain


Superior &
Inferior brachia
ascend
anterolaterally
Superior
brachium
passes from
superior colliculus
to LGB & optic tract

Inferior brachium
connects inferior
colliculus to MGB

Anterior Aspect of Midbrain


Interpeduncular
fossa
deep depression in
the midline

Posterior
perforated
substance
region where
several small blood
vessels perforate
the floor of
interpeduncular
fossa

Crus cerebri

Anterior Aspect of Midbrain


Oculomotor
nerve
emerges from a
groove on medial
side of crus cerebri,
passes forward in
lateral wall of
cavernous sinus

INTERNAL STRUCTURE OF
MIDBRAIN
Cerebral
Peduncles
two lateral halves of
the midbrain,
Divided into A & P
part
Crus Cerebri
anterior part
Tegmentum
posterior part

INTERNAL STRUCTURE OF
MIDBRAIN
Substantia Nigra
pigmented band of
gray matter that
divides the
peduncles

INTERNAL STRUCTURE OF
MIDBRAIN
Cerebral aqueduct
narrow cavity of the
midbrain that connects
3rd & 4th ventricle

Central gray matter


surrounds cerebral
aqueduct

Tectum
part of midbrain
posterior to the cerebral
aqueduct, contains 4
swellings (corpora
quadrigemina)

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI
Inferior
Colliculus
large nucleus of
gray matter that
forms part of
auditory pathway
receives terminal
fibers of lateral
lemniscus
continues through
inferior brachium to
medial geniculate
body

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI
Trochlear Nucleus
situated in central gray
matter close to median
plane just posterior to
medial longitudinal
fasciculus
fibers pass laterally &
posteriorly around
central gray matter,
leaves the midbrain
below inferior colliculi
fibers of trochlear nerve
decussate in superior
medullary velum

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI
Mesencephalic
nuclei of
trigeminal nerve
lateral to cerebral
aqueduct

Decussation of
superior
cerebellar
peduncles
occupies central
part of tegmentum
anterior to cerebral

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI
Medial
Lemniscus
posterior to
substantia nigra

Spinal &
trigeminal nuclei
lateral to medial
lemniscus

Lateral
Lemniscus
posterior to
trigeminal

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI
Substantia Nigra
large motor nucleus
between the
tegmentum & crus
cerebri
composed of mediumsized multipolar
neurons
contains inclusion
granules of pigment
melanin in cytoplasm
concerned with muscle
tone
connected to cerebral
cortex, spinal cord,
hypothalamus, basal

TRANSVERSE SECTION: LEVEL OF


INFERIOR COLLICULI

Crus Cerebri

separated from
tegmentum by substantia
nigra
contains impt descending
tracts
corticospinal &
corticonuclear fibers
occupy the middle 2/3 of
crus
frontopontine fibers
occupy medial part of crus
temporopontine fibers
occupy lateral part of crus
these descending tracts
connect cerebral cortex to
anterior gray column of
cells of spinal cord, cranial
nerve nuclei, pons &

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Superior Colliculus
large nucleus of gray matter
that forms part of visual
reflexes
connected to lateral geniculate
body by superior brachium
receives afferent fibers from
optic nerve, visual cortex, &
the spinotectal tract
efferent fibers form the
tectospinal & tectobulbar
tracts (probably responsible for
the movements of eye, head &
neck in response to visual
stimuli

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Oculomotor
nucleus
situated in central
gray matter close to
median plane just
posterior to MLF
fibers pass
anteriorly to red
nucleus to emerge
on medial side of
crus cerebri in
interpeduncular
fossa

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Medial, Spinal &
Trigeminal
Lemnisci
form a curved band
posterior to
substantia nigra
Lateral lemniscus
does not extend to
this level

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Red Nucleus
rounded mass of
gray matter
between cerebral
aqueduct &
substantia nigra
reddish hue is due
to its vascularity &
the presence of an
iron-containing
pigment in the
cytoplasm of its
neurons

