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Brainstem Lesions

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Lecture Notes of Doctor Bravo

Lecture Notes of Doctor Bravo

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  • This just made my day! Thank you for uploading this!
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  • the slides with 'more info' are still there, but the link does not work. If you view from slide 82 onwards, these are the 'more info' slides.
    If you download and run in a pdf viewer, the links will work.

    Just one note, slide 102 states 'tongue deviates opposite the lesion' which should read 'tongue deviates towards the lesion'

    Thank you for an excellent slide summary of the rule of 4.
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  • Wonderful & easy useful presentation
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  • Anyone know how to access the information when clicking 'more info' on the slides? It seems as though the content was removed.
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  • 1. Lessons on Brainstem Lesions Dr. Dennis Bravo
  • 2. Case A 58 y/o was referred to you because of recent onset of left hemiparesis, left-sided loss of propioception and right-sided tongue deviation. What CNS structures are affected? Explain the symptoms with regards to structures affected. Where is the lesion?
  • 3. review of Brainstem Structure
  • 4. Brainstem Anatomy Midbrain Pons Medulla
  • 5. Brainstem Anatomy Midbrain Pons Medulla
  • 6. Rules of 4* 1. 4 structures in ‘midline’ and begin with ‘M’ 2. 4 motor nuclei in midline and are those that are divisors of 12 (3,4,6,12) 3. 4 structures to the ‘side’ (lateral) and begin with ‘S’ 4. 4 CN in medulla, 4 in pons and 4 above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 7. 1 2 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) RULE of FOUR* 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 8. 2 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 9. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 3 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 10. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 4 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 11. 4 Motor nuclei in 4 Structures in midline midline and are divisors and begin with ‘M’ of 12 ( 3, 4, 6, 12) 4 CN in medulla 4 Structures to the side 4 CN in pons and begin with ‘S’ 4 CN above pons *Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 12. RULE #1 4 Medial Structures •Motor pathway •Medial leminiscus •Medial longitudinal fasciculus •Motor nucleus and nerve
  • 13. RULE #2 4 Medial Motor Nucleus •CN divides number 12 •CN 3, 4, 6, 12 are midline •3, 4, 6, 12 nucleus are midline •5, 7, 9, 11 lateral
  • 14. RULE #3 4 Side Structures •Spinocerebellar pathway •Spinothalamic pathway •Sensory nucleus of CN5 •Sympathetic pathway
  • 15. 4 Medulla Cranial RULE #4 Nerves •Glossopharyngeal (CN9) •Vagus (CN10) •Spinal accessory (CN11) •Hypoglossal (CN12)
  • 16. RULE #4 4 Pons Cranial Nerves •Trigeminal (CN5) •Abducent (CN6) •Facial (CN7) •Auditory (CN8)
  • 17. 4 Cranial Nerves RULE #4 Above Pons •Olfactory (CN1) •Optic (CN2) •Occulomotor (CN3) •Trochlear (CN4)
  • 18. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) More Info Medial lemniscus Medial longditudinal fasciculus Motor nucleus and nerve
  • 19. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral propioception/ Medial lemniscus vibration loss More Info Medial longditudinal fasciculus Motor nucleus and nerve
  • 20. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral Medial lemniscus propioception/ vibration loss Medial longditudinal Ipsilateral internuclear fasciculus ophthalmoplegia More Info Motor nucleus and nerve
  • 21. ne s li e DE id ur FIC M ct I T S tru Motor pathway Contalateral weakness (Corticospinal tract) Contralateral Medial lemniscus propioception/ vibration loss Medial longditudinal Ipsilateral internuclear fasciculus ophthalmoplegia Motor nucleus and Ipsilateral CN nerve function loss
  • 22. al DE er es at ur FIC L ct IT S tru Spinocerebellar Ipsilateral ataxia pathway More Info Spinothalamic Sensory nucleus of CN5 Sympathetic pathway
