Brainstem Lesions

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Brainstem Lesions

  1. 1. Lessons on Brainstem Lesions Dr. Dennis Bravo
  2. 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. 3. review of Brainstem Structure
  4. 4. Brainstem Anatomy Midbrain Pons Medulla
  5. 5. Brainstem Anatomy Midbrain Pons Medulla
  6. 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. 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. 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. 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. 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. 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. 12. RULE #1 4 Medial Structures •Motor pathway •Medial leminiscus •Medial longitudinal fasciculus •Motor nucleus and nerve
  13. 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. 14. RULE #3 4 Side Structures •Spinocerebellar pathway •Spinothalamic pathway •Sensory nucleus of CN5 •Sympathetic pathway
  15. 15. 4 Medulla Cranial RULE #4 Nerves •Glossopharyngeal (CN9) •Vagus (CN10) •Spinal accessory (CN11) •Hypoglossal (CN12)
  16. 16. RULE #4 4 Pons Cranial Nerves •Trigeminal (CN5) •Abducent (CN6) •Facial (CN7) •Auditory (CN8)
  17. 17. 4 Cranial Nerves RULE #4 Above Pons •Olfactory (CN1) •Optic (CN2) •Occulomotor (CN3) •Trochlear (CN4)
  18. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 30. DE CN 4 ns FIC IT Po Ipsilateral facial Trigeminal CN5 sensory loss More Info Abducent CN6 Facial CN7 Auditory CN8
  31. 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. 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. 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. 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. 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. 36. Let’s put your knowledge to use...
  37. 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. 38. Case 58 year old woman •Left hemiparesis •Left-sided loss of propioception •Right-sided tongue deviation
  39. 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. 40. Structure •Motor (CS tract, R) •Medial lemniscus, R •CN12, R
  41. 41. Location Structure •Medial •Motor (CS tract, R) •Medial •Medial lemniscus, R •Medulla •CN12, R
  42. 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. 43. Case 58 year old woman •Left-sided meiosis, anhydrosis, ptosis •Left-sided ataxia •Uvula deviated to right
  44. 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. 45. Structure •Sympathetic tract, Left •Spinocerebellar •CN10, Left
  46. 46. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left
  47. 47. Location Structure •Side, Left •Sympathetic tract, Left •Side, Left •Spinocerebellar •Medulla •CN10, Left Lateral medullary Posterior inferior syndrome (L) cerebellar artery (L)
  48. 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. 49. Case Structure 10 y/o girl with the ff symptoms Left-sided weakness Right eye deviates medially Righ-sided facial weakness
  50. 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. 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. 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. 53. Location Structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  54. 54. Location Structure Medial structure Motor (CS tract, R) LR weakness, CN6 Right CN7, Right
  55. 55. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right CN7, Right
  56. 56. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right
  57. 57. Location Structure Medial structure Motor (CS tract, R) Pons LR weakness, CN6 Right Pons CN7, Right Medial Pons Pons tumor
  58. 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. 59. Assignment What is astrocytoma? Where is it usually located? Who are most often affected?
  60. 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. 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. 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. 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. 64. Location Structure CN3, Left CN3, Left Motor, CS tract, Left
  65. 65. Location Structure Midbrain CN3, Left CN3, Left Motor, CS tract, Left
  66. 66. Location Structure Midbrain CN3, Left Midbrain CN3, Left Motor, CS tract, Left
  67. 67. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left
  68. 68. Location Structure Midbrain CN3, Left Midbrain CN3, Left Medial, Left Motor, CS tract, Left Medial Midbrain Weber’s Syndrome
  69. 69. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia Right-sided propioception loss Involuntary movement
  70. 70. Case Structure 70 y/o male hypertensive suddenly developed Left-sided ipsilateral ophthalmoplegia CN3, Left Right-sided propioception loss Involuntary movement
  71. 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. 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. 73. Location Structure CN3, Left Medial Lemniscus, Left Red nucleus, Left
  74. 74. Location Structure Midbrain, Left CN3, Left Medial Lemniscus, Left Red nucleus, Left
  75. 75. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Red nucleus, Left
  76. 76. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left
  77. 77. Location Structure Midbrain, Left CN3, Left Medial, Left Medial Lemniscus, Left Medial, Left Red nucleus, Left Medial Midbrain Benedikt’s Syndrome
  78. 78. Weber’s Syndrome Benedikt’s Syndrome CN3 CN3 Motor, CS tract Medial Lemniscus Corticobulbar tract Red nucleus Medial midbrain Medial midbrain
  79. 79. Weber’s Benedikt’s
  80. 80. Parinaud’s syndrome •Posterior midbrain •Superior colliculi •Center for upward gaze •Inability to look up (Doll’s eye) •Argylle-Robertson pupil
  81. 81. Any questions? The End
  82. 82. RETURN Brain stem 10% 90%
  83. 83. RETURN LESION Brain stem 10% 90%
  84. 84. RETURN LESION Brain stem 10% 90% Contralateral paralysis
  85. 85. Return
  86. 86. Return LESION
  87. 87. Return LESION Contralateral sensory loss
  88. 88. Return
  89. 89. Return
  90. 90. Return
  91. 91. Return LESION
  92. 92. Return LESION Ipsilateral ataxia
  93. 93. Return LESION Brain Stem Contralateral sensory loss Pain & temperature
  94. 94. Return
  95. 95. Return LESION
  96. 96. Return LESION Ipsilateral facial sensory loss
  97. 97. Horner’s Syndrome Meiosis Ptosis Anhydrosis Return
  98. 98. Deviated to the right Return
  99. 99. Vagus Vagus Levator uvalae Return
  100. 100. Vagus Vagus Levator uvalae Lesion Deviated to the right Return
  101. 101. Vagus Vagus Levator uvalae Lesion Deviated to the right Uvula deviates OPPOSITEthe lesion Return
  102. 102. Tongue deviates OPPOSITE the lesion Deviated to the LEFT Return
  103. 103. Return
  104. 104. Return
  105. 105. Facial weakness Return
  106. 106. Cranial Nerve 3 •EOM except lateral rectus & superior oblique •Down and out •Ptosis •Absent pupillary light reflex Return
  107. 107. Return

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