Transverse section of the spinal cord showing the characteristics of a sacral

98
6-3A level. The gray matter occupies most of the cross-section; its H-shaped appear-
ance is not especially obvious at sacral–coccygeal levels. The white matter is a compara-
tively thin mantle. The sacral cord, although small, appears round in the CT myelogram.
Note the appearance of the sacral spinal cord surrounded by the upper portion of the cauda

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Spinal Cord with CT and MRI
equina (left) and the cauda equina as it appears caudal to the conus medullaris in the lum-
bar cistern (right). Compare with Figure 2-4 on p. 10.

Gracile fasciculus

Dorsolateral tract

Posteromarginal nucleus (lamina I)

Substantia gelatinosa (lamina II)

Lateral corticospinal tract

Nucleus proprius (laminae III,IV)

Propriospinal fibers (ProSp)

Intermediate zone (lamina VII)

Anterolateral system

Lateral motor nuclei (lamina IX)

Reticulospinal tract
Medial motor nuclei (lamina IX)
ProSp

Sensory
Post. column/med. lemniscus sys. Anterolateral system Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, nerve
(somatomotor)
discriminative touch) touch from body) nuclei

Motor
 Lumbar cistern

Anterior horn

Cauda equina

Posterior horn

Filum terminale
internum
Anatomical orientation Clinical orientation CT myelogram CT myelogram

The Spinal Cord with CT and MRI

Lateral motor cell Posterior horn,
column, SE cells SA input

6-3A, 6-3B
Medial motor cell
column,SE cells
Secondary visceral grey,
VA input
Sacral parasympathetic
nuclei, VE cells

6-3B

99
 Transverse section of the spinal cord showing its characteristic appearance at

100
6-4A lumbar levels (L4). Posterior and anterior horns are large in relation to a modest
amount of white matter, and the general shape of the cord is round. Fibers of the medial
division of the posterior root directly enter the gracile fasciculus. The lumbar spinal cord
appears round in the CT myelogram. The roots of upper portions of the cauda equina sur-
round the lower levels of the lumbar spinal cord (right), see also Figure 2-4 on p. 10.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior median sulcus
ProSp
Gracile fasciculus

Medial division fibers

Dorsolateral tract

Posteromarginal nucleus (lamina I)

Substantia gelatinosa (lamina II)

Nucleus proprius (laminae III,IV) Lateral corticospinal tract

Area of lamina V
Area of lamina VI Rubrospinal tract

Intermediate zone (lamina VII) Propriospinal fibers (ProSp)

Anterolateral system
Lateral motor nuclei (lamina IX)

Medullary (lateral)
reticulospinal fibers
Area of lamina VIII
Lateral vestibulospinal tract and
Medial motor nuclei (lamina IX) pontoreticulospinal (Medial
reticulospinal) tract

ProSp Anterior root fibers

Medial longitudinal fasciculus

Anterior corticospinal tract

Anterior median fissure

Sensory
Post. column/med. lemniscus sys. Anterolateral system Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, nerve
(somatomotor)
discriminative touch) touch from body) nuclei

Motor
 Anterior root

Anterior horn

Posterior root

Posterior horn

Anatomical orientation Clinical orientation CT myelogram CT myelogram

The Spinal Cord with CT and MRI

Medial motor cell
column,SE cells
Posterior horn,
SA input
6-4A, 6-4B

Lateral motor cell

column, SE cells

6-4B

101
 Transverse section of the spinal cord showing its characteristic appearance at

102
6-5A thoracic levels (T4). The white matter appears large in relation to the rather
diminutive amount of gray matter. Posterior and anterior horns are small, especially when
compared to low cervical levels and to lumbar levels. The overall shape of the cord is
round. The thoracic spinal cord appears round in CT myelogram.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior median sulcus
ProSp Gracile fasciculus

Posterior intermediate sulcus

Posterolateral sulcus Cuneate fasciculus

Dorsolateral tract Medial division fibers

of posterior root

Posteromarginal nucleus and

substantia gelatinosa (laminae I,II)
Posterior spinocerebellar tract
Nucleus proprius
(laminae III,IV) Lateral corticospinal tract

Dorsal thoracic nucleus

of Clarke (lamina VII)

Rubrospinal tract
Intermediolateral cell column
(lamina VII) Propriospinal fibers (ProSp)

Anterior spinocerebellar tract

Medial motor nuclei (lamina IX)
Medullary (lateral) reticulospinal tract

Spino-olivary fibers Anterior root fibers

Anterolateral system

Lateral vestibulospinal tract

Pontoreticulospinal tract Medial longitudinal fasciculus
ProSp Anterior corticospinal tract
Anterior white commissure
Anterior median fissure

Sensory
Post. column/med. lemniscus sys. Anterolateral system Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, nerve
(somatomotor)
discriminative touch) touch from body) nuclei

Motor
 Anterior horn

Anterior root

Lateral horn

Posterior root

Posterior horn
Anatomical orientation Clinical orientation
CT myelogram CT myelogram

The Spinal Cord with CT and MRI

Medial motor cell Secondary visceral grey,
column,SE cells VA input

6-5A, 6-5B
Sacral parasympathetic Posterior horn,
nuclei, VE cells SA input

6-5B

103
 Transverse section of the spinal cord showing its characteristic appearance at

104
6-6A lower cervical levels (C7). The anterior horn is large, and there is—proportionally
and absolutely—a large amount of white matter. The overall shape of the cord is oval. The
lower portions of the cervical spinal cord (beginning at about C4 and extending through
C8) appear oval in MRI (left) and in CT myelogram (center and right). Although frequently
called lamina X, Rexed (1954) clearly describes nine laminae (I–IX) and an “area X, the

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

central gray substance.” This original designation is used here.
Posterior median sulcus
Interfascicular fasciculus Gracile fasciculus (FGr)
Posterior intermediate sulcus
Dorsolateral tract
Cuneate fasciculus (FCu)
Posteromarginal nucleus (lamina I)
Posterolateral sulcus
Substantia gelatinosa (lamina II)
Posterior spinocerebellar tract
Nucleus proprius (laminae III, IV)
Reticular nucleus of Lateral corticospinal tract
cervical cord

Area of lamina V
Propriospinal
fibers (ProSp)
Area of lamina VI
Area
X Rubrospinal tract

Intermediate zone (lamina VII) Anterior spinocerebellar tract

Medullary (lateral)
reticulospinal tract

Anterolateral system
Lateral motor nuclei
(lamina IX)

Area of lamina VIII Spino-olivary fibers

Medial motor nuclei (lamina IX)

ProSp Anterolateral sulcus

Anterior white commissure

Lateral vestibulospinal tract

Anterior corticospinal tract Pontoreticulospinal (medial reticulospinal) tract

Medial longitudinal fasciculus

and tectospinal tract
Anterior median fissure

Sensory
Post. column/med. lemniscus sys. Anterolateral system Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, nerve
(somatomotor)
discriminative touch) touch from body) nuclei

Motor
 Anterior horn

Anterior root

Posterior root

Posterior horn

FGr + FCu

Anatomical orientation Clinical orientation MRI, T2-weighted image CT myelogram CT myelogram

The Spinal Cord with CT and MRI

Medial motor cell
column, SE cells
6-6A, 6-6B
Lateral motor cell
column, SE cells Posterior horn,
SA input

6-6B

105
 Transverse section of the spinal cord at the C1 level. Lateral corticospinal fibers

106
6-7A are now located medially toward the decussation of the corticospinal fibers,
also called the motor decussation or pyramidal decussation (see also Figure 6-10, p. 112).
At this level, fibers of the spinal trigeminal tract are interdigitated with those of the dorso-
lateral tract. The spinal cord at C1 and C2 levels appears round in CT myelogram when
compared to low cervical levels (see Figure 6-6).

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior median sulcus
Gracile fasciculus (FGr)
ProSp
Posterior intermediate sulcus

Cuneate fasciculus (FCu)

Spinal trigeminal tract and
dorsolateral tract junction

Gelatinosa portion of
spinal trigeminal nucleus
Lateral corticospinal tract (LCSp)
Magnocellular portion of
spinal trigeminal nucleus Posterior spinocerebellar
tract

Rubrospinal
tract

Accessory nucleus Propriospinal

fibers (ProSp)

Anterior spinocerebellar tract

Spino-olivary fibers Medullary (lateral)

reticulospinal tract

Medial motor nuclei Anterolateral system

ProSp Pontoreticulospinal (Medial reticulospinal) tract

Anterior corticospinal tract Lateral vestibulospinal tract

Pyramidal decussation (PyDec)

Medial longitudinal fasciculus
Tectospinal tract

Sensory
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 PyDec

C1 anterior horn

LCSp fibers

C1 posterior horn

FGr + FCu

Anatomical orientation Clinical orientation CT myelogram CT myelogram

The Spinal Cord with CT and MRI

Accessory nucleus,
SE cells

6-7A, 6-7B
Medial motor
cell column, Junction of posterior horn
SE cells with the gelatinosa and
magnocellular parts of the
spinal trigeminal nucleus

