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Lessons on
Brainstem
  Lesions
  Dr. Dennis Bravo
Case
A 58 y/o was referred to you because of recent
  onset of left hemiparesis, left-sided loss of
    propioception and ...
review
         of
Brainstem Structure
Brainstem Anatomy



Midbrain
 Pons
Medulla
Brainstem Anatomy



Midbrain
 Pons
Medulla
Rules of 4*
1. 4 structures in ‘midline’ and begin with ‘M’
2. 4 motor nuclei in midline and are those that
are divisors o...
1                                                             2
                                                          ...
2
                                                              4 Motor nuclei in
4 Structures in midline                 ...
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’...
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’...
4 Motor nuclei in
4 Structures in midline                                    midline and are divisors
  and begin with ‘M’...
RULE #1
    4 Medial Structures

 •Motor pathway
 •Medial leminiscus
 •Medial longitudinal
 fasciculus
 •Motor nucleus and...
RULE #2
 4 Medial Motor Nucleus


 •CN divides number 12
 •CN 3, 4, 6, 12 are midline
 •3, 4, 6, 12 nucleus are midline
 •...
RULE #3
     4 Side Structures


 •Spinocerebellar pathway
 •Spinothalamic pathway
 •Sensory nucleus of CN5
 •Sympathetic ...
4 Medulla Cranial
RULE #4   Nerves


  •Glossopharyngeal (CN9)
  •Vagus (CN10)
  •Spinal accessory (CN11)
  •Hypoglossal (...
RULE #4
  4 Pons Cranial Nerves


   •Trigeminal (CN5)
   •Abducent (CN6)
   •Facial (CN7)
   •Auditory (CN8)
4 Cranial Nerves
RULE #4  Above Pons


  •Olfactory (CN1)
  •Optic (CN2)
  •Occulomotor (CN3)
  •Trochlear (CN4)
ne s
    li e
                                          DE
  id ur                                     FIC
M ct           ...
ne s
    li e
                                              DE
  id ur                                           FIC
M ct ...
ne s
    li e
                                            DE
  id ur                                        FIC
M ct      ...
ne s
    li e
                                            DE
  id ur                                         FIC
M ct     ...
al                                DE
    er es
 at ur                                      FIC
L ct                       ...
al                                   DE
    er es
 at ur                                        FIC
L ct                  ...
al                                   DE
    er es
 at ur                                        FIC
L ct                  ...
al                                   DE
    er es
 at ur                                        FIC
L ct                  ...
DE
 CN lla
4 u
                                           FIC
                                               I  T
  ed
M
 ...
DE
 CN lla
4 u
                                            FIC
                                                I T
  ed
M
...
DE
 CN lla
4 u
                                            FIC
                                                I T
  ed
M
...
DE
 CN lla
4 u
                                            FIC
                                                I  T
  ed
M...
DE
 CN
4 ns
                                       FIC
                                           IT
 Po
                 ...
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
               ...
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
               ...
DE
 CN
4 ns
                                        FIC
                                            IT
 Po
               ...
DE
 4 CN ons                            FIC
       P                                 IT
    ve
A bo
     Olfactory CN1    ...
DE
 4 CN ons                                 FIC
       P                                      I  T
    ve
A bo
     Olfac...
Let’s put your
knowledge to use...
Always remember

        “Pathways and tracts pass through the
   entire length of the brainstem and can be
   likened to ...
Case


58 year old woman
•Left hemiparesis
•Left-sided loss of
propioception
•Right-sided
tongue deviation
Case                   Structure



58 year old woman
•Left hemiparesis     •Motor (CS tract, R)
•Left-sided loss of   •Me...
Structure




•Motor (CS tract, R)
•Medial
lemniscus, R
•CN12, R
Location           Structure




•Medial         •Motor (CS tract, R)
•Medial         •Medial
                lemniscus, R...
Location               Structure




•Medial              •Motor (CS tract, R)
•Medial              •Medial
              ...
Case

58 year old woman
•Left-sided
meiosis,
anhydrosis, ptosis
•Left-sided ataxia
•Uvula deviated
to right
Case                 Structure


58 year old woman
•Left-sided          •Sympathetic
meiosis,             tract, Left
anhy...
Structure