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Red Nucleus
Afferent nucleus
from:
Cerebral cortex
from corticospinal
fibers
Cerebellum through
the superior
cerebellar peduncle
Lentiform nucleus,
subthalamic &
hypothalamic
nuclei, substantia
nigra, spinal cord

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Red Nucleus
Efferent fibers pass
to:
Spinal cord through
rubrospinal tract
Reticular formation
through
rubroreticular tract
Thalamus
Subatantia Nigra

TRANSVERSE SECTION: LEVEL OF


THE SUPERIOR COLLICULI
Reticular formation
situated in tegmentum
lateral & posterior to
red nucleus

Crus Cerebri
contains corticospinal,
corticonuclear &
corticopontine fibers
(same at the level of
inferior colliculus)

Webers Syndrome
Basal Midbrain Infarct

caused by occlusion of a
branch of posterior
cerebral artery that
supplies the midbrain
results in necrosis of
brain tissue involving
oculomotor nerve & crus
cerebri
S/Sx:
Ipsilateral ophthalmoplegia
Contralateral paralysis of
lower part of face, tongue,
& arm & leg
Lateral deviation of eyeball
(paralysis of medial rectus)
Ptosis

Benedikts Syndrome
Paramedian
Midbrain Infarct
Necrosis involves
medial lemniscus &
red nucleus
Contralateral
hemianesthesia &
involuntary
movements of limbs
to opposite side

PONS

GENERAL FEATURES OF PONS


Situated in the posterior cranial fossa
beneath the tentorium cerebelli
Possesses cranial nerve nuclei (CN 5,
6, 7 & 8)
Conduit for ascending & descending
tracts (corticonuclear, corticopontine,
corticospinal, MLF, spinal, lateral &
medial lemniscus)

GROSS APPEARANCE
Anterior to the
cerebellum
Connects the
medulla oblongata to
the midbrain
it is one inch (2.5cm)
long
bridge connecting
the right & left
cerebellar
hemispheres

GROSS APPEARANCE
Anterior Surface

convex from side


to side
shows transverse
fibers that
converge on each
side (middle
cerebellar
peduncle)
Basilar groove:
shallow groove in
the midline which
lodges the basilar

GROSS APPEARANCE
Anterolateral surface

trigeminal nerve
emerges on each
side
medial part:
smaller, motor root
lateral part: larger,
sensory root

GROSS APPEARANCE
Groove between
pons & medulla
(medial to
lateral)
Abducent,
facial,
vestibulocochl
ear nerves

GROSS APPEARANCE
Posterior Surface
hidden from view by
cerebellum
forms upper half of
floor of 4th ventricle
triangular in shape
Limited laterally by
superior cerebellar
peduncles, divided
into symmetrical
halves by median
sulcus

GROSS APPEARANCE
Posterior Surface
Medial
eminence
elongated
elevation
lateral to the
sulcus,
bounded
laterally by
sulcus limitans

GROSS APPEARANCE
Posterior Surface
Facial colliculus
expansion at
inferior end of
medial eminence
produced by the
root of facial
nerve winding
around nucleus
of abducent
nerve

GROSS APPEARANCE
Posterior Surface
Substantia
furruginea
bluish-gray floor of
the superior part of
sulcus limitans
Area Vestibuli
lateral to sulcus
limitans, produced
by underlying
vestibular nuclei

INTERNAL STRUCTURE OF THE


PONS
Divided into A &
P part by
transversely
running fibers of
trapezoid body
Tegmentum
posterior part
Basal
anterior part

Transverse section through the Caudal Part

Passes through
the facial
collicullus

Transverse section through the Caudal Part

Medial
Lemniscus
rotates as it
passes from the
medulla into
the pons
situated in most
anterior part of
tegmentum
accompanied
by the spinal &

Transverse section through the Caudal Part


Facial Nucleus
posterior to lateral
part of medial
lemniscus
Facial colliculus
produced by the
fibers of facial
nerve winding
around the nucleus
of abducent nerve