6-7B

107
 Vascular Syndromes or Lesions of the Spinal Cord
Acute Central Cervical Spinal Cord Syndrome
This results from occlusion of the anterior spinal artery.
Deficit Structure Damage
Bilateral paresis or flaccid paralysis of
upper extremities tracts; ventral gray horns at cervical levels
Irregular loss of pain and temperature sen-
sations bilaterally over body below lesion ment bilaterally)
Hyperextension of the neck may cause damage to the vertebral arteries (origin of the anterior
spinal artery), or it may directly damage the anterior spinal artery, causing a spasm. This vascu-
lar damage leads to a temporary or permanent interruption of blood supply. Deficits may resolve
within a few hours or may be permanent, depending on the extent of vascular complication.
Sparing of the posterior columns (proprioception, vibratory sense) is a hallmark; approximately
the anterior two-thirds of the spinal cord is ischemic.
Thrombosis of Anterior Spinal Artery
This may occur in a hypotensive crisis, as a result of trauma resulting from a dissecting aortic
aneurysm, or in patients with atherosclerosis. It may occur at all spinal levels, but is more fre-
quently seen in thoracic and lumbosacral levels unless trauma is the primary cause. Results are
bilateral flaccid paraplegia (if the lesion is below cervical levels) or quadriplegia (if the lesion is
in cervical levels), urinary retention, and loss of pain and temperature sensation. Flaccid muscles
may become spastic over a period of a day to weeks, with hyperactive muscle stretch reflexes and
extensor plantar (Babinski) reflexes. In addition, lesions at high cervical levels may also result in
paralysis of respiratory muscles. The artery of Adamkiewicz (a large spinal medullary artery) is
usually located at spinal levels T12–L1 and more frequently arises on the left side. Occlusion of
this vessel may infarct lumbosacral levels of the spinal cord.
Hemorrhage in the Spinal Cord
This is rarely seen, but may result from trauma or bleeding from congenital vascular lesions.
Symptoms may develop rapidly or gradually in stepwise fashion, and blood is usually present in
the cerebrospinal fluid.
Arteriovenous Malformation in the Spinal Cord
More frequently found in lower cord levels. Symptoms of a spinal AVM (micturition prob-
lems are seen early, motor deficits, lower back pain) may appear over time and may seem to
resolve then recur (get better, then worse). These lesions are usually found external to the cord
(extramedullary) and can be surgically treated, especially when the major feeding vessels are few
in number and easily identified. Foix-Alajouanine syndrome is an inflammation of spinal veins,
with subsequent occlusion that results in infarct of the spinal cord and a necrotic myelitis. The
symptoms are ascending pain and a flaccid paralysis.
Semi-diagrammatic representation of the internal blood supply to the spinal cord. This
108
6-8 is a tracing of a C4 level, with the positions of principal tracts shown on the left, the
general pattern of blood vessels on the right, and the color-coded pathways correlate with those
on Figure 6-7.
A B B R E V I AT I O N S
6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—Arterial Patterns within the Spinal Cord
AH Anterior (ventral) horn N Representation of neck fibers
AWCom Anterior white commissure PH Posterior (dorsal) horn
CenC Central canal S Representation of sacral fibers
- IZ Intermediate zone T Representation of truck fibers
LE Representation of lower extremity UE Representation of upper extremity
Brown-Séquard Syndrome
This syndrome is a hemisection (functional hemisection) of the spinal cord that may result from
trauma, compression of the spinal cord by tumors or hematomas, or significant protrusion of an
intervertebral disc. The deficits depend on the level of the causative lesion. The classic signs are: 1) a
loss of pain and thermal sensation on the contralateral side of the body beginning about one to two
segments below the level of the lesion (damage to anterolateral system fibers); 2) a loss of discrimi-
native touch and proprioception on the ipsilateral side of the body below the lesion (interruption of
posterior column fibers); and 3) a paralysis on the ipsilateral side of the body below the lesion (dam-
age to lateral corticospinal fibers). This syndrome is classified as an incomplete spinal cord injury,
and patients with this lesion may regain some degree of motor and sensory function. Compression
of the spinal cord may result in some, but not all, of the signs and symptoms of the syndrome.
Syringomyelia
Syringomyelia is a cavitation within the central region of the spinal cord. A cavitation of the
central canal with an ependymal cell lining is hydromyelia. A syrinx may originate in central
portions of the spinal cord, may communicate with the central canal, and is most commonly
seen in cervical levels of the spinal cord. The most common deficits are a bilateral loss of pain
and thermal sensation due to damage to the anterior white commissure: the loss reflects the lev-
els of the spinal cord damaged (e.g., a cape distribution over the shoulder and upper extremities).
The other commonly seen deficit results from extension of the cavity into the anterior horn(s).
The result is unilateral or bilateral paralysis of the upper extremities (cervical levels) or lower
extremities (lumbosacral levels) due to damage to spinal motor neurons. This paralysis is char-
acteristically a lower motor neuron deficit. A syrinx in the spinal cord, particularly in cervical
levels, may be associated with a variety of other developmental defects in the nervous system.
Spinal Cord Lesions
General Concepts
A complete spinal cord lesion is characterized by a bilateral and complete loss of motor and
sensory function below the level of the lesion persisting for more than 24 hours. The vast major-
ity of the patients with complete lesions (95%+) will suffer some permanent deficits. Incomplete
spinal cord lesions are those with preservation of sacral cord function at presentation. The above
described cases are examples of incomplete spinal cord lesions.
 High Cervical
The phrenic nucleus is located in central areas of the anterior horn at levels C3–C7 and receives
descending input from nuclei of the medulla (mainly in the reticular formation) that influence
respiration, particularly inspiration. The phrenic nerve originates primarily from level C4 with
some contributions from C3 and C5 and innervates the diaphragm. A complete spinal cord
lesion between C1 and C3 interrupts medullary input to the phrenic nucleus and may result in
immediate respiratory (and potentially cardiac) arrest. This constitutes a medical emergency
necessitating intervention within minutes, or the patient will die.

Fasciculus gracilis AVC

Fasciculus cuneatus Posterior spinal artery

Posterior spinal medullary artery
Dorsolateral tract

Lateral corticospinal tract

Posterior radicular
Propriospinal fibers artery to posterior root

Arterial Patterns within the Spinal Cord with Vascular Syndromes

PH LE
T
Posterior spinocerebellar tract UE
AWCom Arterial
Rubrospinal tract CenC vasocorona
(AVC)
IZ
S
Anterior spinocerebellar tract LE
Segmental
AH T artery
UE
N
Anterolateral system Anterior radicular artery
to anterior root
Reticulospinal and
vestibulospinal tracts
Medial longitudinal fasciculus and
anterior corticospinal tract Anterior spinal medullary artery

Sulcal artery Anterior spinal artery

6-8

109
 All of the brainstem sections used in Figures 6-11 through 6-15 (medulla), 6-19

110
6-9 through 6-22 (pons), and 6-24 through 6-29 (midbrain, except 6-25) are from an
individual who had an infarct (green in drawing) in the posterior limb of the internal capsule.
This lesion damaged corticospinal fibers (gray in drawing), resulting in a contralateral
hemiplegia of the arm and leg, and damaged sensory radiations that travel from thalamic
nuclei to the somatosensory cortex through the posterior limb of the internal capsule.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Degenerated Corticospinal Tract
Although the patient survived the initial episode, corticospinal fibers (gray) distal to the
lesion (green) underwent degenerative changes and largely disappeared. This Wallerian
(anterograde) degeneration takes place because the capsular infarct effectively separates the
descending corticospinal fibers from their cell bodies in the cerebral cortex. Consequently,
the location of corticospinal fibers in the middle one-third of the crus cerebri of the mid-
brain, in the basilar pons, and in the pyramid of the medulla is characterized by the obvious
lack of myelinated axons in these structures when compared to the opposite side. In the
brainstem, these degenerated fibers are ipsilateral to their cells of origin, but are contralat-
eral to their destination in the spinal cord—hence, the contralateral motor deficit when
these fibers are damaged rostral to the motor decussation. These images give the user the
unique opportunity of seeing where corticospinal fibers are located at all levels of the
human brainstem. Also, one is constantly reminded of: 1) the relationship of corticospinal
fibers to other structures; 2) the deficits one can expect to see at representative levels due to
this lesion; and 3) the general appearance of degenerated fibers in the human central nerv-
ous system. These images can be adapted to a wide range of instructional formats.
 Motor cortex
(precentral gyrus)

Internal capsule,
posterior limb

Infarct in
internal capsule

Midbrain

Degenerated Pons
corticospinal
fibers

The Degenerated Corticospinal Tract

Medulla

Spinal cord

Degenerated
corticospinal
fibers

6-9

111
 Transverse section of the medulla through the motor decussation (decussation

112
6-10A of the pyramids [pyramidal decussation], crossing of corticospinal fibers).
This is the level of the spinal cord–medulla transition. The corticospinal fibers have moved
from their location in the lateral funiculus to the motor decussation (compare this image
with Figure 6-7A, B) and will cross to form the pyramid on the opposite side.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Medulla Oblongata with MRI and CT
Gracile fasciculus
Gracile nucleus (NuGr)
Central gray

Cuneate fasciculus

Cuneate nucleus (NuCu)

Spinal trigeminal tract (SpTTr)

Spinal trigeminal tract

Spinal trigeminal nucleus (SpTNu) (pars caudalis)
Gelatinosa
Magnocellular
Reticulospinal fibers

Pyramidal decussation Rubrospinal tract

Accessory nucleus (AccNu)
(PyDec)
Posterior spinocerebellar tract
Medial longitudinal
fasciculus Anterolateral system (ALS)

Medial motor nuclei

Anterior spinocerebellar tract

Tectospinal tract
Vestibulospinal tract and
reticulospinal tract
Spino-olivary fibers
Pyramid Anterior corticospinal tract

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nerve
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 PyDec

AccNu
ALS

SpTTr+
SpTNu
NuCu

NuGr
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

The Medulla Oblongata with MRI and CT

Medial motor 6-10A, 6-10B
cell column,
SE cells Spinal trigeminal nucleus,
SA input
Accessory nucleus,
SE cells

6-10B

113
 Transverse section of the medulla through the posterior column nuclei

114
6-11A (nucleus gracilis and nucleus cuneatus), caudal portions of the hypoglossal
nucleus, caudal end of the principal olivary nucleus, and middle portions of the sensory
decussation (crossing of internal arcuate fibers).

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Central gray

Gracile nucleus (NuG) Dorsal motor nucleus of vagus

Gracile fasciculus Posterior longitudinal fasciculus

Cuneate fasciculus
Solitary nuclei and tract

Hypoglossal nucleus (HyNu)

Cuneate nucleus (NuCu)
Accessory cuneate nucleus
Posterior spinocerebellar
tract Restiform body

Spinal trigeminal tract (SpTTr)

Internal arcuate fibers
Spinal trigeminal nucleus (SpTNu)
(pars caudalis)
Rubrospinal tract
Nucleus ambiguus
Anterior spinocerebellar tract
Fascicles of hypoglossal nerve
Retro-olivary sulcus
(postolivary sulcus)
Ventral trigeminothalamic tract
Anterolateral system (ALS)
Lateral reticular nucleus
Vestibulospinal fibers
and reticulospinal fibers
Principal olivary nucleus
Pyramid
(Py)
Hypoglossal nerve
Preolivary sulcus
Principal olivary nucleus (PO)
Degenerated corticospinal fibers
Arcuate nucleus
Medial longitudinal fasciculus
Tectospinal tract
Medial accessory olivary nucleus Medial lemniscus (ML)

Sensory
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 Py
ML
PO
ALS
SpTTr+
SpTNu
NuCu
NuGr
HyNu
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

The Medulla Oblongata with MRI and CT

Hypoglossal nucleus,
SE cells
Spinal trigeminal
nucleus, SA input

6-11A, 6-11B
Dorsal motor vagal
nucleus, VE cells
Nucleus ambiguus, Solitary nuclei,
SE cells VA input

6-11B

115
 Transverse section of the medulla through rostral portions of the sensory dec-

116
6-12A ussation (crossing of internal arcuate fibers), obex, and the caudal one-third
of the hypoglossal and principal olivary nuclei.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Area postrema
Level of obex Posterior longitudinal fasciculus

Gracile nucleus (NuGr) Hypoglossal nucleus (HyNu)

Dorsal motor nucleus of vagus

Cuneate fasciculus
Solitary nuclei and tract
Cuneate nucleus (NuCu)

Accessory cuneate nucleus Restiform body (RB)

(+ juxtarestiform body =
inferior cerebellar peduncle)
Nucleus ambiguus

Spinal trigeminal tract (SpTTr) Internal arcuate fibers

Spinal trigeminal nucleus (SpTNu)

