BRAINSTEM

JOEL P. CARREON M.D.

 Brainstem
• It is made up of midbrain, pons and medulla
oblongata
• Occupies the posterior cranial fossa of the skull
• Stalklike in shape
Functions:
1. serves as conduit for ascending tracts and
descending tracts
2. has important reflex centers associated with
respiration, cardiovascular system, conciousness
3. contains nuclei of CN III to XII
MIDBRAIN
 Gross Appearance

• 2cm (0.8 inch) in length

• Connects the pons &
cerebellum with the
forebrain
• Traversed by a narrow
channel, filled with CSF
– cerebral aqueduct
 Posterior Surface

• Rounded eminences
• 4 Colliculi
– (corpora quadrigemina)
• divided into superior &
inferior pairs by a
vertical & transverse
groove
 Posterior Surface
• Superior colliculi
– centers for visual
reflexes
• Inferior colliculi
– lower auditory centers
 Posterior Surface
• Trochlear nerves
– emerge in the midline
below the inferior
colliculi;
– small diameter nerves
that wind around the
lateral aspect of
midbrain & enters lateral
wall of cavernous sinus
 Lateral Aspect of Midbrain

• Superior & Inferior

brachia ascend
anterolaterally
• Superior brachium
– passes from superior
colliculus to LGB & optic
tract
• Inferior brachium
– connects inferior
colliculus to MGB
 Anterior Aspect of Midbrain

• Interpeduncular fossa
– deep depression in the
midline
• Posterior perforated
substance
– region where several
small blood vessels
perforate the floor of
interpeduncular fossa
• Crus cerebri
– on either side of
interpeuncular fossa
 Anterior Aspect of Midbrain
• Oculomotor nerve
– emerges from a groove
on medial side of crus
cerebri, passes forward
in lateral wall of
cavernous sinus
 INTERNAL STRUCTURE OF MIDBRAIN
• Cerebral Peduncles
– two lateral halves of the
midbrain,
– Divided into A & P part
– Crus Cerebri – anterior
part
– Tegmentum – posterior
part
 INTERNAL STRUCTURE OF MIDBRAIN
• Substantia Nigra
– pigmented band of gray
matter that divides the
peduncles
 INTERNAL STRUCTURE OF MIDBRAIN
• Cerebral aqueduct
– narrow cavity of the
midbrain that connects
3rd & 4th ventricle
• Central gray matter
– surrounds cerebral
aqueduct
• Tectum
– part of midbrain
posterior to the cerebral
aqueduct, contains 4
swellings (corpora
quadrigemina)
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
• Inferior Colliculus
– large nucleus of gray
matter that forms part of
auditory pathway
– receives terminal fibers
of lateral lemniscus
– continues through
inferior brachium to
medial geniculate body
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
• Trochlear Nucleus
– situated in central gray
matter close to median plane
just posterior to medial
longitudinal fasciculus
– fibers pass laterally &
posteriorly around central
gray matter, leaves the
midbrain below inferior
colliculi
– fibers of trochlear nerve
decussate in superior
medullary velum
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
• Mesencephalic nuclei
of trigeminal nerve
– lateral to cerebral
aqueduct
• Decussation of superior
cerebellar peduncles
– occupies central part of
tegmentum anterior to
cerebral aqueduct
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
• Medial Lemniscus
– posterior to substantia
nigra
• Spinal & trigeminal
nuclei
– lateral to medial
lemniscus
• Lateral Lemniscus
– posterior to trigeminal
lemniscus
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
• Substantia Nigra
– large motor nucleus between
the tegmentum & crus
cerebri
– composed of medium-sized
multipolar neurons
– contains inclusion granules of
pigment melanin in
cytoplasm
– concerned with muscle tone
– connected to cerebral cortex,
spinal cord, hypothalamus,
basal nuclei
TRANSVERSE SECTION: LEVEL OF INFERIOR
COLLICULI
Crus Cerebri
• separated from tegmentum by
substantia nigra
• contains impt descending tracts
• corticospinal & corticonuclear
fibers occupy the middle 2/3 of
crus
• frontopontine fibers occupy
medial part of crus
• temporopontine fibers occupy
lateral part of crus
• these descending tracts connect
cerebral cortex to anterior gray
column of cells of spinal cord,
cranial nerve nuclei, pons &
cerebellum
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Superior Colliculus
• large nucleus of gray matter that
forms part of visual reflexes
• connected to lateral geniculate
body by superior brachium
• receives afferent fibers from optic
nerve, visual cortex, & the
spinotectal tract
• efferent fibers form the
tectospinal & tectobulbar tracts
(probably responsible for the
movements of eye, head & neck in
response to visual stimuli
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Oculomotor nucleus
– situated in central gray
matter close to median
plane just posterior to
MLF
– fibers pass anteriorly to
red nucleus to emerge
on medial side of crus
cerebri in
interpeduncular fossa
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Medial, Spinal &
Trigeminal Lemnisci
– form a curved band
posterior to substantia
nigra
– Lateral lemniscus does
not extend to this level
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Red Nucleus
– rounded mass of gray
matter between cerebral
aqueduct & substantia
nigra
– reddish hue is due to its
vascularity & the
presence of an iron-
containing pigment in
the cytoplasm of its
neurons
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Red Nucleus
• Afferent nucleus from:
– Cerebral cortex from
corticospinal fibers
– Cerebellum through the
superior cerebellar
peduncle
– Lentiform nucleus,
subthalamic &
hypothalamic nuclei,
substantia nigra, spinal
cord
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Red Nucleus
• Efferent fibers pass to:
– Spinal cord through
rubrospinal tract
– Reticular formation
through rubroreticular
tract
– Thalamus
– Subatantia Nigra
 TRANSVERSE SECTION: LEVEL OF THE
SUPERIOR COLLICULI
• Reticular formation
– situated in tegmentum
lateral & posterior to red
nucleus
• Crus Cerebri
– contains corticospinal,
corticonuclear &
corticopontine fibers (same
at the level of inferior
colliculus)
 Weber’s Syndrome
Basal Midbrain Infarct
• caused by occlusion of a branch
of posterior cerebral artery that
supplies the midbrain
• results in necrosis of brain
tissue involving oculomotor
nerve & crus cerebri
• S/Sx:
– Ipsilateral ophthalmoplegia
– Contralateral paralysis of lower
part of face, tongue, & arm & leg
– Lateral deviation of eyeball
(paralysis of medial rectus)
– Ptosis
– Dilated pupil unresponsive to light
& accommodation
 Benedikt’s Syndrome

