Brainstem lesions

Brainstem
Brainstem - The lower extension of the brain where it connects to the spinal cord. Neurological functions located in the brainstem include those necessary for survival (breathing, digestion, heart rate, blood pressure) and for arousal (being awake and alert).

Brainstem
Most of the cranial nerves come from the brainstem. The brainstem is the pathway for all fiber tracts passing up and down from peripheral nerves and spinal cord to the highest parts of the brain.

 Medulla Oblongata - The medulla oblongata functions primarily as a relay station for the crossing of motor tracts between the spinal cord and the brain. It also contains the respiratory, vasomotor and cardiac centers, as well as many mechanisms for controlling reflex activities such as coughing, gagging, swallowing and vomiting.

Functions
Crossing of motor tracts. Cardiac Center. Respiratory Center. Vasomotor (nerves having muscular control of the blood vessel walls) Center Centers for cough, gag, swallow, and vomit.

Function
Cranial Nerves: CN IX - Glossopharyneal (Muscles and mucous membranes of pharynx, the constricted openings from the mouth and the oral pharynx and the posterior third of tongue.), [mixed]. CN X - Vagus (Pharynx, larynx, heart, lungs, stomach), [mixed]. CN XI - Accessory (Rotation of the head and shoulder), [motor]. CN XII - Hypoglossal (Intrinsic muscles of the tongue), [motor].

Signs and symptoms

Movement: Ipsilateral (same side) plegia (paralysis). Pupils:
Size: Dilated. Reactivity: Fixed.

LOC: Comatose. Respiratory:

Abnormal breathing patterns. Ataxic. Clustered. Hiccups.

CN Palsies (Inability to control movement):

Absent Cough. Gag.

 Midbrain - The midbrain serves as the nerve pathway of the cerebral hemispheres and contains auditory and visual reflex centers.

Function
Nerve pathway of cerebral hemispheres. Auditory and Visual reflex centers. Cranial Nerves: CN III - Oculomotor (Related to eye movement), [motor]. CN IV - Trochlear (Superior oblique muscle of the eye which rotates the eye down and out), [motor].

Signs and symptoms

Weber's: CN III palsy and ptosis (drooping) ipsalateral (same side of body). Pupils:
Size: Midposition to dilated. Reactivity: Sluggish to fixed.

LOC (Loss of consciousness): Varies Movement: Abnormal extensor ( muscle that extends a part). Respiratory: Hyperventilating. CN (Cranial Nerve) Deficits: CN III, CN IV.

 Pons - The pons is a bridge-like structure which links different parts of the brain and serves as a relay station from the medulla to the higher cortical structures of the brain. It contains the respiratory center.

Function
Respiratory Center. Cranial Nerves: CN V - Trigeminal (Skin of face, tongue, teeth; muscle of mastication), [motor and sensory]. CN VI - Abducens (Lateral rectus muscle of eye which rotates eye outward), [motor]. CN VII - Facial (Muscles of expression), [motor and sensory]. CN VIII - Acoustic (Internal auditory passage), [sensory].

Signs and symptoms

Pupils:
Size: Pinpoint

LOC:
Semi-coma "Akinetic Mute". "Locked In" Syndrome.

Movement:
Abnormal extensor. Withdrawal.

Respiratory:
Apneustic (Abnormal respiration marked by sustained inhalation). Hyperventilation.

CN Deficits: CN VI, CN VII.

 Lesions of the Medulla oblongata

Lateral medullary syndrome

Lateral medullary syndrome (also called Wallenberg's syndrome and posterior inferior cerebellar artery syndrome) is a disease in which the patient has difficulty with swallowing or speaking or both owing to one or more patches of dead tissue (known as an infarct) caused by interrupted blood supply to parts of the brain.

Wallenberg syndrome
Posterior inferior cerebellar artery (PICA). (Wallenberg's syndrome) This is the commonest brain stem stroke. There is loss of pain and temperature sensation from the same side of the face (spinal trigeminal tract and nucleus) and from the contralateral limbs (spinothalamic tract);

WALLENBERG SYNDROME
ipsilateral paralysis of vocal cord and palatal muscles (nucleus ambiguus); ipsilateral ataxia (inferior cerebellar peduncle), vertigo (vestibular nuclei), and an ipsilateral Horner's syndrome (due to interruption of hypothalamospinal or reticulospinal fibres destined for the preganglionic sympathetic neurons in the upper thoracic segments of the spinal cord).

