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Brain Stem Presentation Transcript

  • 1. Nabeel Kouka, MD, DO, MBA www.brain101.info
  • 2. Basic Strucrure of Brain Stem 1. Roof Plate 2. Tegmentum 3. Basal Portion
  • 3. Basilar (Basal) Portion Descending Fibers from Cerebral Cortex 1. Corticospinal Tract 2. Corticobulbar Tract 3. Corticopontocerebellar Fiber Corticopontine Fiber Pons Proper (Ventral Pons) Pontocerebellar Fiber Pyramidal Tract
  • 4. Corticospinal Tract Origin: Cerebral Cortex Brodmann Area 4 (Primary Motor Area, M I) Brodmann Area 6 (Premotor Area, PM ) Brodmann Area 3,1,2 (Primary Somesthetic Area, S I) Brodmann Area 5 (Anterior Portion of Sup. Parietal Lobule) Corona Radiata lnternal Capsule, Posterior Limb Crus Cerebri, Middle Portion Longitudinal Pontine Fiber Pyramid - pyramidal decussation Corticospinal Tract - Lateral and Anterior Termination: Spinal Gray (Rexed IV-IX) Basal Portion Descending Tracts
  • 5. Corticobulbar Tract - Corticofugal fibers projecting to, and terminating in, portions of lower brainstem - Termination: 1) motor nuclei (upper motor neuron pathway) hypoglossal, ambiguus, facial motor, trigeminal motor, abducens, trochlear and oculomotor nucleus 2) sensory relay nuclei nuclei gracilis and cuneatus, trigeminal sensory nucleus, solitary tract nucleus 3) reticular formation (corticoreticular fiber) Basal Portion Descending Tracts
  • 6. Basal Portion Descending Tracts Corticobulbar Tract - UMN Pathway - Corticofugal fibers projecting to cranial motor nuclei GSE - hypoglossal (XII), abducens (VI), trochlear (IV) and oculomotor (III) nucleus SVE - ambiguus (IX, X, XI), facial motor (VII), trigeminal motor (V) nucleus - largely bilateral laryngeal, pharyngeal, palatal and upper facial muscles of mastication and extraocular muscles - unilateral lower facial musculature (facial palsy) SCM and trapezius (uncrossed) --- spinal accessory - Pseudobulbar Palsy --- syndrome of bilateral UMN lesion
  • 7. Basal Portion Descending Tracts Corticopontocerebellar Fiber - Corticofugal fibers projecting to cerebellar hemisphere - consists of 2 neuron chain 1. Corticopontine fiber projecting to pontine nuclei 2. Pontocerebellar fiber crossed mudline and enter cerebellum as middle cerebellar peduncle
  • 8. Roof Plate Midbrain Superior Colliculus : vision Inferior Colliculus : hearing Closed Medulla Nucleus Gracilis et Cuneatus : discriminative touch sensation cf. Cerebelum : equilibrium
  • 9. Roof Plate of Hypothetized Chordate Ancestor A. olfaction B. vision C. hearing D. equilibrium E. discriminative touch sensation 1. epithalamus 2. superior colliculus 3. inferior colliculus 4. cerebellum 5. nucleus gracilis et cuneatus
  • 10. Tegmentum Cranial nerve Nuclei Precerebellar Nuclei Reticular Formation Tracts Ascending Cortical Pathway Cerebellar Circuits Descending Tract Composite Bundle
  • 11. Cranial Nerves Columns of Brain Stem Motor Column 1. GSE 2. SVE 3. GVE Sensory Column 4. VA (GVA & SVA) 5. GSA 6. SSA
  • 12. Components of Cranial Nerves
  • 13. General Somatic Efferent Nuclei (GSE) Hypoglossal Nucleus XII Abducens Nucleus VI Trochlear Nucleus IV Oculomotor Nucleus III
  • 14. Special Visceral Efferent Nuclei (SVE) Nucleus Ambiguus IX, X, XI Facial Motor Nucleus VII Trigeminal Motor Nucleus V