• Paramedian Midbrain
Infarct
• Necrosis involves
medial lemniscus & red
nucleus
• Contralateral
hemianesthesia &
involuntary movements
of limbs to opposite
side
PONS
 GENERAL FEATURES OF PONS

• Situated in the posterior cranial fossa beneath

the tentorium cerebelli
• Possesses cranial nerve nuclei (CN 5, 6, 7 & 8)
• Conduit for ascending & descending tracts
(corticonuclear, corticopontine, corticospinal,
MLF, spinal, lateral & medial lemniscus)
 GROSS APPEARANCE
• Anterior to the
cerebellum
• Connects the medulla
oblongata to the
midbrain
• it is one inch (2.5cm)
long
• “bridge” connecting the
right & left cerebellar
hemispheres
 GROSS APPEARANCE
Anterior Surface

• convex from side to side

• shows transverse fibers
that converge on each
side (middle cerebellar
peduncle)
• Basilar groove: shallow
groove in the midline
which lodges the basilar
artery
 GROSS APPEARANCE
Anterolateral surface

• trigeminal nerve
emerges on each side
• medial part: smaller,
motor root
• lateral part: larger,
sensory root
 GROSS APPEARANCE
• Groove between
pons & medulla
(medial to lateral)
– Abducent, facial,
vestibulocochlear
nerves
 GROSS APPEARANCE
Posterior Surface
• hidden from view by
cerebellum
• forms upper half of
floor of 4th ventricle
• triangular in shape
• Limited laterally by
superior cerebellar
peduncles, divided into
symmetrical halves by
median sulcus
 GROSS APPEARANCE
Posterior Surface
• Medial eminence
– elongated
elevation lateral to
the sulcus,
bounded laterally
by sulcus limitans
 GROSS APPEARANCE
Posterior Surface
• Facial colliculus
– expansion at
inferior end of
medial eminence
produced by the
root of facial
nerve winding
around nucleus of
abducent nerve
 GROSS APPEARANCE
Posterior Surface
• Substantia furruginea
– bluish-gray floor of
the superior part of
sulcus limitans
• Area Vestibuli
– lateral to sulcus
limitans, produced by
underlying vestibular
nuclei
 INTERNAL STRUCTURE OF THE PONS
• Divided into A & P
part by transversely
running fibers of
trapezoid body
• Tegmentum
– posterior part
• Basal
– anterior part
 Transverse section through the Caudal Part