•Sympathetic
tract, Left

•Spinocerebellar
•CN10, Left
Location          Structure




•Side, Left      •Sympathetic
                 tract, Left

•Side, Left      •Spinocerebel...
Location                Structure




•Side, Left           •Sympathetic
                      tract, Left

•Side, Left   ...
Assignment

   In lateral medullary syndrome
(Wallenberg syndrome), there are
associated analgesia and
thermoanalgesia of ...
Case                Structure


10 y/o girl
with the ff symptoms

Left-sided weakness

Right eye deviates medially


Righ-...
Case                     Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)

...
Case                      Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)
...
Case                      Structure


10 y/o girl
with the ff symptoms

Left-sided weakness           Motor (CS tract, R)
...
Location         Structure




           Motor (CS tract, R)

           LR weakness, CN6 Right


                 CN7, R...
Location             Structure




Medial structure   Motor (CS tract, R)

                   LR weakness, CN6 Right


   ...
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


   ...
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


   ...
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


   ...
Location             Structure




Medial structure   Motor (CS tract, R)

     Pons          LR weakness, CN6 Right


   ...
Assignment

What is astrocytoma?
Where is it usually located?
Who are most often affected?
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        opht...
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        opht...
Case                    Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
        opht...
Case                         Structure

70 y/o male hypertensive
suddenly developed

       Left-sided ipsilateral
       ...
Location        Structure




               CN3, Left

               CN3, Left

           Motor, CS tract, Left
Location        Structure




Midbrain        CN3, Left

                CN3, Left

            Motor, CS tract, Left
Location        Structure




Midbrain        CN3, Left

Midbrain        CN3, Left

            Motor, CS tract, Left
Location          Structure




 Midbrain          CN3, Left

 Midbrain          CN3, Left


Medial, Left   Motor, CS trac...
Location           Structure




  Midbrain            CN3, Left

  Midbrain            CN3, Left


 Medial, Left     Moto...
Case                  Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmop...
Case                  Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      ophthalmop...
Case                        Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      opht...
Case                        Structure

70 y/o male hypertensive
suddenly developed

     Left-sided ipsilateral
      opht...
Location         Structure




                CN3, Left

           Medial Lemniscus, Left


             Red nucleus, Le...
Location            Structure




Midbrain, Left        CN3, Left

                 Medial Lemniscus, Left


             ...
Location            Structure




Midbrain, Left        CN3, Left

 Medial, Left    Medial Lemniscus, Left


             ...
Location            Structure




Midbrain, Left        CN3, Left

 Medial, Left    Medial Lemniscus, Left


 Medial, Left...
Location             Structure




Midbrain, Left          CN3, Left

 Medial, Left      Medial Lemniscus, Left


 Medial,...
Weber’s Syndrome      Benedikt’s Syndrome



       CN3                   CN3

 Motor, CS tract      Medial Lemniscus

Cor...
Weber’s   Benedikt’s
Parinaud’s syndrome
•Posterior midbrain
•Superior colliculi
•Center for upward
gaze
•Inability to look up
(Doll’s eye)
•Ar...
Any questions?
     The End
RETURN


      Brain stem




10%   90%
RETURN


LESION         Brain stem




         10%   90%
RETURN


LESION         Brain stem




         10%   90%
                       Contralateral
                        par...
Return
Return

LESION
Return

LESION




         Contralateral
         sensory loss
Return
Return
Return
Return


LESION
Return


      LESION



Ipsilateral
  ataxia
Return




LESION   Brain Stem

                            Contralateral
                            sensory loss

      ...
Return
Return




         LESION
Return




             LESION




         Ipsilateral facial
           sensory loss
Horner’s Syndrome



 Meiosis
  Ptosis
Anhydrosis


             Return
Deviated
to the right



     Return
Vagus                    Vagus
        Levator uvalae




                         Return
Vagus                          Vagus
        Levator uvalae


                                  Lesion



                ...
Vagus                              Vagus
            Levator uvalae


                                      Lesion



    ...
Tongue
  deviates
OPPOSITE the
   lesion


  Deviated
 to the LEFT


   Return
Return
Return
Facial weakness




                  Return
Cranial Nerve 3
•EOM except lateral
rectus & superior
oblique
•Down and out
•Ptosis
•Absent pupillary
light reflex



     ...
Return
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Brainstem Lesions

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Lecture Notes of Doctor Bravo

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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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