  • 15. General Visceral Efferent Nuclei (GVE) Dorsal Motor Nucleus of Vagus X Inferior Salivatory Nucleus IX Superior Salivatory Nucleus VII Edinger-Westphal Nucleus III
  • 16. Motor Nuclei of Cranial Nerves 1. GSE III, IV, VI, XII 2. SVE V, VII, IX, X, XI 3. GVE III, VII, IX, X
  • 17. General Somatic Afferent Nuclei (GSA) Trigeminal Sensory Nucleus V, VII, IX, X Mesencephalic Tract Nucleus Principal (Main) Sensory Nucleus Spinal Tract Nucleus pars oralis pars interpolaris pars caudalis
  • 18. Visceral Afferent Nuclei (VA) Nucleus Tractus Solitarius VII, IX, X General Visceral Afferent (GVA) Special Visceral Afferent (SVA): Taste Gustatory Nucleus
  • 19. Special Somatic Afferent Nuclei (SSA) Cochlear Nucleus VIIIc Dorsal Cochlear Nucleus Ventral Cochlear Nucleus Vestibular Nucleus VIIIv Medial Vestibular Nucleus Lateral Vestibular Nucleus Superior Vestibular Nucleus Inferior Vestibular Nucleus
  • 20. Sensory Nuclei of Cranial Nerves 1. VA GVA --- IX, X SVA --- VII, IX, X 2. GSA V, VII, IX, X 3. SSA VIIIc, VIIIv
  • 21. Precerebellar Nuclei Accessory Cuneate Nucleus Inferior Olivary Nuclear Complex Vestibular Nuclus Red Nucleus Perihypoglossal Nucleus Precerebellar Reticular Nuclei
  • 22. Precerebellar Nuclei 1. Red Nucleus 2. Vestibular Nucleus 3. Inferior Olivary Nucleus 4. Perhypoglossal Nuclei 5. Accessory Cuneate Nucleus
  • 23. Reticular Formation A. Raphe Nuclei B. Central Nuclear Group C. Lateral Nuclear Group D. Precerebellar Reticular Nuclei A B C D
  • 24. Central Nuclear Group of Reticular Formation Gigantocellular Reticular Nucleus Caudal Reticulopontine Nucleus Oral Reticulopontine Nucleus Subcuneiform Nucleus Cuneiform Nucleus
  • 25. Lateral Nuclear Group of Reticular Formation Central Nucleus of Medulla Oblongata Superficial Ventrolateral Reticular Area Parvicellular Reticular Nucleus Parabrachial Nucleus Pedunculopontine Nucleus
  • 26. Raphe Nuclei - Serotonergic Neuron Nucleus Raphe Obscrus, B 2 Nucleus Raphe Pallidus, B 1 Nucleus Raphe Magnus, B 3 Pontine Raphe Nucleus, B 5 Median Raphe or Superior Central Nucleus, B 6, B 8 Dorsal Raphe Nucleus, B 7 Nucleus Linealis
  • 27. Norepinephrinergic & Dopaminergic Neuron Norepinephrinergic Neuron Nucleus Locus Ceruleus, A 6 Dopaminergic Neuron Retrorubral Area, A 8 Ventral Tegmental Area, A 10 Substantia Nigra, Pars Compacta, A 9
  • 28. Ascending Cortical Pathway Posterior White Column-Medial Lemniscal Pathway medial lemniscus Spinothalamic and Spinoreticular Tract spinal lemniscus Ventral and Dorsal Trigeminothalamic Tract trigeminal lemniscus Auditory Pathway: lateral lemniscus Taste (Gustatory) Pathway: central tegmental tract Vestibular Pathway: medial lemniscus
  • 29. Ascending Cortical System General Sensation Brain Stem Pathways for General Sensation Touch & Proprioception from body Posterior White Colum-Medial Lemniscal Pathway Pain & Temperature from body Spinothalamic Tract cf. Spinoreticular or Spinoreticulothalamic Tract General Sensation from Face Trigeminothalamic Tracts
  • 30. Posterior White Column - medial Lemniscal Pathway & Spinothalamic Tract