• Passes through the

facial collicullus
 Transverse section through the Caudal Part

• Medial Lemniscus
– rotates as it passes
from the medulla
into the pons
– situated in most
anterior part of
tegmentum
– accompanied by
the spinal & lateral
lemnisci
Transverse section through the Caudal Part

• Facial Nucleus
– posterior to lateral
part of medial
lemniscus
• Facial colliculus
– produced by the
fibers of facial
nerve winding
around the nucleus
of abducent nerve
 Transverse section through the Caudal Part
• Medial Longitudinal
Fasciculus
– situated beneath the
floor of 4th ventricle on
either side of midline
– main pathway that
connects vestibular &
cochlear nuclei with the
nuclei controlling EOM
(oculomotor, trochlear
& abducent nuclei)
 Transverse section through the Caudal Part

Medial Vestibular Nucleus

• lateral to the abducent
nucleus, in close relation to
inferior cerebellar peduncle
• Found at this level:
• Superior of lateral & inferior
part of superior vestibular
nucleus
• Posterior & Anterior Cochlear
nuclei
Transverse section through the Caudal Part

• Spinal nucleus of
trigeminal nerve & its
tract
– anteromedial to inferior
cerebellar peuncle
Transverse section through the Caudal Part

• Trapezoid body
– made up of fibers
derived from
cochlear nuclei &
nuclei of trapezoid
body
– lie transversely on
anterior part of
tegmentum
 Transverse section through the Caudal Part
Basilar part of Pons contains:
• Pontine nuclei
– small masses of nerve
cells
– where corticopontine
fibers of crus cerebri of
midbrain terminate
– Axons of pontine nuclei
give origin to Transverse
fibers of pons
 Transverse section through the Caudal Part
Basilar part of Pons contains:
• Transverse Fibers of Pons
– cross the midline &
intersect the
corticospinal &
corticonuclear tract,
breaking them into
small bundles
– enter the middle
cerebellar peduncle &
are distributed to
cerebellar hemisphere
Transverse section through the Caudal Part
Basilar part of Pons contains:
• Transverse Fibers 
Middle Cerebellar
Peduncle 
Cerebellum
– forms the main
pathway linking
the cerebral cortex
to the cerebellum
Transverse section through the Cranial Part

• Passes through the

trigeminal nuclei
• Internal structure is
similar to that seen at
the caudal level except
it now contains motor &
principal sensory nuclei
of trigeminal nerve
Transverse section through the Cranial Part

• Motor Nucleus of
Trigeminal Nerve
– beneath the lateral
part of 4th ventricle
within reticular
formation
– motor fibers travel
anteriorly thru the
substance of the
pons and exit on
anterior surface
Transverse section through the Cranial Part

• Principal Sensory
Nucleus of Trigeminal
Nerve
– situated on lateral
side of motor
nucleus
– continuous
inferiorly with
nucleus of spinal
tract
Transverse section through the Cranial Part