(pars interpolaris) Anterior spinocerebellar tract
Lateral reticular nucleus
Reticular formation Rubrospinal tract

Anterolateral system (ALS)

Hypoglossal fibers

Retro-olivary sulcus
(postolivary sulcus)
Posterior accessory olivary nucleus
Principal olivary nucleus (PO)

Ventral trigeminothalamic tract Central tegmental tract

Pyramid and amiculum of olive
(Py)
Olivocerebellar fibers
Preolivary sulcus

Medial accessory olivary nucleus

Arcuate nucleus Degenerated corticospinal fibers

Nucleus raphe, obscurus Medial longitudinal fasciculus

Tectospinal tract
Medial lemniscus (ML)

Sensory
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 Py
ML
PO
ALS
SpTTr+
SpTNu
RB
NuCu+NuGr
HyNu
Anatomical orientation Clinical orientation
MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

The Medulla Oblongata with MRI and CT

Hypoglossal nucleus,
SE cells Spinal trigeminal
nucleus, SA input
6-12A, 6-12B
Dorsal motor vagal
nucleus, VE cells
Solitary nuclei,
Nucleus ambiguus, VA input
SE cells

6-12B

117
 Transverse section of the medulla through rostral portions of the hypoglossal

118
6-13A nucleus and the middle portions of the principal olivary nucleus. The fourth
ventricle has flared open at this level, and the restiform body is enlarging to become a
prominent structure on the dorsolateral aspect of the medulla.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Nucleus raphe, obscurus
Dorsal motor nucleus
of the vagus Posterior longitudinal fasciculus
Medial Solitary nuclei and tract
vestibular nucleus (MVNu) Hypoglossal nucleus (HyNu)
Sulcus limitans Spinal trigeminal nucleus (SpTNu)
Inferior (spinal) (pars interpolaris)
vestibular nucleus (InfVNu)
Spinal trigeminal tract (SpTTr)
Accessory
cuneate nucleus

Restiform body (RB)

(+ Juxtarestiform body =
Inferior cerebellar peduncle) Reticular formation
Rubrospinal tract

Nucleus ambiguus
Anterior spinocerebellar tract
Vagus nerve
Anterolateral system (ALS)
Lateral reticular nucleus Central tegmental tract
and amiculum of olive

Posterior accessory
olivary nucleus

Principal olivary nucleus (PO)

Olivocerebellar fibers

Pyramid (Py)
Hypoglossal nerve
Ventral trigeminothalamic tract
Medial accessory olivary nucleus
Degenerated corticospinal fibers
Arcuate nucleus
Medial longitudinal fasciculus (MLF)
Nucleus raphe, pallidus Tectospinal tract
Medial lemniscus (ML)

Sensory
Post. column/med. lemniscus sys. Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, trigeminothalamic fibers (pain/ nerve
(somatomotor)
discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 Py
ML
PO
ALS
SpTTr+
SpTNu
RB
InfVNu
+ MVNu
HyNu
+ MLF
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

The Medulla Oblongata with MRI and CT

Hypoglossal nucleus,
SE cells
Dorsal motor vagal
nucleus, VE cells
Nucleus ambiguus,
SE cells
Spinal trigeminal
nucleus, SA input
6-13A, 6-13B
Vestibular nuclei,
SA input
Solitary nucleus,
VA input

6-13B

119
 Transverse section of the medulla through the posterior (dorsal) and anterior

120
6-14A (ventral) cochlear nuclei and root of the glossopharyngeal nerve. This corre-
sponds to approximately the rostral third to fourth of the principal olivary nucleus, to the
location of the lateral recess of the fourth ventricle, and to the general area of the medulla–
pons junction.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior longitudinal fasciculus
Nucleus raphe, obscurus Nucleus prepositus (NuPre)
Medial vestibular nucleus (MVNu)
Inferior salivatory nucleus Striae medullares of fourth ventricle
Solitary nuclei Inferior (or spinal) vestibular nucleus (InfVNu)
Cerebellum Anterior (ventral)
Solitary tract
cochlear nucleus

Posterior (dorsal)
cochlear nucleus
Posterior (dorsal)
cochlear nucleus

Restiform body
(RB)

Anterior (ventral)
cochlear nucleus
Reticular formation
Cochlear nerve

Glossopharyngeal
nerve Pontobulbar nucleus
Spinal trigeminal tract (SpTTr)
Spinal trigeminal nucleus (SpTNu)
(pars oralis)
Rubrospinal tract

Anterior spinocerebellar tract Nucleus ambiguus

Anterolateral system (ALS)
Reticulospinal fibers
Central tegmental tract
Posterior accessory olivary nucleus and amiculum of olive

Pyramid
(Py) Olivocerebellar fibers
Principal olivary nucleus
Degenerated corticospinal fibers
Ventral trigeminothalamic tract

Medial accessory olivary nucleus

Nucleus raphe, pallidus
Arcuate nucleus
Medial longitudinal fasciculus (MLF)
Tectospinal tract
Medial lemniscus (ML)

Sensory
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 Py
ML
ALS
SpTTr+
SpTNu
RB
InfVNu
+ MVNu

NuPre
Anatomical orientation Clinical orientation MRI, T1-weighted image +MLF MRI, T2-weighted image CT cisternogram

Spinal trigeminal
nucleus, SA input
Cochlear nuclei,
SA input
6-14A, 6-14B
Inferior salivatory
nucleus, VE cells

The Medulla Oblongata with MRI and CT

Nucleus ambiguus, Vestibular nuclei,
SE cells SA input
Solitary nuclei,
VA input

6-14B

121
 Transverse section of the medulla–pons junction through the rostral pole of

122
6-15A the principal olivary nucleus and through caudal portions of the facial motor
nucleus. This plane is just caudal to the main portions of the abducens nucleus. Pontine
nuclei at this level may also be called arcuate nuclei. CochNu = posterior and anterior coch-
lear nuclei.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior longitudinal fasciculus Superior medullary velum

Superior
cerebellar
peduncle
Juxtarestiform body Inferior
cerebellar
Restiform body peduncle
(RB)

Superior vestibular nucleus

Medial longitudinal fasciculus
Medial vestibular nucleus
(MVNu)
Lateral vestibular nucleus Nucleus raphe, obscurus
(LVNu)

Abducens nucleus
Solitary nuclei and tract

Spinal trigeminal nucleus

(SpTNu) (pars oralis) Solitary tract
Reticular formation
Facial nerve
Anterior (ventral)
cochlear nucleus
Vestibular root of Facial nucleus (FacNu)
eighth nerve

Pontobulbar nucleus Rubrospinal tract

(or body)

Spinal trigeminal tract (SpTTr) Medial Anterior spinocerebellar

Secondary cochlear fibers lemniscus tract
(ML)
Superior olive
Anterolateral system
Tectospinal tract (ALS)

Ventral trigeminothalamic tract Superior olive

Pyramid
(Py) Secondary cochlear fibers
Principal olivary nucleus

Nucleus raphe, magnus Central tegmental tract

Nucleus raphe, pallidus

Corticospinal fibers (CSp) Degenerated corticospinal fibers

Sensory
Pontine nuclei
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 Py/CSp
ML
ALS
FacNu
SpTTr+
SpTNu
RB
CochNu
MVNu
Anatomical orientation Clinical orientation +LVNu CT cisternogram
MRI, T1-weighted image MRI, T2-weighted image

Solitary nuclei,
Facial motor VA input
nucleus, SE cells Vestibular nuclei,
SA input
Abducens nucleus,
SE cells 6-15A, 6-15B

Spinal trigeminal
nucleus, SA input

The Medulla Oblongata with MRI and CT

6-15B

123
 Vascular Syndromes or Lesions of the Medulla Oblongata

124
6-16
of each section, and the general pattern of arterial distribution overlies these structures on
Medial Medullary Syndrome
the right side. The general distribution patterns of arteries in the medulla, as illustrated
This results from occlusion of branches of the anterior spinal artery. here, may vary from patient to patient. For example, the territories served by adjacent ves-
sels may overlap to differing degrees at their margins, or the territory of a particular vessel

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—Arterial Patterns within the Medulla Oblongata
Deficit Structure Damage may be smaller or larger than seen in the typical pattern.
Contralateral hemiplegia of upper extremity (UE),
trunk, and lower extremity (LE)
Contralateral loss of position sense, vibratory A B B R E V I AT I O N S
sense, and discriminative touch (UE, trunk, LE) FCu Cuneate fasciculus Py
Deviation of tongue to ipsilateral side when FGr Gracile fasciculus RB Restiform body (+ juxtarestiform body = inferior
protruded; muscle atrophy and fasciculations hypoglossal nucleus ML cerebellar peduncle)
NuCu Cuneate nucleus RetF Reticular formation
The medial medullary syndrome (Déjèrine syndrome) is rare compared to the more common
NuGr Gracile nucleus
occurrence of the lateral medullary syndrome. Nystagmus may result if the lesion involves the
medial longitudinal fasciculus or the nucleus prepositus hypoglossi. The lesion may involve ven-

of the face is rarely seen. The combination of a contralateral hemiplegia and ipsilateral deviation formation or to the vagal motor nucleus may result in hiccup (singultus). Bilateral medullary
of the tongue is called an inferior alternating hemiplegia when the lesion is at this level. damage may cause the syndrome of the “Ondine curse,” an inability to breathe without willing
it or “thinking about it”; the onset of this condition represents a medical emergency.
Lateral Medullary Syndrome
Tonsillar Herniation
dorsolateral medulla (PICA syndrome, Wallenberg syndrome - tonsil-
lar herniation) down through the foramen magnum has serious consequences for function of the

Deficit
Contralateral loss of pain and thermal sense
on body
face
Dysphagia, soft palate paralysis, hoarseness,
diminished gag reflex
anhidrosis, flushing of face)
Nausea, diplopia, tendency to fall to
ipsilateral side, nystagmus, vertigo
fossa, or a shift in pressure in the cranial cavity (such as during a lumbar puncture in a patient
Structure Damage
with a mass lesion) in cases of tonsillar herniation, the cerebellar tonsils “cone” downward
into and through the foramen magnum. The result is a compression of the medulla (mechanical
damage to the medulla plus occlusion of vessels), damage to respiratory and cardiac centers,
and sudden respiratory and cardiac arrest. This may constitute a medical emergency, especially
if the onset is sudden, and must be addressed immediately
for further information on tonsillar herniation.
nerves
Syringobulbia
syringobulbia) may exist with syringomyelia, be independ-
medial) ent of syringomyelia, or, in some cases, both may exist and communicate with each other. The

of syringobulbia may include weakness of tongue muscles (hypoglossal nucleus or nerve), weak-
ness of pharyngeal, palatal, and vocal musculature (ambiguus nucleus), nystagmus (vestibular
cause dysgeusia. Dyspnea and tachycardia may be seen in patients with damage to the dorsal nuclei), and loss of pain and thermal sensation on the ipsilateral side of the face (spinal trigemi-
 Vestibular nuclei Solitary nuclei and tract
Posterior (dorsal) cochlear nucleus Nucleus prepositus
Medial longitudinal fasciculus
Spinal trigeminal tract Fourth ventricle
and nucleus
Rostral
Anterolateral system