  • 23. al DE er es at ur FIC L ct I T S tru Spinocerebellar Ipsilateral ataxia pathway Contralateral pain/temp Spinothalamic sensory loss More Info Sensory nucleus of CN5 Sympathetic pathway
  • 24. al DE er es at ur FIC L ct I T S tru Spinocerebellar Ipsilateral ataxia pathway Contralateral pain/temp Spinothalamic sensory loss Sensory nucleus of Ipsilateral pain/ temp CN5 loss in face More Info Sympathetic pathway
  • 25. al DE er es at ur FIC L ct I T S tru Spinocerebellar Ipsilateral ataxia pathway Contralateral pain/temp Spinothalamic sensory loss Sensory nucleus of Ipsilateral pain/ temp CN5 loss in face Ipsilateral Horner’s Sympathetic pathway syndrome More Info
  • 26. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Vagus CN10 Spinal accessory CN11 Hypoglossal CN12
  • 27. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness More Info Spinal accessory CN11 Hypoglossal CN12
  • 28. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness Ipsilateral shoulder Spinal accessory CN11 weakness Hypoglossal CN12
  • 29. DE CN lla 4 u FIC I T ed M Glossopharyngeal Ipsilateral pharyngeal CN9 sensory loss Ipsilateral palatal Vagus CN10 weakness Ipsilateral shoulder Spinal accessory CN11 weakness Ipsilateral weakness of Hypoglossal CN12 tongue More Info
  • 30. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss More Info Abducent CN6 Facial CN7 Auditory CN8
  • 31. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness More Info Facial CN7 Auditory CN8
  • 32. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness Ipsilateral facial Facial CN7 weakness More Info Auditory CN8
  • 33. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss Ipsilateral eye Abducent CN6 abduction weakness Ipsilateral facial Facial CN7 weakness Auditory CN8 Ipsilateral deafness
  • 34. DE 4 CN ons FIC P IT ve A bo Olfactory CN1 Not in midbrain Optic CN2 Not in midbrain Eye turned out and Occulomotor CN3 down More Info Trochlear CN4
  • 35. DE 4 CN ons FIC P I T ve A bo Olfactory CN1 Not in midbrain Optic CN2 Not in midbrain Eye turned out and Occulomotor CN3 down Eye unable to look down Trochlear CN4 when looking towards nose More Info
  • 36. Let’s put your knowledge to use...
  • 37. Always remember “Pathways and tracts pass through the entire length of the brainstem and can be likened to ‘meridians of longitude‘ whereas the various cranial nerves can be regarded as ‘parallels of latitude‘. If you establish where the meridians of longitude and parallels of latitude intersect then you have established the site of the lesion.” Gates, P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266
  • 38. Case 58 year old woman •Left hemiparesis •Left-sided loss of propioception •Right-sided tongue deviation
  • 39. Case Structure 58 year old woman •Left hemiparesis •Motor (CS tract, R) •Left-sided loss of •Medial propioception lemniscus, R •Right-sided •CN12, R tongue deviation
  • 40. Structure •Motor (CS tract, R) •Medial lemniscus, R •CN12, R
  • 41. Location Structure •Medial •Motor (CS tract, R) •Medial •Medial lemniscus, R •Medulla •CN12, R
  • 42. Location Structure •Medial •Motor (CS tract, R) •Medial •Medial lemniscus, R •Medulla •CN12, R Medial medullary Vertebral artery, syndrome (R) medullary branch (R)
  • 43. Case 58 year old woman •Left-sided meiosis, anhydrosis, ptosis •Left-sided ataxia •Uvula deviated to right
  • 44. Case Structure 58 year old woman •Left-sided •Sympathetic meiosis, tract, Left anhydrosis, ptosis •Left-sided ataxia •Spinocerebellar •Uvula deviated •CN10, Left to right
  • 45. Structure •Sympathetic tract, Left •Spinocerebellar •CN10, Left
  • 46. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left
  • 47. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left Lateral medullary Posterior inferior syndrome (L) cerebellar artery (L)
  • 48. Assignment In lateral medullary syndrome (Wallenberg syndrome), there are associated analgesia and thermoanalgesia of the ipsilateral face. Why? What brainstem structure is affected?
  • 49. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Right eye deviates medially Righ-sided facial weakness