• Trapezoid Body &

Medial lemniscus
– same position
(anterior part of
tegmentum)
• Lateral & Spinal
Lemnisci
– Lateral to medial
lemniscus
 TUMORS OF THE PONS
Astrocytoma of the Pons
• the most common tumor of the brainstem occurring
in childhood
• S/Sx (ipsilateral CN paralysis & contralateral
hemiparesis):
• Weakness of facial muscle on same side (facial nerve
nucleus)
• Weakness of lateral rectus msn on 1 or both sides
(abducent N nucleus)
• Nystagmus (vestibular nucleus)
• Weakness of jaw muscles (trigeminal N nucleus)
 TUMORS OF THE PONS
Astrocytoma of the Pons
• Impairment of hearing (cochlear nuclei)
• Contralateral hemi/quadriparesis (corticospinal fibers)
• Anesthesia to light tough, preserved pain over face
(principal sensory nucleus of CN5; spinal nucleus & tract
of CN5 intact)
• Contralateral sensory defects of trunk & limbs (medial &
spinal lemnisci)
• Ipsilateral cerebellar s/sx (corticopontocerebellar tracts)
• Impairment of conjugate eye deviation (MLF)
 Pontine Hemorrhage
• Blood supply of pons: basilar artery, &
anterior, inferior, superior cerebellar arteries
• S/Sx: Ipsilateral facial paralysis & contralateral
paralysis of limbs
– Paralysis of conjugate eye deviation (abducent
nucleus & MLF)
 Gross Appearance of Medulla Oblongata

• Connects the pons superiorly with the spinal cord

inferiorly
• Junction of the medulla and spinal cord is at the
origin of the anterior and posterior roots of the
first cervical spinal nerve, which corresponds
approximately to the level of the foramen
magnum
• Conical in shape
• Central canal – continues upward to the lower half
of medulla
• Cavity of 4th ventricle – expansion of the upper
half of medulla
anterior median fissure of the medulla
• anterior surface of medulla
• Continuous inferiorly with the anterior median fissure of
the spinal cord
• on each side are swelling called the PYRAMID

pyramid
• composed of bundles of nerve fibers -> corticospinal
fibers (from large nerve cells in precentral gyrus of the
cerebral cortex
• tapers inferiorly
• where nerve fibers cross the opposite side forming the
decussation of the pyramids
anterior external arcuate fibers
• few nerve fibers that emerge from the anterior median fissure
above the decussation and pass laterally over the surface of the
medulla to enter the cerebellum

olives
• posterolateral to the pyramids
• oval elevations by inferior olivary nuclei
• rootlets of Hypoglossal nerve- groove between pyramid and olive
• roots of Glossopharyngeal and vagus nerves and cranial roots of
the accessory nerve- groove between olive and inferior cerebellar
peduncle
• posterior to the olives are the INFERIOR CEREBELLAR
PEDUNCLES-> connect medulla to cerebellum
 floor of the fourth ventricle
• forms by the posterior surface of inferior half of the
medulla oblongata
• continuous with the posterior spinal cord and possesses a
posterior median sulcus

gracile nucleus
• produce an elongated swelling-> gracile tubercle
• situated on each side of the median sulcus

• cuneate nucleus
• Produce a swelling-> cuneate tubercle
• lateral to the gracile nucleus
 INTERNAL STRUCTURE
expansion of neural tube-> form hindbrain vesicle->
4th ventricle-> extensive lateral spread-> alteration if
position of derivatives of alar and basal plates of the
embryo
Four levels
1. level of decussation of pyramids
2. level of decussation of lemnisci
3. level of the olives
4. level just inferior to the pons
1. LEVEL of DECUSSATION of PYRAMIDS

– the great motor decussation

– superior – corticospinal occupy and form pyramid
– inferior ->cross median plane->continue down the SC
in lateral white column as lateral corticospinal tract
– fasciculus gracilis and cuneatus – ascend superiorly
posterior to the central gray matter
– nucleus gracilis and cuneatus – appear as posterior
extensions of the central gray
– substantia gelatinosa –in posterior gray column;
continuous with the inferior end of the nucleus of the
spinal tract of the trigeminal nerve
2. LEVEL of the DECUSSATION of LEMNISCI
• inferior half of the medulla oblongata
• great sensory decussation
• anterior to the central gray matter and posterior to the pyramids
• formed from the internal arcuate fibers-
• emerged from the anterior aspects of the nucleus gracilis and
cuneatus
• travel anteriorly and laterally around central gray matter-> curve
medially toward midline -> decussate with fibers of opposite side
• nucleus of the spinal tract of the trigeminal nerve- lateral to the
internal arcuate fibers
• the spinal tract of the trigeminal nerve lies lateral to the nucleus
• the lateral and anterior spinothalamic tracts and the spinotectal tracts
occupy an area lateral to the decussation of the lemnisci – SPINAL
LEMNISCUS
• spinocerebellar,vestibulospinal and rubrospinal tracts – anterolateral
of medulla oblongata
3. LEVEL of the Olives
• passes across inferior part of fourth ventricle
• amount of gray matter increase at this level
• found are nuclei of CN VIII, IX, X, XI, XII