Transverse section through the Caudal Part

Medial Longitudinal
Fasciculus
situated beneath the
floor of 4th ventricle on
either side of midline
main pathway that
connects vestibular &
cochlear nuclei with
the nuclei controlling
EOM (oculomotor,
trochlear & abducent
nuclei)

Transverse section through the Caudal Part


Medial Vestibular
Nucleus
lateral to the abducent
nucleus, in close relation to
inferior cerebellar peduncle
Found at this level:
Superior of lateral &
inferior part of superior
vestibular nucleus
Posterior & Anterior
Cochlear nuclei

Transverse section through the Caudal Part

Spinal nucleus of
trigeminal nerve
& its tract
anteromedial to
inferior cerebellar
peuncle

Transverse section through the Caudal Part

Trapezoid body
made up of
fibers derived
from cochlear
nuclei & nuclei of
trapezoid body
lie transversely
on anterior part
of tegmentum

Transverse section through the Caudal Part


Basilar part of Pons contains:

Pontine nuclei
small masses of
nerve cells
where corticopontine
fibers of crus cerebri
of midbrain terminate
Axons of pontine
nuclei give origin to
Transverse fibers of
pons

Transverse section through the Caudal Part


Basilar part of Pons contains:
Transverse Fibers of
Pons
cross the midline &
intersect the
corticospinal &
corticonuclear tract,
breaking them into
small bundles
enter the middle
cerebellar peduncle &
are distributed to
cerebellar hemisphere

Transverse section through the Caudal Part


Basilar part of Pons contains:

Transverse
Fibers
Middle
Cerebellar
Peduncle
Cerebellum
forms the main
pathway
linking the
cerebral cortex

Transverse section through the


Cranial Part
Passes through the
trigeminal nuclei
Internal structure is
similar to that seen
at the caudal level
except it now
contains motor &
principal sensory
nuclei of trigeminal
nerve

Transverse section through the


Cranial Part
Motor Nucleus of
Trigeminal Nerve
beneath the lateral
part of 4th
ventricle within
reticular formation
motor fibers travel
anteriorly thru the
substance of the
pons and exit on
anterior surface

Transverse section through the


Cranial Part
Principal Sensory
Nucleus of
Trigeminal Nerve
situated on
lateral side of
motor nucleus
continuous
inferiorly with
nucleus of spinal
tract

Transverse section through the


Cranial Part
Trapezoid Body
& Medial
lemniscus
same position
(anterior part of
tegmentum)
Lateral & Spinal
Lemnisci
Lateral to
medial
lemniscus

TUMORS OF THE PONS


Astrocytoma of the Pons
the most common tumor of the brainstem
occurring in childhood
S/Sx (ipsilateral CN paralysis &
contralateral hemiparesis):
Weakness of facial muscle on same side
(facial nerve nucleus)
Weakness of lateral rectus msn on 1 or
both sides (abducent N nucleus)
Nystagmus (vestibular nucleus)
Weakness of jaw muscles (trigeminal N
nucleus)

TUMORS OF THE PONS


Astrocytoma of the Pons
Impairment of hearing (cochlear nuclei)
Contralateral hemi/quadriparesis (corticospinal
fibers)
Anesthesia to light tough, preserved pain over
face (principal sensory nucleus of CN5; spinal
nucleus & tract of CN5 intact)
Contralateral sensory defects of trunk & limbs
(medial & spinal lemnisci)
Ipsilateral cerebellar s/sx (corticopontocerebellar
tracts)
Impairment of conjugate eye deviation (MLF)

Pontine Hemorrhage
Blood supply of pons: basilar artery,
& anterior, inferior, superior
cerebellar arteries
S/Sx: Ipsilateral facial paralysis &
contralateral paralysis of limbs
Paralysis of conjugate eye deviation
(abducent nucleus & MLF)