  • 31. Posterior White Colum-Medial Lemniscal Pathway Modality: Discriminative Touch Sensation (include Vibration) and Conscious Proprioception (Position Sensation, Kinesthesia) from body Receptor: Most receptors except free nerve endings Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion) Posterior White Column 2nd Neuron: Dorsal Column Nuclei (Nucleus Gracilis et Cuneatus) Internal Arcuate Fiber - Lemniscal Decussation - Medial Lemniscus 3rd Neuron: Thalamus (VPLc) Internal Capsule ----- Corona Radiata Termination: Primary Somesthetic Area (S I)
  • 32. DRG: Dorsal Root Ganglion 1. Posterior White Column A. Nucleus gracilis B. Nucleus cuneatus 2. Medial Lemniscus 3. Corona Radiata C. Thalamus (VPLc) D. Cerebral Cortex (S I) Posterior White Column-Medial Lemniscal Pathway DRG D
  • 33. Spinothalamic Tract Modality: Pain & Temperature Sensation, Light Touch from body Receptor: Free Nerve Ending Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion) 2nd Neuron: Dorsal Horn (Lamina I, IV, V) Anterior White Commissure Spinothalamic Tract (Spinal Lemniscus) 3rd Neuron: Thalamus (VPLc & CL) Internal Capsule ----- Corona Radiata Termination: Primary Somesthetic Area (S I)
  • 34. Spinoreticulothalamic Tract (Paleospinothalamic Tract) Modality: Pain & Temperature Sensation, Light Touch from body Receptor: Free Nerve Ending Ist Neuron: Dorsal Root Ganglion (Spinal Ganglion) 2nd Neuron: Dorsal Horn (Lamina I, IV, V) Anterior White Commissure Spinothalamic Tract (Spinal Lemniscus) 3rd Neuron: Reticular Formation 4rd Neuron: Thalamus (CL, Sm, POm) Internal Capsule ----- Corona Radiata Termination: Diffuse Cerebral Cotex
  • 35. DRG: Dorsal Root Ganglion A. Posterior (dorsal) horn 1. Spinothalamic tract B. Reticular formation 2. Spinoreticular tract C. Thalamus (VPLc, CL) 3. Corona Radiata D. Cerebral Cortex (S I) Spinothalamic Tract (Neospinothalamic Tract) Spinoreticular Tract (Paleospinothalamic Tract) DRG D
  • 36. Trigeminothalamic Tract Modality: General Sensation from face Receptor: Most receptors in the face Ist Neuron: Trigeminal (Semilunar) Ganglia 2nd Neuron: Trigeminal Sensory Nucleus pain & temperature ---- pars caudalis of spinal tract nucleus of V Ventral and Dorsal Trigeminothalamic Tract 3rd Neuron: Thalamus (VPM) Internal Capsule ----- Corona Radiata Termination: Primary Somesthetic Area (S I)
  • 37. Trigeminothalamic Tract A. trigeminal ganglion B. trigeminal sensory nucleus C. thalamus (VPM) D. cerebral cortex (S I) 1. spinal tract of trigeminal nerve 2. ventral trigeminothalamic tract 3. dorsal trigeminothalamic tract 4. corona radiata V. trigeminal nerve
  • 38. Ascending Cortical System Special Sensation Brain Stem Pathways for Special Sensation Gustatory Sensation (Taste, SVA) ----- Taste Pathway Auditory Sensation (Hearing, SSA) ----- Auditory Pathway Vestibular Sensation (Equilibrium, SSA) ----- Vestibular Pathway
  • 39. Auditory Pathway Modality: Auditory Sensation (Hearing) Receptor: Organ of Coti of Cochlear Duct Cranial Nerve: VIIIc 1st Neuron: Spiral Ganglion 2nd Neuron: Cochlear Nucleus, Ventral & Dorsal dorsal, intermediate and ventral acoustic striae trapezoid body lateral lemniscus 3rd Neuron: Inferior Colliculus brachium of inferior colliculus 4th Neuron: Medial Geniculate Nucleus (MG) auditory radiation Termination: Primary Auditory Area (A I) Brodmann area 31, 32
  • 40. Auditory Pathways A. spiral ganglion B. dorsal and ventral cochlear nucleus C. inferior colliculus D. medial geniculate nucleus E. Primary auditory area F. superior olivary nucleus G. nucleus of lateral lemniscus 1. acoustic striae & trapezoid body 2. lateral lemniscus 3. brachium of inferior colliculus 4. auditory radiation 5. commissure of inferior colliculus VIIIc. cochlear division