Inferior olivary complex

Hypoglossal nucleus RetF

Dorsal motor nucleus of vagus

Solitary nuclei and tract

RB
Nucleus ambiguus ML
Caudal
Spinal trigeminal tract
and nucleus

RetF

Arterial Patterns within the Medulla Oblongata with Vascular Syndromes

Hypoglossal nerve
Solitary nuclei and tract Anterolateral system

Hypoglossal nucleus
NuGr
Corticospinal fibers
Internal arcuate fibers NuCu
Spinal trigeminal tract
and nucleus Nucleus ambiguus Inferior olivary complex
(principal nucleus)

Posterior spino-
cerebellar tract FCu
FGr
Lateral cortico-
spinal tract Medial lemniscus (ML)
Posterior spino-
cerebellar tract Py Pyramid (Py)

Medial lemniscus Anterior spinal artery

Posterior spinal artery (and arterial vasocorona in spinal cord)

Vertebral artery

Pyramidal decussation Posterior inferior cerebellar artery

Anterolateral
system Anterolateral system Anterior inferior cerebellar artery
Rubrospinal Vertebral artery plus paramedian branches of caudal portions
tract of basilar artery

6-16

125
 Transverse section through the dorsal aspects of the medulla at the level of the

126
6-17A cochlear nuclei and the cerebellar nuclei. The plane corresponds to about the
middle of the dentate nucleus and caudal portions of the globose and emboliform nuclei.
For additional details of the medulla at about this level, see Figure 6-14 on p. 120.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Cerebellar Nuclei
Fastigial nucleus, FNu
(medial cerebellar nucleus)

Globose nucleus, GNu

(posterior interposed cerebellar nucleus)

DNu FNu

Emboliform nucleus (ENu)

(anterior interposed
cerebellar nucleus)
GNu
Dentate nucleus, DNu
(lateral cerebellar nucleus)
Inferior medullary velum
Hilum of dentate nucleus
DNu

Uvula

Tonsil of cerebellum
(Ton)
Tela choroidea
Nodulus

Choroid plexus Posterior (dorsal)

cochlear nucleus
Lateral recess of
fourth ventricle
Restiform body
Anterior (ventral) (RB)
cochlear nucleus
Inferior (spinal)
vestibular nucleus
Spinal trigeminal tract Solitary nuclei and tract
Spinal trigeminal nucleus (pars oralis) Medial vestibular nucleus
Inferior salivatory nucleus
Medial longitudinal fasciculus (MLF)
Nucleus prepositus Tectospinal tract

Sensory
Posterior column/medial lemniscus system Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
(proprioception/vibratory sense, (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor)
discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 MLF
RB

Ton
DNu

ENu

GNu

MRI, T1-weighted image MRI, T2-weighted image

Anatomical orientation Clinical orientation

Inferior salivatory
nucleus, VE cells Cochlear nuclei,
SA input
6-17A, 6-17B

Solitary nucleus,
VA input
Vestibular nuclei,
SA input

The Cerebellar Nuclei

6-17B

127
 Transverse section through dorsal portions of the pons at the level of the

128
6-18A abducens nucleus (and facial colliculus) and through rostral portions of the
cerebellar nuclei. For additional details of the pons at this level, see Figure 6-19 on p. 130.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Fastigial nucleus, FNu
(medial cerebellar nucleus)
Globose nucleus, GNu
(posterior interposed
cerebellar nucleus)

Emboliform nucleus, ENu

(anterior interposed cerebellar
nucleus)
GNu Dentate nucleus (DNu)
(lateral cerebellar nucleus)
FNu
ENu

Superior cerebellar peduncle (SCP)

(brachium conjunctivum)

Juxtarestiform body (JRB) Inferior

Superior vestibular nucleus Abducens nucleus cerebellar
Restiform body (RB) peduncle

Medial vestibular nucleus

Superior salivatory nucleus Lateral vestibular nucleus (LVNu)

Spinal trigeminal tract

Spinal trigeminal nucleus Facial nerve

(pars oralis)

Facial nerve Facial motor nucleus

Central tegmental tract Abducens nerve
Medial longitudinal fasciculus (MLF)
Tectospinal tract

Sensory
Cranial
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral nerve
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nuclei

Motor
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
 MLF
LVNu
RB
JRB
SCP
DNu
ENu
GNu
FNu
MRI, T1-weighted image MRI, T2-weighted image

Anatomical orientation Clinical orientation

Superior salivatory Vestibular nuclei,

nucleus, VE cells SA input
Abducens nucleus, Spinal trigeminal
SE cells nucleus, SA input
6-18A, 6-18B
Facial motor nucleus, Solitary nuclei,
SE cells VA input

The Cerebellar Nuclei

6-18B

129
 Transverse section of the caudal pons through the facial motor nucleus, abdu-

130
6-19A cens nucleus (and facial colliculus), and the intramedullary course of fibers of
facial and abducens nerves.

Posterior longitudinal fasciculus Superior medullary velum

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Pons with MRI and CT
Abducens nucleus (AbdNu) Medial longitudinal fasciculus (MLF)
Tectospinal tract

Superior
vestibular Superior vestibular nucleus
nucleus

Superior
cerebellar Restiform body
peduncle (RB)
(SCP)

Facial nerve,
internal genu
Medial vestibular nucleus
(MVNu)
Mesencephalic tract
Juxtarestiform body and nucleus
Lateral vestibular nucleus Superior salivatory
(LVNu) nucleus, SSNu
Solitary nuclei and tract
SSNu Principal sensory nucleus
Spinal trigeminal tract Reticular formation
(SpTTr) Trigeminal motor nucleus
Spinal trigeminal nucleus Trigeminal nerve
(SpTNu)(pars oralis)
Anterior spinocerebellar
tract

Rubrospinal tract
Facial nerve
Medial
lemniscus Anterolateral system
(ML) (ALS)
Facial motor nucleus
(FacNu) Central tegmental tract

Lateral lemniscus Trapezoid body

and nuclei

Superior olive Pontocerebellar fibers

Pontine nuclei

Abducens nerve Pontine nuclei

Corticospinal fibers (CSp)

Degenerated corticospinal fibers

Ventral trigeminothalamic tract Nucleus raphe, magnus

Sensory
Post. column/med. lemniscus sys. Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, trigeminothalamic fibers (pain/ nerve
(somatomotor)
discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 CSp ML
ALS
FacNu
SpTTr+
SpTNu
RB
LVNu+MVNu
SCP
AbdNu
MLF
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Facial nucleus, Vestibular nuclei,

SE cells SA input
6-19A, 6-19B
Abducens nucleus, Spinal to principal
SE cells sensory nuclei,
SA input
Superior salivatory
nucleus, VE cells

The Pons with MRI and CT

6-19B

131
 Transverse section of the pons through the rostral pole of the facial nucleus

132
6-20A and the internal genu of the facial nerve and rostral portions of the abducens
nucleus.

Superior medullary velum

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Medial longitudinal fasciculus
Tectospinal tract Facial nerve, Internal genu
(Fac,G)

Mesencephalic nucleus
and tract
Superior
cerebellar
peduncle
(SCP)
Posterior longitudinal fasciculus Anterior spinocerebellar tract

Superior vestibular
nucleus (SVNu)
Abducens nucleus Principal sensory nucleus
(AbdNu) (caudal part)
Mesencephalic nucleus
and tract
Superior salivatory nucleus Trigeminal motor nucleus
Fac,G (caudal part)
Reticular
Spinal trigeminal nucleus formation Middle cerebellar peduncle
and tract (SpTNu + Tr)
(rostral end)
Facial nerve
Trigeminal nerve

Anterolateral system
Facial motor nucleus (ALS)
Medial lemniscus Rubrospinal tract
(ML)
Anterolateral system
Central tegmental tract

Pontine nuclei
Lateral lemniscus

Superior olive

Abducens nerve

Ventral trigeminothalamic tract Pontocerebellar fibers

Degenerated corticospinal fibers

Corticospinal fibers (CSP)

Trapezoid body
Pontine nuclei Nucleus raphe, magnus

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)

Motor
 CSp
ML
ALS
SpTTr+
SpTNu
SVNu
SCP
AbdNu+
Fac,G
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Facial motor nucleus,

SE cells Spinal trigeminal
nucleus, SA input
Abducens nucleus, 6-20A, 6-20B
SE cells
Vestibular nuclei,
SA input
Superior salivatory
nucleus, VE cells

The Pons with MRI and CT

6-20B

133
 Transverse section of the pons through the principal sensory nucleus and

134
6-21A motor nucleus of the trigeminal nerve.

Medial longitudinal fasciculus (MLF) Central grey (periventricular grey)

Superior medullary velum

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Posterior longitudinal fasciculus Mesencephalic nucleus (MesNu + Tr)
Tectospinal tract Mesencephalic tract

Superior cerebellar peduncle

(CP)
(brachium conjunctivum)

Anterior spinocerebellar tract

(ASCT)

Principal sensory nucleus Nucleus ceruleus

(PSNu)
Trigeminal motor nucleus Trigeminal motor nucleus
(TriMotNu)
Reticular formation Lateral lemniscus
Trigeminal nerve (TriNr)
Middle cerebellar peduncle
(brachium pontis)
Lateral lemniscus
Superior olive ASCT

Lateral lemniscus, nucleus Anterolateral system

Pontine nuclei (ALS)
Rubrospinal tract

Central tegmental tract

Pontine nuclei Ventral trigeminothalamic tract

Medial lemniscus (ML)

Pontocerebellar fibers
Reticulotegmental nucleus

Corticospinal fibers (CSP) Degenerated corticospinal fibers

Nucleus raphe, pontis

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)

Motor
 CSp
TriNr
ML
ALS
PSNu
TriMotNu
SCP
MesNu+Tr
MLF
Anatomical orientation Clinical orientation
MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Mesencephalic tract
Trigeminal motor and nucleus, SA cells
nucleus, SE cells Principal sensory
nucleus, SA input
6-21A, 6-21B

The Pons with MRI and CT

6-21B

135
 Transverse section of the rostral pons through the exit of the trochlear nerve

136
6-22A and rostral portions of the exit of the trigeminal nerve. See also Figure 6-21
on p. 134.
Cerebral aqueduct Frenulum
Central gray (periaqueductal gray)

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Nucleus raphe, dorsalis
Trochlear nerve, exit
Locus ceruleus
Dorsal trigeminothalamic tract Mesencephalic nucleus and tract (MesNu + Tr)

Superior cerebellar peduncle (SCP)

(brachium conjunctivum) Medial longitudinal fasciculus (MLF)

Central tegmental tract Reticular formation

Nucleus centralis, superior Lateral lemniscus and

nuclei of lateral lemniscus
Anterolateral system (ALS) Tectospinal tract

Medial lemniscus (ML)

Ventral
trigeminothalamic
tract Rubrospinal tract

Middle Cerebellar peduncle

(brachium pontis)
Pontine nuclei

Pontocerebellar
fibers

Trigeminal nerve

Basilar pons

Degenerated corticospinal fibers

Corticospinal fibers (CSP)

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)

Motor
 CSp

ML
ALS
SCP

MesNu+Tr
MLF
Anatomical orientation Clinical orientation
MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Mesencephalic tract
and nucleus, SA cells
6-22A, 6-22B

The Pons with MRI and CT

6-22B

137
 Vascular Syndromes or Lesions of the Pons Semi-diagrammatic representation of the internal distribution of arteries in the pons.