Gross Appearance of Medulla Oblongata


Connects the pons superiorly with the
spinal cord inferiorly
Junction of the medulla and spinal cord is
at the origin of the anterior and posterior
roots of the first cervical spinal nerve,
which corresponds approximately to the
level of the foramen magnum
Conical in shape
Central canal continues upward to the
lower half of medulla
Cavity of 4th ventricle expansion of the
upper half of medulla

anterior median fissure of the medulla


anterior surface of medulla
Continuous inferiorly with the anterior
median fissure of the spinal cord
on each side are swelling called the PYRAMID
pyramid
composed of bundles of nerve fibers ->
corticospinal fibers (from large nerve cells in
precentral gyrus of the cerebral cortex
tapers inferiorly
where nerve fibers cross the opposite side
forming the decussation of the pyramids

anterior external arcuate fibers


few nerve fibers that emerge from the anterior
median fissure above the decussation and pass
laterally over the surface of the medulla to enter the
cerebellum

olives
posterolateral to the pyramids
oval elevations by inferior olivary nuclei
rootlets of Hypoglossal nerve- groove between
pyramid and olive
roots of Glossopharyngeal and vagus nerves and
cranial roots of the accessory nerve- groove
between olive and inferior cerebellar peduncle
posterior to the olives are the INFERIOR
CEREBELLAR PEDUNCLES-> connect medulla to

floor of the fourth ventricle


forms by the posterior surface of inferior half of
the medulla oblongata
continuous with the posterior spinal cord and
possesses a posterior median sulcus
gracile nucleus
produce an elongated swelling-> gracile tubercle
situated on each side of the median sulcus
cuneate nucleus
Produce a swelling-> cuneate tubercle
lateral to the gracile nucleus

INTERNAL STRUCTURE
expansion of neural tube-> form hindbrain
vesicle-> 4th ventricle-> extensive lateral
spread-> alteration if position of derivatives
of alar and basal plates of the embryo
Four levels
1. level of decussation of pyramids
2. level of decussation of lemnisci
3. level of the olives
4. level just inferior to the pons

1. LEVEL of DECUSSATION of
PYRAMIDS
the great motor decussation
superior corticospinal occupy and form
pyramid
inferior ->cross median plane->continue
down the SC in lateral white column as
lateral corticospinal tract
fasciculus gracilis and cuneatus ascend
superiorly posterior to the central gray
matter
nucleus gracilis and cuneatus appear as
posterior extensions of the central gray

2. LEVEL of the DECUSSATION of


LEMNISCI
inferior half of the medulla oblongata
great sensory decussation
anterior to the central gray matter and posterior to the
pyramids
formed from the internal arcuate fibers emerged from the anterior aspects of the nucleus gracilis
and cuneatus
travel anteriorly and laterally around central gray
matter-> curve medially toward midline -> decussate
with fibers of opposite side
nucleus of the spinal tract of the trigeminal nervelateral to the internal arcuate fibers
the spinal tract of the trigeminal nerve lies lateral to the
nucleus
the lateral and anterior spinothalamic tracts and the

3. LEVEL of the Olives


passes across inferior part of fourth ventricle
amount of gray matter increase at this level
found are nuclei of CN VIII, IX, X, XI, XII

A. olivary nuclear complex


largest nucleus is inferior olivary nucleus
gray matter shaped like a crumpled bag
responsible for the elevation on the surface
of the medulla called the OLIVE
smaller dorsal and medial accessory olivary
nuclei also are present

Olivary (contd)
Inferior cerebellar peduncle- where fibers of
inferior olivary nucleus cross to enter
cerebellum
Afferent fibers: reach inferior olivary nuclei
from spinal cord (spino-olivary tracts) and
from the cerebellum and cerebral cortex
FUNCTION: voluntary muscle movement

B. vestibulocochlear nuclei

Made up of ff nuclei:
medial vestibular nucleus
inferior vestibular nucleus
lateral vestibular nucleus
superior vestibular nucleus
two cochlear nuclei : anterior and posterior
cochlear nucleus
anterior cochlear nucleus on anterolateral
aspect of the inferior cerebellar peduncle
posterior cochlear nucleus on posterior
aspect of the peduncle lateral to floor of the
fourth ventricle