  • 41. Auditory Pathway A. spiral ganglion B. dorsal cochlear nucleus C. ventral cochlear nucleus D. superior olivary nucleus 1. dorsal acoustic striae 2. intermediate acoustic striae 3. ventral acoustic striae 4. efferent cochlear bundle 5. trapezoid body 6. lateral lemniscus
  • 42. Vestibular Pathway Modality: Equilibrium Sensation Receptor: Macula & Crista Ampullaris Cranial Nerve: VIIIv Ist Neuron: Vestibular Ganglion 2nd Neuron: Vestibular Nucleus vestibulothalamic fiber (medial lemniscus) 3rd Neuron: Thalamus (VPLo, VPI?) Internal Capsule ----- Corona Radiata Termination: Primary Vestibular Area ----- Primary Somesthetic Area (Brodmann area 3a, 2v )
  • 43. Vestibular Pathway 1. Vestibulocerebellar Tract 2. Vestibulospinal Tract 3. Vestibulothalamic Tract 4. Medial Longitudinal fasciculus (MLF) - ascending portion - descending portion - interstitiospinal tract
  • 44. Taste (Gustatory) Pathway Modality: Taste Sensation Receptor: Taste Bud Cranial Nerve: VII, IX, X Ist Neuron: Geniculate Ganglion (VII) Inferior Ganglion (IX, X) 2nd Neuron: Nucleus Tractus Solitarius (Gustatory Nucleus) solitariothalamic fiber (central tegmental tract) 3rd Neuron: Thalamus (VPMpc) Internal Capsule ----- Corona Radiata Termination: Gustatory Area Brodmann area 43 & parainsular cortex
  • 45. Taste Pathways A. nucleus tractus solitarius (gustatory nucleus) B. thalamus (VPMpc) C. Brodmann area 43 D. parainsular cortex E. parabrachial nucleus 1. solitariothalamic fiber (central tegmental tract) 2. corona radiata VII. facial nerve IX. glossopharyngeal nerve X. vagus nerve
  • 46. Cerebellar Circuits Superior, Middle and Inferior Cerebellar Peduncle Vestibulocerebellum - Vestibular Nucleus Spinocerebellum - Red Nucleus and Spinal Cord Pontocerebellum - Cerebral Cortex and Pontine Nuclei Inferior Olivary Nuclear Complex
  • 47. Afferent Connections of Cerebellum Inferior Cerebellar Peduncle 1. posterior spinocerebellar tract 2. cuneocerebellar tract 3. vestibulocerebellar tract Middle cerebellar Peduncle - corticopontocerebellar pathway Superior Cerebellar Peduncle - anterior spinocerebellar tract
  • 48. Efferent Connections of Cerebellum Superior Cerebellar Peduncle 1. dentatothalamic fiber 2. interpositorubral fiber 3. ascending portion of uncinate fasciculus of Russell Inferior Cerebellar Peduncle 1. direct fastigiovestibular fiber 2. descending portion of uncinate fasciculus of Russell
  • 49. Connections of Inferior Olivary Nuclear Complex 1. Olivocerebellar Tract 2. Cortico-olivary Tract 3. Rubro-olivary Tract 4. Vestibulo-olivary Tract 5. Spino-olivary Tract
  • 50. Descending Tracts Rubrospinal Tract Tectospinal tract Vestibulospinal Tract Reticulospinal Tract pontine and medullary Descending Autonomic Pathway
  • 51. Brain Stem Descending Tracts Descending Tracts from Brain Stem Dorsolateral (Motor) Pathway Rubrospinal Tract Ventromedial (Motor) Pathway Tectospinal Tract Vestibulospinal Tract MLF (Medial Longitudinal Fasciculus) - interstitiospinal tract Sensory Modulation pathways Raphespinal & Cerulospinal Pathways Descending Autonomic Pathways