138
6-23 Selected main structures are labeled on the left side of each section; the general pat-
tern of arterial distribution overlies these structures on the right side. Some patients may have
Medial Pontine Syndrome
-
This results from occlusion of paramedian branches of basilar artery. ple, the adjacent territories served by vessels may overlap to differing degrees at their margins,
or the territory of a particular vessel may be smaller or larger than seen in the general

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—Arterial Patterns within the Pons
Deficit Structure Damage pattern.
Contralateral hemiplegia of UE, trunk, and
LE A B B R E V I AT I O N S
Contralateral loss or decrease of position
BP Basilar pons MLF
and vibratory sense and discriminative
CSp RB Restiform body (+ =
touch of UE, trunk, and LE
CTT Central tegmental tract inferior cerebellar peduncle)
Ipsilateral lateral rectus muscle paralysis MCP RetF Reticular formation
Paralysis of conjugate gaze toward side of (brachium pontis) SCP Superior cerebellar peduncle (brachium
lesion (pontine gaze center) ML conjunctivum)

The combination of corticospinal deficits on one side of the body coupled with a cranial Ipsilateral paralysis of facial muscles
nerve motor deficit on the opposite is called a middle alternating hemiplegia when the lesion is Ipsilateral paralysis of masticatory
at this level. Diplopia will result (abducens nerve lesion) on gaze toward the side of the lesion. muscles
Involvement of the abducens nucleus may also result in an inability to adduct the contralateral
Ipsilateral Horner syndrome
medial rectus muscle (damage to abducens internuclear neurons).
hypacusis), Ipsilateral loss of pain and thermal
parts of the middle cerebellar peduncle (some ataxia), the facial motor nucleus (ipsilateral facial sense from face
paralysis), the spinal trigeminal tract and nucleus (ipsilateral loss of pain and thermal sensation Contralateral loss of pain and thermal
from the face), and the anterolateral system (contralateral loss of pain and thermal sensation sense from UE, trunk, and LE
from the body). Paralysis of conjugate horizontal gaze
(at mid- to caudal levels)
contralateral loss of vibratory sense, proprioception,
and discriminative touch), the motor nucleus of the trigeminal nerve (ipsilateral paralysis of
masticatory muscles), or may damage the anterolateral system and rostral portions of the spinal
trigeminal tract and nucleus (loss of pain and thermal sensation from the body [contralateral] located in lateral pontine areas at caudal levels versus lateral pontine areas at rostral levels.
and from the face [ipsilateral]).
Lesions in the medial pontine areas, especially at more caudal levels, may be known as
the Foville syndrome or Raymond syndrome the section on medial pontine syndrome.
different but they may be used interchangeably. See Table 3-2 on p. 54 for more information on Lesions that damage more lateral pontine areas generally are referred to as the Gubler syn-
this point. drome (or the Millard-Gubler syndrome, although Gubler is preferred). In some instances, the
term midpontine base syndrome is used to describe a basilar pontine lesion that involves the
Lateral Pontine Syndrome trigeminal root as well. Occlusion of the basilar artery may result in a locked-in-syndrome. This

This results from occlusion of the long circumferential branches of the basilar artery. while sparing most of the major ascending sensory pathways in the brainstem. While the patient
Deficit Structure Damage -
ments of the eyelids and/or eyes.
lesion (caudal and rostral levels)
Vertigo, nausea, nystagmus, deafness,
tinnitus, vomiting (at caudal levels)
 Rostral Mesencephalic nucleus and tract
Trochlear nerve
Medial longitudinal fasciculus (MLF)

Lateral lemniscus
Superior medullary velum

Fourth ventricle Anterolateral system SCP

Trigeminal nuclei:
Mesencephalic
Motor SCP
Caudal ML
Principal sensory

Trigeminal nerve MCP

Vestibular nuclei
RetF CSp

Spinal trigeminal
nucleus Anterolateral system CTT
Abducens nucleus BP
MLF ML
RB

Arterial Patterns within the Pons with Vascular Syndromes

Spinal trigeminal
tract
MCP

Facial nerve

Facial motor nucleus

ML
Anterolateral system

Paramedian branches of basilar artery

Ventral trigeminothalamic fibers Long circumferential branches of basilar
Abducens nerve artery and branches of anterior inferior
CSp cerebellar artery
Short circumferential branches of basilar
artery
Long circumferential branches of basilar
Basilar pons (BP) artery and branches of superior
cerebellar artery

6-23

139
 Transverse section of the brainstem at the pons–midbrain junction through

140
6-24A the inferior colliculus, caudal portions of the decussation of the superior cer-
ebellar peduncle, and rostral parts of the basilar pons. The plane of section is just caudal to
the trochlear nucleus. IC = inferior colliculus on the cisternogram; the T1 and T2 are at a
slightly different plane of section.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Midbrain with MRI and CT
Inferior colliculus, commissure
Inferior colliculus, pericentral nucleus Central gray (periaqueductal gray)

Inferior colliculus (IC), central nucleus Cerebral aqueduct

Posterior longitudinal fasciculus

Lateral lemniscus Nucleus raphe, dorsalis

Inferior colliculus, external nucleus

Mesencephalic nucleus and tract
(MesNu + Tr)
Reticular formation
Nucleus ceruleus
Trochlear nerve
Medial longitudinal fasciculus (MLF)
Dorsal trigeminothalamic tract
Central tegmental tract
Anterolateral system (ALS)
Superior cerebellar
Ventral trigeminothalamic tract peduncle (SCP), decussation Tectospinal tract

Medial lemniscus (ML)

Nucleus centralis, superior

Rubrospinal tract

Parietopontine fibers
Occipitopontine fibers
Crus cerebri Temporopontine fibers

Pontocerebellar fibers

Corticospinal fibers (CSp)

Pontine nuclei

Degenerated corticospinal fibers

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 CSp

ML
ALS
SCP

MesNu+Tr IC
MLF

MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Anatomical orientation Clinical orientation

Mesencephalic tract
and nucleus, SA cells
6-24A, 6-24B

The Midbrain with MRI and CT

6-24B

141
 Transverse section of the brainstem showing structures specifically character-

142
6-25A istic of the level of the inferior colliculus. These include the nuclei of the infe-
rior colliculus, trochlear nucleus, decussation of the superior cerebellar peduncle, caudal
aspects of the substantia nigra, and the crus cerebri. The plane of section also includes the
most rostral tip of the basilar pons.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Inferior colliculus, commissure

Inferior colliculus, pericentral nucleus

Inferior colliculus, external nucleus
Central gray (periaqueductal gray)
Inferior colliculus (IC), central nucleus
Inferior colliculus, brachium
Lateral lemniscus
Cerebral aqueduct
Nucleus raphe, dorsalis
Posterior longitudinal fasciculus
Dorsal trigeminothalamic tract Mesencephalic nucleus and tract (MesNu+Tr)
Anterolateral system Nucleus ceruleus
Reticular formation Trochlear nucleus (TroNu)
Central tegmental tract Anterolateral system (ALS)

Ventral trigeminothalamic tract Medial longitudinal fasciculus (MLF)

Tectospinal tract
Medial lemniscus (ML)
Medial lemniscus (ML)
PPon Superior cerebellar
OPon peduncle, decussation
(SCPDec)
TPon Parietopontine fibers (PPon)
Occipitopontine fibers (OPon)
Temporopontine fibers (TPon)
SNpc

Corticospinal
fibers (CSp) u)
N
(C s)
s
er er
ib ib
a r f ar f
le lb
Crus cerebri uc bu
c on tico
ti r Corticospinal and corticonuclear fibers
or co FPon
C (

Substantia nigra, pars compacta (SNpc)

Rostral tip,
basilar pons Frontopontine fibers (FPon)

Rubrospinal tract
Blood vessels Interpeduncular nucleus

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)

Motor
 SCPDec
CSp+CNu

SN
ML
ALS
TroNu+MLF
IC
MesNu+Tr
Anatomical orientation Clinical orientation
MRI, T1-weighted image MRI, T2-weighted image

Trochlear nucleus,
SE cells
6-25A, 6-25B

Mesencephalic tract
and nucleus, SA cells

The Midbrain with MRI and CT

6-25B

143
 Transverse section of the midbrain through the trochlear nucleus and decus-

144
6-26A sation of the superior cerebellar peduncle. The section also includes caudal
parts of the superior colliculus and the rostral tip of the basilar pons. IC = inferior collicu-
lus on the T1-weighted MRI; at the plane of this section, the T2-weighted MRI and cister-
nogram are at a slightly more caudal plane compared to the line drawing.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Cerebral aqueduct

Posterior longitudinal fasciculus

Central gray (periaqueductal gray)

Superior colliculus Nucleus raphe, dorsalis

Trochlear nucleus (TroNu)

Inferior colliculus, brachium

Mesencephalic nucleus and tract

(MesNu + Tr)

Spinotectal fibers
Reticular formation
Anterolateral
system (ALS)
Dorsal trigeminothalamic tract Spinothalamic fibers

Medial longitudinal fasciculus (MLF)

Tectospinal tract
Central tegmental tract
Medial lemniscus (ML)

Ventral trigeminothalamic tract

Superior cerebellar
peduncle, decussation
(SCPDec) Substantia nigra (SN),
pars compacta
PPon
OPon
TPon

Parietopontine fibers (PPon)

Occipitopontine fibers (OPon)
Temporopontine fibers (TPon)
)

Corticospinal
rs) Nu

Crus cerebri fibers (CSp)

ibe (C
r f rs
lba ibe
bu r f
co a
r ti ucle

Degenerated corticospinal fibers

(cocon

FPon
r ti
Co

Frontopontine fibers (FPon)

Interpeduncular nucleus
Interpeduncular fossa
Rubrospinal tract

Sensory
Pontine nuclei

Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/ nerve
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head) nuclei

Motor
 CSp+CNu
SN
ML
ALS
SCPDec
IC
MesNu+Tr
TroNu+MLF
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Trochlear nucleus, Mesencephalic tract