C. nucleus ambiguus
consists of large motor neuron
situated deep within the reticular formation
emerging nerve fibers join the
glossopharyngeal, vagus and cranial part of
the accessory n
FUNCTION: contribute to voluntary skeletal
mucle

D. central gray matter


Passing from medial to lateral :
hypoglossal nucleus
dorsal nucleus of vagus

pontine nuclei
arcuate nuclei (inferiorly displaced)
situated on anterior of pyramids
receives nerve fibers from the cerebral cortex and
send efferent fibers to the cerebellum through the
ANTERIOR EXTERNAL ARCUATE FIBERS

pyramids
situated in anterior part of the medulla separated
by anterior median fissure
contain the corticospinal and some corticonuclear
fibers
corticospinal fibers descend to spinal cord
corticonuclear fibers are distributed to motor
nuclei of cranial nerves w/in medulla

reticular formation
Has diffuse mixture of nerve fibers and cells
deeply placed posterior to the olivary nucleus
also present in pons and medulla
CN IX,X and cranial part of CN XI
run forwad and laterally through the reticular formation
Emerge from between the olives and inferior cerebellar
peduncles
CN XII
run anteriorly and laterally through the reticular formation
and emerge between the pyramids and the olives

4. LEVEL just INFERIOR to the PONS


The lateral vestibular nucleus has replaced the inferior
vestibular nucleus cochlear nuclei are visible on the
anterior and posterior surfaces of the inferior cerebellar
peduncle

CLINICAL NOTES
Medulla Oblongata
contains many cranial nerve nuclei that are concerned with
vital functions (e.g., regulation of heart rate and respiration)
serves as a conduit for the passage of ascending and
descending tracts connecting the spinal cord to the higher
centers of the nervous system.
Involved in demyelinating diseases, neoplasms, and vascular
disorders.
Raised Pressure in the Posterior Cranial Fossa and Its
Effect on the Medulla Oblongata
tumors of the posterior cranial fossa-> ICP-> tends to be
pushed toward the area of least resistance ->downward
herniation of the medulla and cerebellar tonsils through the
foramen magnum.
Symptoms of headache, neck stiffness, and paralysis of the
glossopharyngeal, vagus, accessory, and hypoglossal nerves
owing to traction
extremely dangerous to perform a lumbar puncture

Arnold-Chiari Phenomenon
congenital anomaly in which there is a
herniation of the tonsils of the cerebellum
and the medulla oblongata through the
foramen magnum into the vertebral canal.
blockage of the exits in the roof of the fourth
ventricle to the cerebrospinal fluid->internal
hydrocephalus.
S/Sx involvement of last four cranial nerves

Vascular Disorders of the Medulla Oblongata


1. Lateral Medullary Syndrome of Wallenberg
. The lateral part of the medulla oblongata supplied by: the
posterior inferior cerebellar artery, which is usually a
branch of the vertebral artery
. Thrombosis of the arteries produces signs and symptoms:
dysphagia and dysarthria due to paralysis of the ipsilateral
palatal and laryngeal muscles (innervated by the nucleus
ambiguus); analgesia and thermoanesthesia on the
ipsilateral side of the face (nucleus and spinal tract of the
trigeminal nerve);
. vertigo, nausea, vomiting, and nystagmus (vestibular
nuclei); ipsilateral Horner syndrome (descending
sympathetic fibers); ipsilateral cerebellar signsgait and
limb ataxia (cerebellum or inferior cerebellar peduncle); and
contralateral loss of sensations of pain and temperature
(spinal lemniscusspinothalamic tract)

2. Medial Medullary Syndrome


The medial part of the medulla oblongata is
supplied by: vertebral artery
Thrombosis produces
signs and symptoms: contralateral hemiparesis
(pyramidal tract), contralateral impaired sensations
of position and movement and tactile discrimination
(medial lemniscus), and ipsilateral paralysis of
tongue muscles with deviation to the paralyzed side
when the tongue is protruded (hypoglossal nerve).

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