  • 52. Composite Bundle Medial Longitudinal Fasciculus (MLF) Dorsal Longitudinal Fasciculus (DLF) Central Tegmental Tract
  • 53. Components of Medial Longitudinal Fasciculus (MLF) Descending Components Medial Vestibulospinal Tract from medial and inferior vestibular nucleus Interstitiospinal Tract from interstitial nucleus of Cajal Ascending Components Efferents from Medial Vestibular Nucleus contralateral III, IV, interstitial nucleus bilateral VI nucleus Efferents from Superior Vestibular Nucleus ipsilateral III, IV, interstitial nucleus
  • 54. Ascending Components solitariohypothalamic fiber (visceral afferent fiber) ascending serotonergic fiber Descending Component descending fibers from hypothalamus to periaqueductal gray and dorsal tegmental nucleus Components of Dorsal Longitudinal Fasciculus (DLF, fasciculus of Sch ü tz)
  • 55. Components of Central Tegmental Tract Ascending Components reticulothalamic fiber solitariothalamic fiber (secondary taste fiber) Descending Component rubro-olivary tract
  • 56. Spinomedullary Transition (Level of Pyramidal Decussation) Roof Plate - fasciculus gracilis and fasciculus cuneatus Tegmentum Cranial and Spinal Nerve Nuclei Supraspinal Nucleus Spinal Nucleus of Trigeminal Nerve, Pars Caudalis Reticular Formation Central Nucleus of Medulla Oblongata (Ventral Reticular Nucleus) Unclassified Nuclei Retroambiguus Nucleus Tracts Spinal Tracts of Trigeminal Nerve Basal Part - Pyramid, Pyramidal Decussation
  • 57. Cranial & Spinal N. Nuclei 1. Supraspinal Nucleus 2. Spinal Accessory Nucleus Cranial & Spinal Nerve XI. Accessory Nucleus C1. motor root of 1st cervical nerve Spinomedullary Transition (Level of Pyramidal Decussation)
  • 58. Lower Medulla (Level of Lemniscal Decussation) Roof Plate - nucleus gracilis and nucleus cuneatus Tegmentum Cranial and Spinal Nerve Nuclei Hypoglossal Nucleus, Ambiguus Nucleus Solitary Tract Nucleus, Dorsal Motor Nucleus of X Reticular Formation Lateral Reticular Nucleus Precerebellar Nuclei Inferior Olivary Nuclear Complex Tracts Ventral Trigeminothalamic Tract Internal Arcuate Fiber, Lemniscal Decussation Basal Part - Pyramid, Pyramidal Decussation
  • 59. Lower Medulla (Level of Lemniscal Decussation) Roof Plate A. Nucleus Gracilis B. Nucleus Cuneatus Cranial Nerve Nuclei 1. Hypoglossal Nucleus 2. Nucleus Ambiguus 3. Dorsal Motor Nucleus of X 4. Nucleus Tractus Solitarius 5. Spinal Tract Nucleus of Trigeminal Nerve
  • 60. Lower Medulla (Level of Lemniscal Decussation) Precerebellar Nucleus 1. Inferior Olivary Nuclear Complex 1a. Principal Inferior Olivary Nucleus 1b. Medial Accessory Olivary Nucleus 1c. Dorsal Accessory Olivary Nucleus 2. Nucleus Intercalatus 3. Nucleus Conterminalis 4. Arcuate Nucleus
  • 61. Lower Medulla (Level of Lemniscal Decussation) Reticular Formation 1. Lateral Reticular Nucleus 2. Central Nucleus of Medulla Oblongata 2d. subnucleus dorsalis 2v. subnucleus ventralis
  • 62. Clinical Syndromes of Lower Medulla A. Hypoglossal Alternating Hemiplegia B. Avelis Syndrome C. Jackson Syndrome D. Tapia Syndrome 1. pyramidal tract 2. hypoglossal nerve 3. spinothalamic tract 4. nucleus ambiguus
  • 63. Hypoglossal Palsy Lower Motor Neuron Syndrome Deviation of Tongue to affected side Atrophy of Tongue Muscles