SE cells and nucleus, SA cells
6-26A, 6-26B

The Midbrain with MRI and CT

6-26B

145
 Transverse section of the midbrain through the superior colliculus, caudal

146
6-27A parts of the oculomotor nucleus, and caudal parts of the red nucleus. The
plane of section is caudal to the Edinger-Westphal complex but includes rostral portions of
the decussation of the superior cerebellar peduncle, which, at this level, are intermingled
with the caudal part of the red nucleus. (LE = lower extremity; UE = upper extremity.) At
this level, spinothalamic fibers are the main constituents of the bundle indicated as the ante-

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

rolateral system at lower levels.
Cerebral aqueduct

Posterior longitudinal fasciculus

Central gray (periaqueductal gray)
Oculomotor nucleus (OcNu)
Superior colliculus

Mesencephalic nucleus and tract (MesNu + Tr)

Dorsal trigeminothalamic tract
Spinotectal tract

Reticular formation Medial longitudinal fasciculus (MLF)

Inferior colliculus, brachium Spinothalamic fibers

(SpThF)

Ventral trigeminothalamic tract Central tegmental tract

Medial geniculate nucleus

Posterior (dorsal)
tegmental decussation

Medial
Pallidonigral fibers lemniscus
(ML) Red nucleus
Nigrostriatal fibers
Corticonigral fibers Substantia nigra
pars compacta (SNpc)

SNpc Substantia nigra

pars reticulata (SNpr)
PPon
OPon
Crus cerebri TPon
SNpr Parietopontine fibers (PPon)
LE
Occipitopontine fibers (OPon)
Trunk Temporopontine fibers (TPon)
)
s) u
er N

UE
fib s (C

Degenerated corticospinal fibers

ar er
ulb fib

Corticospinal Superior cerebellar peduncle, decussation

ob ar

(SCPDec)
tic le

fibers (CSp)
or uc

FPon
(c con

Frontopontine fibers (FPon)

r ti
Co

Rubrospinal tract
Anterior (ventral) tegmental decussation
Red nucleus (RNu),
caudal aspect
Interpeduncular nucleus
Oculomotor nerve

Sensory
Post. column/med. lemniscus sys. Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers
(proprioception/vibratory sense, (pain/thermal sense, trigeminothalamic fibers (pain/ nerve
(somatomotor)
touch from body) thermal sense, touch from head) nuclei

Motor
discriminative touch)
 SCPDec
+RNu
CSP+CNu
SN
ML
SpThF
OcNu+MLF
MesNu+Tr

Anatomical orientation Clinical orientation

MRI, T1-weighted image MRI, T2-weighted image CT cisternogram

Oculomotor nucleus, Mesencephalic

SE cells nucleus, SA cells
6-27A, 6-27B

The Midbrain with MRI and CT

6-27B

147
 Transverse section of the midbrain through the superior colliculus, rostral

148
6-28A portions of the oculomotor nucleus, including the Edinger-Westphal complex,
and the exiting fibers of the oculomotor nerve. The plane of this section is also through cau-
dal portions of the diencephalon including the pulvinar nuclear complex and the medial and
lateral geniculate nuclei. LE = lower extremity; UE = upper extremity; CC = crus cerebri;
OpTr = optic tract.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Cerebral aqueduct
Superior colliculus, commissure Posterior longitudinal fasciculus
Central grey (periaqueductal grey)
Superior colliculus (SC)
Edinger-Westphal preganglionic nucleus (EWpgNu)
Edinger-Westphal centrally projecting nucleus Spinotectal tract
Mesencephalic tract and nucleus (MesNu + Tr)

Superior colliculus, brachium

Dorsal trigeminothalamic tract
Pulvinar nuclear
complex
Ventral trigeminothalamic tract

Spinothalamic fibers
(SpThF) Inferior colliculus, brachium

Lateral Medial geniculate Peripeduncular nucleus

geniculate nucleus
nucleus (MGNu)
(LGNu)
Medial
lemniscus
(ML) PPon Red nucleus
(RNu)

pc
OPon

SN
pr
Optic tract
TPon SN Parietopontine fibers (PPon)
Occipitopontine fibers (OPon)
Temporopontine fibers (TPon)

Corticonigral fibers LE
Pallidonigral fibers Trunk Degenerated corticospinal fibers
Nigrostriatal fibers UE

Corticospinal fibers (CSp) FPon Cerebellorubral fibers and

cerebellothalamic fibers

Central tegmental tract

Corticonuclear fibers (CNu)
(corticobulbar fibers) Medial longitudinal fasciculus (MLF)

Substantia nigra,
pars reticulata (SNpr) Frontopontine fibers (FPon)
Habenulopeduncular tract
Substantia nigra,
pars compacta (SNpc) Oculomotor nuclei (OcNu)
Oculomotor nerve

Sensory
Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)

Motor
 RNu
OpTr
CSp+CNu
SN
ML Crus
SpThF cerebri

OcNu+MLF
+EWpgNu
SC
MesNu+Tr
SC
Anatomical orientation Clinical orientation MRI, T1-weighted image MRI, T2-weighted image

RNu
CC
ML
LGNu
MGNu

SpThF
SC
OcNu+MLF+EWpgNu
MRI, T1-weighted image MRI, T2-weighted image

Edinger-Westphal
preganglionic
nucleus, SE cells
6-28A, 6-28B
Oculomotor nucleus,
SE cells Mesencephalic tract
and nucleus, SA cells

The Midbrain with MRI and CT

6-28B

149
 Slightly oblique section through the midbrain–diencephalon junction. The

150
6-29A section passes through the posterior commissure, the rostral end of the red
nucleus, and ends just dorsal to the mammillary body. At this level, the structure labeled
mammillothalamic tract probably also contains some mammillotegmental fibers. Struc-
tures at the midbrain–thalamus junction are best seen in an MRI angled to accommodate
that specific plane. To make the transition from drawing to stained section to MRI easy,

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

selected structures in the MRI are labeled.
Dorsal
trigeminothalamic tract
Cerebral aqueduct

Central grey (periaqueductal grey)

Pineal Nucleus of Darkschewitsch

Nucleus of Cajal
Pulvinar nuclear complex (Pul)
Superior
colliculus Medial longitudinal fasciculus

Central tegmental tract Brachium of

Medial superior colliculus
Pretectal Posterior geniculate
nuclei commissure nucleus (MGNu)
Spinothalamic fibers

Lateral geniculate
nucleus (LGNu)
Ventral trigemino-
thalamic tract Medial lemniscus

Peripeduncular nucleus Cerebellorubral fibers and

Red nucleus Cerebellothalamic fibers
Parietopontine fibers (RNu)
Occipitopontine fibers Transition from
Temporopontine fibers crus cerebri (CC) to
Optic internal capsule
Corticospinal tract
fibers (OpTr)

Corticonuclear fibers Subthalamic nucleus

(corticobulbar fibers)
Frontopontine fibers Supraoptic nucleus
Habenulopeduncular tract
Fornix (F)
Hypothalamus
Mammillothalamic tract (MTTr)
Third ventricle

Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral

Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)

6-29A
 OpTr

F, MTTr
OpTr
CC
LGNu
RNu MGNu
Pul Pul
Anatomical orientation Clinical orientation MRI, T2-weighted image MRI, inversion recovery

The Midbrain with MRI and CT

6-29B

151
 Vascular Syndromes or Lesions of the Midbrain
Medial Midbrain (Weber) Syndrome
This may result from occlusion of the paramedian branches of the P1 segment of the posterior
cerebral artery (PCA).
Deficit Structure Damage
Contralateral hemiplegia of UE, trunk, and LE
Ipsilateral paralysis of eye movement: eye oriented
down and out and pupil dilated and fixed
This combination of motor deficits at this level of the brainstem is called a superior alter-
nating hemiplegia. This pattern consists of ipsilateral paralysis of eye movement (with pupil
dilation) and contralateral hemiplegia of the upper and lower extremities. Damage to the corti-
conuclear (corticobulbar) fibers in the crus cerebri may result in a partial deficit in tongue and
facial movement on the contralateral side. These cranial nerve deficits are seen as a deviation of
the tongue to the side opposite the lesion on protrusion and a paralysis of the lower half of the
facial muscles on the contralateral side. Although parts of the substantia nigra are frequently
involved, akinesia and dyskinesia are not frequently seen.
Central Midbrain Lesion (Claude Syndrome)
Deficit Structure Damage
Ipsilateral paralysis of eye movement: eye oriented
down and out and pupil dilated and fixed
Contralateral ataxia and tremor of cerebellar origin
fibers
The lesion in this syndrome may extend laterally into the medial lemniscus and the dorsally
adjacent ventral trigeminothalamic fibers. If this was the case, there could conceivably be a loss
or diminution of position and vibratory sense and of discriminative touch from the contralateral
arm and partial loss of pain and thermal sensation from the contralateral face.
Benedikt Syndrome
This results from a larger lesion of the midbrain that essentially involves both of the sepa-
rate areas of Weber and Claude. The main deficits are contralateral hemiplegia of the extremi-
ties (corticospinal fibers), ipsilateral paralysis of eye movement with dilated pupil (oculomotor
nerve), and cerebellar and rubral tremor and ataxia (red nucleus and cerebellothalamic fibers).
Slight variations may be present based on the extent of the lesion.
Parinaud Syndrome
This syndrome is usually caused by a tumor in the pineal region, such as germinoma, astrocy-
toma, pineocytoma/pineoblastoma, or any of a variety of other tumors that impinge on the supe-
rior colliculi. The potential for occlusion at the cerebral aqueduct in these cases also indicates
that hydrocephalus may be a component of this syndrome. The deficits in these patients consist
Semi-diagrammatic representation of the internal distribution of arteries in the mid-
152
6-30 brain. Selected main structures are labeled on the left side of each section; the typical
pattern of arterial distribution overlies these structures on the right side. The general distribu-
tion patterns of the vessels to the midbrain, as shown here, may vary somewhat from patient to
patient. For example, the adjacent territories served by neighboring vessels may overlap to dif-
fering degrees at their margins, or the territory of a particular vessel may be larger or smaller
6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—Arterial Patterns within the Midbrain
than seen in the general pattern.
A B B R E V I AT I O N S
BP Basilar pons MGNu Medial geniculate nucleus
CC Crus cerebri ML Medial lemniscus
DecSCP Decussation of the superior RNu Red nucleus
cerebellar peduncle SC Superior colliculus
IC Inferior colliculus SCP Superior cerebellar peduncle
LGNu Lateral geniculate nucleus SN Substantia nigra
of a paralysis of upward gaze (superior colliculi), hydrocephalus (occlusion of the cerebral aque-
duct), and eventually a failure of eye movement due to pressure on the oculomotor and trochlear
nuclei. These patients also may exhibit nystagmus due to involvement of the medial longitudinal
fasciculus.
Uncal Herniation
Herniation of the uncus occurs in response to large and/or rapidly expanding lesions most fre-
quently in the temporal lobe; this is a supratentorial location. Uncal herniation is an extru-
sion of the uncus through the tentorial notch (tentorial incisura) with resultant pressure on
the oculomotor nerve and the crus cerebri. Initially, the pupils, unilaterally or bilaterally, may
dilate or respond slowly to light, followed by weakness of oculomotor movement. As herniation
progresses, the pupils become fully dilated, oculomotor movements may be slow or absent, and
the eyes deviate slightly laterally because of the unopposed actions of the abducens nerves. There
is usually weakness on the contralateral side of the body due to compression of corticospinal
fibers in the crus cerebri. This combination of ipsilateral oculomotor palsy and a contralateral
hemiplegia is also known as a superior alternating hemiplegia.
An alternative situation is when the pressure from the uncal herniation shifts the entire mid-
brain to the opposite side. In this case, the oculomotor root may be stretched or avulsed on the
side of the herniation (the ipsilateral side), and the crus cerebri on the contralateral impaled
against the edge of the tentorium cerebelli with consequent damage to corticospinal fibers within
the crus. This patient presents with an oculomotor palsy and a hemiplegia of the UE and LE
both on the same side of the body. This combination of deficits is called the Kernohan syndrome
(or Kernohan phenomenon).
Especially large, or bilateral, supratentorial lesions may also result in decorticate rigidity
(flexion of forearm, wrist, and fingers with adduction of UE; extension of LE with internal
rotation and plantar flexion of foot). As the lesion descends through the tentorial notch into
an infratentorial location, decorticate rigidity gives rise to decerebrate rigidity (UE and LE
extended, toes pointed inward, forearm pronated, and head and neck extended—opisthotonos).
 Edinger-Westphal preganglionic nucleus
Edinger-Westphal centrally projecting nucleus