WALLENBERG SYNDROME

 Horner's syndrome, due to loss of sympathetic action on the eye, comprises miosis (small pupil), ptosis (drooping eyelid, but not closed as in a IIIrd nerve palsy) and apparent enophthalmos. (The eyeball appears further back in the orbit than the normal eye; this appearance is caused by the ptosis.)

 It is the clinical manifestation resulting from occlusion of the posterior inferior cerebellar artery (PICA) or one of its branches or of the vertebral artery, in which the lateral part of the medulla oblongata infarcts, resulting in a typical pattern. The most commonly affected artery is the vertebral artery, followed by the PICA, superior middle and inferior medullary arteries.

 The formatio reticularis of the medulla oblongata, shown by a transverse section passing through the middle of the olive. (Testut.) 1. . 2. . 3. , with 3, its internal part (), and 3, its external part (). 4. . 5. Pyramid. 6. . 7. with the two accessory olivary nuclei. 8. , with 8, its nucleus of origin. 9. , with 9, its nucleus of termination. 10. . 11. (nucleus of origin of motor fibers of glossopharyngeal, vagus, and cerebral portion of spinal accessory). 12. . 13. . 14. Head of posterior column, with 14, the lower sensory root of trigeminal nerve. 15. . 16. Anterior external arcuate fibers, with 16, the nucleus arcuatus. 17. 18. Nucleus of fasciculus teres. 19. .

Millard Gubler syndrome

Millard-Gubler syndrome
It is a syndrome of unilateral softening of the brain tissue arising from obstruction of the blood vessels of the pons, involving the sixth and seventh cranial nerves and fibers of the corticospinal tract, and is associated with paralysis of the abducens (including diplopia, internal strabismus, and loss of power to rotate the affected eye outward) and facial nerves and of the extremities. It is also known as "crossed hemiplegia".

Diagnosis
This syndrome is easier to diagnose today thanks to the technical advances in brain imaging (CT, MRI).

 Facial motor nucleus and fibres of VII. Descending motor fibres (but most are ventral to the lesion). Ipsilateral lower motor neuron facial paralysis. Contralateral upper motor weakness of limbs (which recovers with time).

 Cerebral softening (encephalomalacia) is a localized softening of the brain substance, due to hemorrhage or inflammation. Three varieties, distinguished by their colour and representing different stages of the morbid process, are known respectively as red, yellow, and white softening.

Fovilles syndrome
Foville's syndrome is caused by the blockage of the perforating branches of the basilar artery in the region of the brainstem known as the pons.[1] Structures affected by the infarct are the nuclei of cranial nerves VI and VII, corticospinal tract, medial lemniscus, and the medial longitudinal fasciculus.

Fovilles syndrome
This produces ipsilateral horizontal gaze palsy and facial nerve palsy and contralateral hemiparesis, hemisensory loss, and internuclear ophthalmoplegia

 Abducens nucleus. Facial motor nucleus. Ipsilateral VI nerve palsy and inability of the contralateral eye to adduct when attempting a conjugate movement. The contralateral eye does adduct with convergence to look at a near object. Ipsilateral lower motor neuron facial paralysis.

Raymond's syndrome
Descending motor fibres. Fibres of abducens nerve. Contralateral hemiplegia. Ipsilateral VI nerve palsy (but no abnormality of movements of contralateral eye).

Midbrain lesions
Webers syndrome Fibres of III. Descending motor fibres in cerebral peduncle. Ipsilateral oculomotor palsy. Contralateral hemiplegia. Contralateral tremor. (Tremor is usually attributed to interruption of cerebellothalamic fibres but it may be continuous, from involvement of pallidothalamic fibres rostral to the red nucleus.

Parinaud's syndrome
Pressure on superior colliculi, usually by a pineal tumour, is transmitted to preoculomotor nuclei in region of posterior commissure and periaqueductal region

Parinauds syndrome
Paralysis of upward gaze and convergence, often accompanied by other pupillary and eye movement abnormalities. Various pre-oculomotor nuclei, concerned with vertical eye movements, are present in the affected region