  • 64. Open Medulla (Mid-olivary Level) Tegmentum Cranial Nerve Nuclei Medial Vestibular Nucleus Spinal Tract Nucleus of V, pars interpolaris Precerebellar Nuclei Accessory Cuneate Nucleus Nucleus of Roller, Nucleus Interfascicularis Hypoglossi Reticular Formation Lateral Reticular Nucleus, subtrigeminal portion Unclassified Nuclei Area Postrema Tracts: Inferior Cerebellar Peduncle, DLF Basal Part - Pyramid
  • 65. Cranial Nerve Nuclei 1. Hypoglossal Nucleus 2. Nucleus Ambiguus 3. Dorsal Motor Nucleus of X 4. Nucleus Tractus Solitarius 5. Spinal Tract Nucleus, pars interpolaris 6. Medial Vestibular Nucleus Open Medulla (Mid-olivary Level)
  • 66. Open Medulla (Mid-olivary Level) Precerebellar Nucleus 1. Accessory Cuneate Nucleus 2. Inferior Olivary Nuclear Complex 2a. Principal Inferior Olivary Nuc. 2b. Medial Accessory Olivary Nuc. 2c. Dorsal Accessory Olivary Nuc. 3. Nucleus Intercalatus 4. Nucleus of Roller 5. Nucleus Interfascicularis Hypoglossi 6. Nucleus Conterminalis
  • 67. Open Medulla (Mid-olivary Level) XII. Hypoglossal Nerve 1. Hypoglossal Nucleus X. Vagus Nerve 2. Nucleus Ambiguus 3. Dorsal Motor Nucleus of X 4. Nucleus Tractus Solitarius 5. Spinal Tract Nucleus of V
  • 68. A. Dejerine’s Syndrome 1. pyramidal tract 2. hypoglossal nerve 3. medial lemniscus B. Wallenberg Syndrome 4. spinothalamic tract 5. spinal tract of trigeminal nerve 6. nucleus ambiguus 7. descending autonomic pathway Clinical Syndromes of Open Medulla
  • 69. Wallenberg Syndrome Spinothalamic tract - contralateral loss of pain and temperature sensation at the body Spinal tract of trigeminal nerve - ipsilateral loss of pain and temperature sensation at the face Nucleus ambiguus - dysphageia, dysarthria, hoarseness D escending autonomic pathway - Horner’s syndrome (meiosis, ptosis, anhydrosis)
  • 70. Open Medulla (Upper Level of Medulla) Tegmentum Cranial Nerve Nuclei Inferior Vestibular Nucleus Dorsal Cochlear Nucleus Precerebellar Nuclei Nucleus Prepositus Hypoglossi Reticular Formation Gigantocellular Reticular Nucleus Paragigantocellular Reticular Nucleus Parvocellular Reticular Nucleus Raphe Nuclei Unclassified Nuclei retrofacial, supravestibular nucleus, nucleus interpositus Tracts: stria medullaris of 4th ventricle Basal Part - Pyramid
  • 71. Cranial Nerve Nuclei 1. Nucleus Ambiguus 2. Nucleus Tractus Solitarius 3. Spinal Tract Nucleus, pars oralis 4. Medial Vestibular Nucleus 5. Inferior Vestibular Nucleus 6. Dorsal Cochlear Nucleus Open Medulla (Upper Level of Medulla)
  • 72. Open Medulla (Upper Level of Medulla) Precerebellar Nucleus 1. Inferior Olivary Nuclear Complex 2a. Principal Inferior Olivary Nuc. 2b. Medial Accessory Olivary Nuc. 2c. Dorsal Accessory Olivary Nuc. 2. Nucleus Prepositus Hypoglossi 3. Pontobulbar Body 4. Arcuate Nucleus 5. Medial Vestibular Nucleus 6. Inferior Vestibular Nucleus
  • 73. Open Medulla (Upper Level of Medulla) Reticular Formation 1. Paramedian reticular Nucleus 2. Gigantocellular Reticular Nucleus 3. paragigantocellular Reticular Nucleus 4. Parvocellular Reticular Nucleus 5. Nucleus raphe Obscrus (B 2 ) 6. Nucleus Raphe Pallidus (B 1 ) 7. Nucleus Raphe Magnus (B 3 ) Unclassifiied Nuclei A. Nucleus Retrofacialis B. Supravestibular Nucleus C. Nucleus Interpositus
  • 74. IX. glossopharyngeal Nerve 1. Nucleus Ambiguus 2. Inferior Salivatory Nucleus 3. Nucleus Tractus Solitarius 4. Spinal Tract Nucleus of V Open Medulla (Upper Level of Medulla)