Oculomotor nucleus

Anterolateral system
Rostral
SC
Ventral trigeminothalamic
fibers MGNu

LGNu
Oculomotor nerve
Mesencephalic nucleus
Trochlear nucleus ML
IC
Caudal Medial longitudinal fasciculus SN RNu

Anterolateral system
Cerebral aqueduct Ventral trigeminothalamic
fibers ML
CC

Arterial Patterns within the Midbrain with Vascular Syndromes

Periaqueductal gray

Lateral lemniscus DecSCP

Anterolateral SN
system

CC
SCP
ML

CC Anteromedial (paramedian) branches of basilar bifurcation

and P1 segment

Anterolateral (short circumferential) branches of the

quadrigeminal and medial posterior choroidal arteries

Lateral branches of quadrigeminal (level of inferior colliculus),

quadrigeminal and posterior medial choroidal arteries (level
of superior colliculus)
BP
Medial longitudinal fasciculus Quadrigeminal and superior cerebellar arteries (level of
inferior colliculus), quadrigeminal and posterior medial
choroidal arteries (level of superior colliculus)
Interpeduncular fossa
Thalamogeniculate artery

6-30

153
 Coronal section of forebrain through the splenium of the corpus callosum

154
6-31A and the crus of the fornix, and extending into the inferior colliculus and exit
of the trochlear nerve. Many of the structures labeled in this figure can be identified easily
in the T1-weighted MRI adjacent to the photograph.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—The Diencephalon and Basal Nuclei with MRI
Cingulate gyrus

Medial longitudinal stria Cingulum

of indusium griseum
Lateral longitudinal stria
Hippocampal commissures

Atrium of lateral ventricle

Tapetum

Caudate
nucleus, body

Choroid plexus
Corpus callosum,
splenium

Optic radiations Caudate

nucleus

Stria terminalis
Fornix, crus
Pulvinar Pineal
Caudate
nucleus, tail
Inferior colliculus
Superior cistern
Fimbria of
hippocampus
Hippocampal
formation

Lateral ventricle,
inferior horn

Cerebellum

Trochlear nerve Superior cerebellar peduncle

The Diencephalon and Basal Nuclei with MRI 155
6-31B
 Coronal section of the forebrain through the pulvinar and the medial and

156
6-32A lateral geniculate nuclei. The section extends into upper portions of the
midbrain tegmentum. Many of the structures labeled in this figure can be easily identified in
the T1-weighted MRI adjacent to the photograph.

Cingulate gyrus

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Cingulum
Medial longitudinal stria Lateral longitudinal stria
of indusium griseum

Choroid plexus
Fornix, body
External medullary lamina
Lateral ventricle, body

Caudate nucleus, body

Insula
Stria terminalis (StTer)

Corpus callosum,
Medial body
geniculate
nucleus

Inferior pulvinar Pulvinar

nucleus nuclear
Superior cistern Medial complex Internal capsule
nucleus
Retrolenticular limb
Optic radiations Lateral Sublenticular limb
nucleus
Lateral
geniculate
nucleus
Hippocampus,
StTer and bed fimbria of
nucleus

Caudate
nucleus, tail

Hippocampal
formation
Alveus of
hippocampus

Lateral ventricle,
inferior horn

Superior colliculus, brachium Central grey (periaqueductal grey)

Inferior colliculus, brachium Trochlear nucleus

Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral Sensory Cranial
Corticospinal fibers nerve
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor) Motor nuclei
sense, discriminative touch) touch from body) thermal sense, touch from head)
The Diencephalon and Basal Nuclei with MRI 157
6-32B
 Slightly oblique section of the forebrain through the pulvinar, ventral postero-

158
6-33A medial, and ventral posterolateral nuclei .The section extends rostrally
through the subthalamic nucleus and ends in the caudal hypothalamus, just dorsal to the
mammillary bodies, as seen by the position of the (postcommissural) fornix.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Habenulopeduncular tract
Habenular commissure
Habenular nucleus
Pulvinar
nuclear
complex

Centromedian nucleus of thalamus

Lateral
nucleus Medial Pineal
nucleus

Ventral posterolateral
nucleus of thalamus Third
ventricle

Dorsomedial
nucleus of
thalamus
Ventral posteromedial
nucleus of thalamus Internal capsule,
posterior limb

Globus pallidus:
Lateral segment
Medial segment

Subthalamic
nucleus

Zona incerta

Lenticular fasciculus Ansa lenticularis

Column of fornix
Thalamic fasciculus Anterior commissure

Mammillothalamic tract Hypothalamus

Posterior column/medial lemniscus Anterolateral system Spinal trigeminal and/or ventral

Corticospinal fibers
system (proprioception/vibratory (pain/thermal sense, trigeminothalamic fibers (pain/
(somatomotor)
sense, discriminative touch) touch from body) thermal sense, touch from head)
The Diencephalon and Basal Nuclei with MRI 159
6-33B
 Coronal section of the forebrain through the lateral dorsal nucleus, massa

160
6-34A intermedia, and subthalamic nucleus. Many of the structures labeled in this
figure can be easily identified in the T1-weighted MRI adjacent to the photograph.

Medial longitudinal stria

of indusium griseum
Cingulate gyrus

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Lateral longitudinal stria
Cingulum
Fornix, body Corpus callosum, body

Lateral ventricle, body

Stria medullaris thalami

Caudate nucleus, body
Lateral dorsal nucleus of thalamus

Stria terminalis (StTer)

Internal medullary lamina

Choroid plexus
Internal capsule, External medullary lamina and
posterior limb thalamic reticular nucleus

Insula
Extreme capsule

Claustrum Dorsomedial Ventral lateral

Putamen nucleus nucleus
External capsule

Globus pallidus: Thalamic fasciculus

Lateral segment
Zona incerta
Medial segment
Red
nucleus Lenticular fasciculus

Optic tract
Subthalamic nucleus
Caudate
nucleus, tail
StTer
Crus
cerebri
Lateral ventricle,
inferior horn Substantia nigra

Hippocampal formation

Alveus of hippocampus
Basilar pons

Cerebellothalamic fibers Posterior cerebral artery

Crus cerebri

Corticospinal fibers
(somatomotor)
The Diencephalon and Basal Nuclei with MRI 161
6-34B
 Coronal section of the forebrain through the anterior nucleus of the thalamus

162
6-35A and mammillary body. Many of the structures labeled in this figure can be
easily identified in the T1-weighted MRI. lat. = Lateral segment; med. = Medial segment.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Cingulate gyrus Cingulum
Medial longitudinal stria Corpus callosum, body

Lateral longitudinal stria

of indusium griseum
Lateral ventricle, body
Fornix, body
Choroid plexus
Caudate nucleus, body
Stria medullaris thalami

Stria terminalis Dorsomedial nucleus of

thalamus

Anterior nucleus External medullary lamina and

thalamic reticular nucleus

Internal capsule,
posterior limb Internal medullary lamina

Extreme capsule Ventral lateral

nucleus Thalamic fasciculus
Putamen
Claustrum lat. Zona incerta
Third ventricle
External capsule
Lenticular fasciculus
Globus
Insula pallidus
med.
Subthalamic nucleus
Optic tract

Amygdaloid
nuclear
complex

Lateral ventricle,
inferior horn

Mammillothalamic tract

Mammillary body
Hippocampal formation Alveus of hippocampus
Posterior hypothalamus
Corticospinal fibers
(somatomotor)
The Diencephalon and Basal Nuclei with MRI 163
6-35B
 Slightly oblique section of the forebrain through the anterior nucleus of the

164
6-36A thalamus and the subthalamic nucleus. The section also includes the rostral
portion of the midbrain tegmentum. Many of the structures labeled in this figure can be
easily identified in the T1-weighted MRI adjacent to the photograph. VL = ventral lateral
nucleus of thalamus; VA = ventral anterior nucleus of thalamus.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Stria medullaris thalami
Caudate
nucleus, body Anterior nucleus

Fornix, body
Choroid plexus
Lateral ventricle, body
Stria terminalis
Mammillothalamic
tract Corpus callosum, Internal medullary lamina
body

Internal capsule,
posterior limb
External medullary
lamina and
thalamic reticular
External capsule nucleus

Ventral lateral
Claustrum Putamen nucleus
Dorsomedial
Globus pallidus, VL to VA nucleus
lateral segment transition
Extreme capsule
Third Cerebellorubral fibers and
Thalamic ventricle Red nucleus cerebellothalamic fibers
fasciculus Zona
Lenticular incerta
fasciculus Lateral geniculate
nucleus
Subthalamic
nucleus

Optic tract
Caudate Crus cerebri
nucleus, tail

Lateral ventricle, Corticonigral fibers

inferior horn Pallidonigral fibers
Nigrostriatal fibers

Hippocampus Substantia nigra Oculomotor nerve

The Diencephalon and Basal Nuclei with MRI 165
6-36B
 Coronal section of the forebrain through the interventricular foramen, genu
6-37A

166
of the internal capsule, rostral tip of the dorsal thalamus, and about the mid-
dle third of the hypothalamus. Many of the structures labeled in this figure can be easily
identified in the T1-weighted MRI adjacent to the photograph.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Medial longitudinal stria Cingulate gyrus

Lateral longitudinal stria

of indusium griseum Septum pellucidum

Fornix, column

Corpus callosum, Choroid plexus

body
Caudate nucleus, head

Interventricular foramen

Lateral ventricle

Claustrum
Extreme capsule
Internal capsule,
External capsule genu
Insula
Putamen Stria terminalis Anterior
nucleus
Ventral anterior nucleus