  • 50. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially Righ-sided facial weakness
  • 51. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially LR weakness, CN6 Right Righ-sided facial weakness
  • 52. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Motor (CS tract, R) Right eye deviates medially LR weakness, CN6 Right Righ-sided facial weakness CN7, Right
  • 53. Location Structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  • 54. Location Structure Medial structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  • 55. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right CN7, Right
  • 56. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right
  • 57. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right Medial Pons Pons tumor
  • 58. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right Medial Pons Pons tumor Millard-Gubler Syndrome
  • 59. Assignment What is astrocytoma? Where is it usually located? Who are most often affected?
  • 60. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia Loss of pupilary light reflex, left eye Paralysis of right arm and leg
  • 61. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye Paralysis of right arm and leg
  • 62. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye CN3, Left Paralysis of right arm and leg
  • 63. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Loss of pupilary light reflex, left eye CN3, Left Paralysis of right arm and leg Motor, CS tract, Left
  • 64. Location Structure CN3, Left CN3, Left Motor, CS tract, Left
  • 65. Location Structure Midbrain CN3, Left CN3, Left Motor, CS tract, Left
  • 66. Location Structure Midbrain CN3, Left Midbrain CN3, Left Motor, CS tract, Left
  • 67. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left
  • 68. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left Medial Midbrain Weber’s Syndrome
  • 69. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss Involuntary movement
  • 70. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Involuntary movement
  • 71. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Medial Lemniscus, Left Involuntary movement
  • 72. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Medial Lemniscus, Left Involuntary movement Red nucleus, Left
  • 73. Location Structure CN3, Left Medial Lemniscus, Left Red nucleus, Left
  • 74. Location Structure Midbrain, Left CN3, Left Medial Lemniscus, Left Red nucleus, Left
  • 75. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Red nucleus, Left
  • 76. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left
  • 77. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left Medial Midbrain Benedikt’s Syndrome
  • 78. Weber’s Syndrome Benedikt’s Syndrome CN3 CN3 Motor, CS tract Medial Lemniscus Corticobulbar tract Red nucleus Medial midbrain Medial midbrain
  • 79. Weber’s Benedikt’s
  • 80. Parinaud’s syndrome •Posterior midbrain •Superior colliculi •Center for upward gaze •Inability to look up (Doll’s eye) •Argylle-Robertson pupil
  • 81. Any questions? The End
  • 82. RETURN Brain stem 10% 90%
  • 83. RETURN LESION Brain stem 10% 90%
  • 84. RETURN LESION Brain stem 10% 90% Contralateral paralysis
  • 85. Return
  • 86. Return LESION
  • 87. Return LESION Contralateral sensory loss
  • 88. Return
  • 89. Return
  • 90. Return
  • 91. Return LESION
  • 92. Return LESION Ipsilateral ataxia
  • 93. Return LESION Brain Stem Contralateral sensory loss Pain & temperature
  • 94. Return
  • 95. Return LESION
  • 96. Return LESION Ipsilateral facial sensory loss
  • 97. Horner’s Syndrome Meiosis Ptosis Anhydrosis Return
  • 98. Deviated to the right Return
  • 99. Vagus Vagus Levator uvalae Return
  • 100. Vagus Vagus Levator uvalae Lesion Deviated to the right Return
  • 101. Vagus Vagus Levator uvalae Lesion Deviated to the right Uvula deviates OPPOSITEthe lesion Return
  • 102. Tongue deviates OPPOSITE the lesion Deviated to the LEFT Return
  • 103. Return
  • 104. Return
  • 105. Facial weakness Return
  • 106. Cranial Nerve 3 •EOM except lateral rectus & superior oblique •Down and out •Ptosis •Absent pupillary light reflex Return
  • 107. Return