  • 75. Pontomedullary Junction Tegmentum Cranial Nerve Nuclei Facial Motor Nucleus Ventral Cochlear Nucleus Precerebellar Nuclei Reticular Formation Unclassified Nuclei nucleus ovalis Tracts Basal Part - Pyramid Cranial Nerve - Vestibulocochlear Nerve (VIII) Facial Nerve (VII)
  • 76. Cranial Nerve Nuclei 1. Facial Motor Nucleus 2. Nucleus Ambiguus 3. Spinal Tract Nucleus, pars oralis 4. Medial Vestibular Nucleus 5. Inferior Vestibular Nucleus 6. Ventral Cochlear Nucleus Pontomedullary Junction
  • 77. Pontomedullary Junction Precerebellar Nucleus 1. Principal Inferior Olivary Nucleus 2. Nucleus Prepositus Hypoglossi 3. Pontobulbar Body 4. Arcuate Nucleus 5. Medial Vestibular Nucleus 6. Inferior Vestibular Nucleus
  • 78. Pontomedullary Junction Reticular Formation 1. Paramedian reticular Nucleus 2. Gigantocellular Reticular Nucleus 3. paragigantocellular Reticular Nucleus 4. Parvocellular Reticular Nucleus 7. Nucleus Raphe Magnus (B 3 ) Unclassifiied Nuclei A. Nucleus Interpositus B. Nucleus Ovalis
  • 79. Lower Pons (Level of Abducens Nucleus) Tegmentum Cranial Nerve Nuclei Abducens Nucleus, Main Sensory Nucleus of V Nuclei of Auditory Pathway Superior Olivary Nuclear Complex Reticular Formation Caudal Pontine Reticular & Subceruleus Nucleus Tracts Trapezoid Body, lateral Lemniscus, Central tegmental Tract Basal Part: Pons Proper: Pontine Nuclei , Transverse Pontine Fiber, Longitudinal Pontine Fiber (Pyramidal Tract)
  • 80. Lower Pons (Level of Abducens Nucleus) Cranial Nerve Nuclei 1. Abducens Nucleus 2. Main Sensory Nucleus of V 3. Lateral vestibular Nucleus 4. Superior Vestibular Nucleus Auditory Relay Nuclei A. Superior Olivary Nucleus B. Nucleus of Trapezoid body
  • 81. Lower Pons (Level of Abducens Nucleus) Reticular Formation 1. Gigantocellular Reticular Nucleus 2. Caudal Pontine Reticular Nucleus 3. Parvocellular Reticular Nucleus 4. Nucleus Subceruleus
  • 82. VII. Facial Nerve 1. Facial Motor Nucleus 2. Superior Salivatory Nucleus 3. Nucleus Tractus Solitarius 4. Spinal Tract Nucleus of V VI. Abducens Nerve 5. Abducens Nucleus
  • 83. A. Facial Palsy B. A + decreased salivation C. A + B + hyperacusis D. A + B + C + decrased lacrimal secretion E. Central Type Facial Palsy 1. Facial Motor Nucleus 2. Superior Salivatory Nucleus 3. Solitary Nucleus 4. Spinal Tract Nucleus of Trigeminal Nerve
  • 84. Facial Palsy (Bell’s Palsy) Lower Motor Neuron Syndrome Triple W Sign - Wrinkle, Wink, Whistle
  • 85. Right facial paralysis Facial Palsy (Bell’s Palsy)
  • 86. Central Type Facial Palsy Upper Motor Neuron Syndrome facial motor nucleus neurons supplying forehead muscle Bilateral Corticobulbar Tract
  • 87. Abducens Palsy Lower Motor Neuron Syndrome Lateral Gaze Paralysis
  • 88. Upper Pons (Level of Trigeminal Motor Nucleus) Tegmentum Cranial Nerve Nuclei Trigeminal Motor Nucleus, Mesencephalic Tract Nucleus of Trigeminal Nerve Nuclei of Auditory Pathway Nucleus of Lateral Lemniscus Reticular Formation Reticular Tegmental Nucleus Unclassified Nucleus Pontine Central Gray: Ch6 Tracts Trigeminal Nerve Fiber Basal Part: Pons Proper
  • 89. Upper Pons (Level of Trigeminal Motor Nucleus) Cranial Nerve Nuclei 1. Trigeminal Motor Nucleus 2. Main Sensory Nucleus of V 3. Mesencephalic Tract Nucleus of V 4. Superior Vestibular Nucleus Auditory Relay Nuclei A. Nucleus of Lateral Lemniscus