Globus pallidus:
Third
Lateral segment ventricle Lenticular fasciculus
Medial segment

Fornix, column

Anterior commissure Ansa lenticularis

Basal nucleus
Ventral amygdalofugal of Meynert
fibers

Supraoptic
decussation Lateral hypothalamic
area
Optic tract
Arcuate
Amygdaloid nucleus (complex) Dorsomedial Hypothalamic
Ventromedial nuclei
Supraoptic
The Diencephalon and Basal Nuclei with MRI 167
6-37B
 Coronal section of the forebrain through the anterior commissure and rostral

168
6-38A aspects of the hypothalamus. Many of the structures labeled in this figure can
be identified easily in the T1-weighted MRI.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Cingulate gyrus
Medial longitudinal stria
of indusium griseum Cingulum

Lateral longitudinal stria

Septum pellucidum
Septal nuclei

Caudate nucleus, head Fornix, column

Corpus callosum,
body
Stria terminalis

Internal capsule, Anterior commissure

genu to anterior limb

Lateral ventricle,
anterior horn
Claustrum

Extreme capsule

Putamen
External capsule
Globus pallidus,
lateral segment

Insula

Diagonal band
(of Broca)
Basal nucleus of Meynert
Lateral olfactory
stria Supraoptic nucleus

Uncus Preoptic area

Optic tract of hypothalamus Anterior perforated
substance
Amygdaloid nucleus Supraoptic decussation

Infundibulum
Third ventricle
The Diencephalon and Basal Nuclei with MRI 169
6-38B
 Coronal section of the forebrain through the head of the caudate nucleus,

170
6-39A rostral portions of the optic chiasm, and the nucleus accumbens. Many of the
structures labeled in this figure can be easily identified in the T1-weighted MRI adjacent to
the photograph.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Anterior cerebral Cingulate gyrus
arteries Cingulum

Lateral longitudinal stria

Medial longitudinal stria

of indusium griseum

Corpus callosum, body

Internal capsule,
anterior limb
Lateral ventricle,
anterior horn

Caudate nucleus,
head

Septum
pellucidum
Insula

Extreme capsule
Putamen

External capsule
Globus pallidus,
lateral segment

Claustrum Nucleus accumbens

Medial
Optic chiasm olfactory
stria

Lateral olfactory stria

Diagonal band (of Broca) Paraterminal gyrus Middle cerebral artery

Anterior cerebral artery

The Diencephalon and Basal Nuclei with MRI 171
6-39B
 Coronal section of the forebrain through the head of the caudate nucleus and

172
6-40A the anterior horn of the lateral ventricle. Many of the structures labeled in
this figure can be identified easily in the T1-weighted MRI adjacent to the photograph.

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections

Anterior cerebral arteries
Cingulate gyrus Cingulum

Lateral longitudinal stria

Medial longitudinal stria
of indusium griseum

Corpus callosum, body

External capsule
Corpus callosum, rostrum Lateral ventricle, Extreme capsule
anterior horn

Caudate nucleus,
Septum head
pellucidum
Internal capsule,
anterior limb

Putamen
Claustrum

Subcallosal gyrus

Olfactory sulcus

Orbital gyri
Olfactory tract
Anterior cerebral arteries
Gyrus rectus (straight gyrus)
The Diencephalon and Basal Nuclei with MRI 173
6-40B
 Vascular Syndromes or Lesions of the Forebrain Semi-diagrammatic representation of the internal distribution of arteries to the dien-

Forebrain vascular lesions result in a wide range of deficits that include motor and sensory losses
and a variety of cognitive disorders. Forebrain vessels may be occluded by a thrombus. This is
a structure (usually a clot) formed by blood products and frequently attached to the vessel wall.
174
6-41 cephalon, basal nuclei, and internal capsule. Selected structures are labeled on the left
side of each section; the general pattern of arterial distribution overlies these structures on the
right side. The general distribution patterns of arteries in the forebrain, as shown here, may
vary from patient to patient. For example, the adjacent territories served by neighboring vessels
may overlap to varying degrees at their margins or the territory of a particular vessel may be

6: Internal Morphology of the Spinal Cord and Brain in Stained Sections—Arterial Patterns within the Forebrain
Deficits may appear slowly, or wax and wane, as the blood flow is progressively restricted.
Vessels may also be occluded by embolization. A foreign body, or embolus (fat, air, piece of larger or smaller than seen in the general pattern.
thrombus, piece of sclerotic plaque, clump of bacteria, etc.), is delivered from some distant site
A B B R E V I AT I O N S
into the cerebral circulation where it lodges in a vessel. Because this is a sudden event, deficits
usually appear quickly and may progress rapidly. Interruption of blood supply to a part of the APS Anterior perforated substance HyTh Hypothalamus
forebrain results in an infarct of the area served by the occluded vessel. BCorCl Body of corpus callosum PulNu Pulvinar nuclear complex
CC Crus cerebri Put Putamen
Lesion in the Subthalamic Nucleus CM Centromedian nucleus of SplCorCl Splenium of the corpus callosum
Small vascular lesions occur in the subthalamic nucleus, resulting in rapid and unpredictable flailing thalamus VA Ventral anterior nucleus of
movements of the contralateral extremities (hemiballismus). Movements are more obvious in the DMNu Dorsomedial nucleus of thalamus
upper extremity than in the lower extremity. The clinical expression of this lesion is through corti- thalamus VL Ventral lateral nucleus of
cospinal fibers; therefore, these deficits are located on the side of the body contralateral to the lesion. GP Globus pallidus thalamus

Occlusion of Lenticulostriate Branches to Internal Capsule Anterior Choroidal Artery Syndrome

Damage to the internal capsule may result in contralateral hemiplegia (corticospinal fibers) and a
loss, or diminution, of sensory perception (pain, thermal sense, proprioception) caused by dam-
age to thalamocortical fibers traversing the posterior limb to the overlying sensory cortex. If the
lesion extends into the genu of the capsule (damaging corticonuclear fibers), a partial paralysis
of facial muscles and tongue movement may also occur contralaterally.
Infarction of Posterior Thalamic Nuclei
Occlusion of vessels to posterior thalamic regions results in either a complete sensory loss (pain/
thermal sense, touch, and vibratory and position sense) on the contralateral side of the body or
a dissociated sensory loss. In the latter case, the patient may experience pain/thermal sensory
losses but not position/vibratory losses, or vice versa. As the lesion resolves, the patient may
experience intense persistent pain, thalamic pain, or anesthesia dolorosa.
Occlusion of Distal Branches of the Anterior or Middle Cerebral Arteries
Occlusion of distal branches of the anterior cerebral artery (ACA) results in motor and sensory losses
in the contralateral foot, leg, and thigh owing to damage to the anterior and posterior paracentral
gyri (primary motor and sensory cortices for the lower extremity). Occlusion of distal branches of the
middle cerebral artery (MCA) results in contralateral motor and sensory losses of the upper extrem-
ity, trunk, and face with sparing of the leg and foot, and a consensual deviation of the eyes to the ipsi-
lateral side. This represents damage to the precentral and postcentral gyri and the frontal eye fields.
Watershed Infarct
Sudden systemic hypotension, hypoperfusion, or embolic showers may result in infarcts at bor-
der zones between the territories served by the ACA, MCA, and posterior cerebral artery (PCA).
Anterior watershed infarcts (at the ACA–MCA junction) result in a contralateral hemiparesis
(mainly the LE) and expressive language or behavioral changes. Posterior watershed infarcts
(MCA–PCA interface) result in visual deficits and language problems.
Occlusion of the anterior choroidal artery may result from small emboli or small vessel disease.
This syndrome may also occur as a complication of temporal lobectomy (removal of the tempo-
ral lobe to treat intractable epilepsy). The infarcted area usually includes the optic tract, lower
portions of the basal nuclei, and lower aspects of the internal capsule.
The patient experiences a contralateral homonymous hemianopia (damage to the optic tract) and
a contralateral hemiplegia (damage to corticospinal fibers at the transition of the internal capsule
into the crus cerebri). If the infarct involves enough of the posterior limb to also damage thalamocor-
tical fibers from the ventral posterolateral nucleus to the somatosensory cortex, the patient will also
have a hemianesthesia (or possibly hemihypesthesia) on the same side of the body as the hemiplegia.
Parkinson Disease
Parkinson disease (paralysis agitans) results from a loss of the dopamine-containing cells in the
substantia nigra. Although this part of the brain is located in the midbrain, the terminals of these
nigrostriatal fibers are in the putamen and caudate nucleus. The classic signs and symptoms of this
disease are a stooped posture, resting tremor, rigidity, shuffling or festinating gait, and difficulty ini-
tiating or maintaining movement (akinesia, hypokinesia, or bradykinesia). Initially, the tremor and
walking difficulty may appear on one side of the body, but these signs usually spread to both sides
with time. This is a neurodegenerative disease that has a dementia component in its later stages.
Transient Ischemic Attack
A transient ischemic attack, commonly called TIA, is a temporary (and frequently focal) neurolog-
ical deficit that usually resolves within 10 to 40 minutes from the onset of symptoms. The cause
is temporary occlusion of a vessel or inadequate perfusion of a restricted vascular territory. TIAs
that last 60 minutes or more may result in some permanent deficits. This vascular event may take
place anywhere in the central nervous system but is more common in the cerebral hemisphere.
 Anterior commissure

Column of fornix
Head of caudate nucleus Septum pellucidum

Rostral Anterior limb of internal capsule

Body of fornix BCorCl
Claustrum
Put

Insula GP
Body of caudate nucleus

Anterior nucleus of thalamus APS

HyTh
Posterior limb of internal capsule
Caudal
VA–VL
Put
G
Lateral dorsal nucleus DMNu
P
Stria terminalis

Optic tract Amygdaloid

Arterial Patterns within the Forebrain with Vascular Syndromes

nuclear
External capsule complex
Put VL
Crus of fornix DM
Red nucleus Nu
CM Hippocampal formation

Hypothalamus
CC Mammillary body
Subthalamic nucleus

SplCorCl
Retrolenticular Medial posterior choroidal artery
limb of
internal capsule PulNu Thalamogeniculate branches of posterior cerebral artery (branch of P2)

Anterior choroidal artery

Optic tract
Substantia nigra Lateral striate branches (lenticulostriate arteries) of the middle
cerebral artery
Tail of caudate nucleus Thalamoperforating branches of posterior cerebral artery (branch of P1)
Lateral geniculate
nucleus
Posteromedial branches of posterior cerebral artery (P1 segment) and
Hippocampal formation branches of posterior communicating artery
Medial geniculate
nucleus
Pineal Anterolateral branches of middle and anterior cerebral artery

Medial striate branch of anterior cerebral artery (branch of A2)

Anteromedial branches of anterior cerebral artery and anterior

communicating artery
6-41

175