  • 90. Upper Pons (Level of Trigeminal Motor Nucleus) Reticular Formation 1. Caudal Pontine Reticular Nucleus 2. Nucleus Subceruleus 3. Reticular Tegemntal Nucleus of Bekhterew (Nucleus Papilloformis of Olszewski and Baxter)
  • 91. A. Millard-Gubler Syndrome B. Raymond Syndrome C. Foville Syndrome D. Raymond-Cestan Syndrome E. Marie-Poix Syndrome 1. pyramidal tract 2. MLF 3. medial lemniscus 4. spinothalamic tract 5. trigeminal motor nucleus 6. main sensory nucleus of V 7. spinal tract of trigeminal nerve 8. middle cerebellar peduncle Clinical Syndromes of Pons
  • 92. Trigeminal Neuralgia (tic douloureux) - excruciating episodic pain in the area supplied by trigeminal nerve, especially second and third division - trigger point - intense pain makes the patient grimace (tic) - antiepileptic drug (phenytoin, carbamazepine ) is effective - surgical treatment
  • 93. Lower Midbrain (Level of Inferior Colliculus) Roof Plate - Tectum: Inferior Colliculus Tegmentum Cranial Nerve Nuclei Trochlear Nucleus Reticular Formation Cuneiform, Pedunculopontine, Parabrachial and Median Raphe (Superior Central) Nucleus Unclassified Nuclei Periaqueductal Gray Tracts Decussation of Superior Cerebellar Peduncle Basal Part - Crus Cerebri, Pons Proper
  • 94. Lower Midbrain (Level of Inferior Colliculus) Roof Plate A. Inferior Colliculus Cranial Nerve Nuclei 1. Mesencephalic Tract Nucleus of Trigeminal Nerve 2. Trochlear Nucleus
  • 95. Lower Midbrain (Level of Inferior Colliculus) Reticular Formation 1. Cuneiform Nucleus 2. Pedunculopontine Nucleus 3. Nucleus Locus ceruleus 4. Parabrachial Nucleus 5. Dorsal Raphe Nucleus 6. Median Raphe Nucleus Unclassified Nuclei A. Periaqueductal Gray B. Dorsal Tegmental Nucleus of Gudden C. Interpeduncular Nucleus D. Parabigeminal Nucleus C 6 5
  • 96. Upper Midbrain (Level of Superior Colliculus) Roof Plate - Tectum: Superior Colliculus Tegmentum Cranial Nerve Nuclei Oculomotor and Edinger-Westphal Nucleus Reticular Formation - Subcuneiform Nucleus Precerebellar Nuclei Red Nucleus Unclassified Nuclei Substantia Nigra, Paranigral, Paralemniscal Nucleus Ventral Tegmental Area (VTA) Tracts Brachium of Inferior Colliculus Basal Part - Crus Cerebri
  • 97. Upper Midbrain (Level of Superior Colliculus) Roof Plate A. Superior Colliculus Precerebellar Nucleus B. Red Nucleus Cranial Nerve Nuclei 1. Mesencephalic Tract Nucleus of V 2. Oculomotor Nucleus 3. Edinger-Westphal Nucleus
  • 98. Upper Midbrain (Level of Superior Colliculus) Reticular Formation A. Cuneiform Nucleus B. Subcuneiform Nucleus Unclassified Nuclei 1. Periaqueductal Gray 2. Paralemniscal Nucleus 3. Substantia Nigra 3a. Pars Compacta 3b. Pars Reticulata 4. Paranigral Nucleus 5. Ventral Tegmental Area
  • 99. Clinical Syndromes of Upper Midbrain A. Weber Syndrome B. Foix Syndrome C. Benedikt’s Syndrome D. Claude Syndrome E. Parinaud’s Syndrome 1. pyramidal tract 2. superior cerebellar peduncle 3. red nucleus 4. medial lemniscus 5. superior colliculus 6. cerebral aqueduct 7. MLF 8. oculomotor nucleus
  • 100. Weber Syndrome Pyramidal tract - contralateral UMN syndrome at the body and lower face (contralateral hemiparesis) Oculomotor Nerve - ipsilateral ocular palsy - external strabismus - mydriasis - loss of accommodation - normal consensual light reflex