A. olivary nuclear complex

• largest nucleus is inferior olivary nucleus
• gray matter shaped like a crumpled bag
• responsible for the elevation on the surface of the
medulla called the OLIVE
• smaller dorsal and medial accessory olivary nuclei also
are present
Olivary (cont’d)

• Inferior cerebellar peduncle- where fibers of inferior

olivary nucleus cross to enter cerebellum
• Afferent fibers: reach inferior olivary nuclei from spinal
cord (spino-olivary tracts) and from the cerebellum
and cerebral cortex
• FUNCTION: voluntary muscle movement
 B. vestibulocochlear nuclei

• Made up of ff nuclei:
• medial vestibular nucleus
• inferior vestibular nucleus
• lateral vestibular nucleus
• superior vestibular nucleus
• two cochlear nuclei : anterior and posterior cochlear
nucleus
• anterior cochlear nucleus on anterolateral aspect of the
inferior cerebellar peduncle
• posterior cochlear nucleus on posterior aspect of the
peduncle lateral to floor of the fourth ventricle
 C. nucleus ambiguus
• consists of large motor neuron
• situated deep within the reticular formation
• emerging nerve fibers join the glossopharyngeal, vagus
and cranial part of the accessory n
• FUNCTION: contribute to voluntary skeletal mucle

D. central gray matter

• Passing from medial to lateral :
• hypoglossal nucleus
• dorsal nucleus of vagus
• nucleus of tractus solitarius
• medial and inferior vestibular nuclei
 pontine nuclei
• arcuate nuclei (inferiorly displaced)
• situated on anterior of pyramids
• receives nerve fibers from the cerebral cortex and send
efferent fibers to the cerebellum through the ANTERIOR
EXTERNAL ARCUATE FIBERS

pyramids
• situated in anterior part of the medulla separated by
anterior median fissure
• contain the corticospinal and some corticonuclear fibers
• corticospinal fibers descend to spinal cord
• corticonuclear fibers are distributed to motor nuclei of
cranial nerves w/in medulla
 reticular formation
• Has diffuse mixture of nerve fibers and cells
• deeply placed posterior to the olivary nucleus
• also present in pons and medulla
CN IX,X and cranial part of CN XI
• run forwad and laterally through the reticular formation
• Emerge from between the olives and inferior cerebellar
peduncles
CN XII
• run anteriorly and laterally through the reticular formation and
emerge between the pyramids and the olives

4. LEVEL just INFERIOR to the PONS

• The lateral vestibular nucleus has replaced the inferior
vestibular nucleus cochlear nuclei are visible on the anterior and
posterior surfaces of the inferior cerebellar peduncle
 CLINICAL NOTES
Medulla Oblongata
• contains many cranial nerve nuclei that are concerned with vital
functions (e.g., regulation of heart rate and respiration)
• serves as a conduit for the passage of ascending and descending
tracts connecting the spinal cord to the higher centers of the
nervous system.
• Involved in demyelinating diseases, neoplasms, and vascular
disorders.
Raised Pressure in the Posterior Cranial Fossa and Its Effect on the
Medulla Oblongata
• tumors of the posterior cranial fossa-> ↑ICP-> tends to be pushed
toward the area of least resistance ->downward herniation of the
medulla and cerebellar tonsils through the foramen magnum.
• Symptoms of headache, neck stiffness, and paralysis of the
glossopharyngeal, vagus, accessory, and hypoglossal nerves owing
to traction
• extremely dangerous to perform a lumbar puncture
 Arnold-Chiari Phenomenon

• congenital anomaly in which there is a herniation of the

tonsils of the cerebellum and the medulla oblongata
through the foramen magnum into the vertebral canal.
• blockage of the exits in the roof of the fourth ventricle
to the cerebrospinal fluid->internal hydrocephalus.
• S/Sx – involvement of last four cranial nerves
 Vascular Disorders of the Medulla Oblongata
1. Lateral Medullary Syndrome of Wallenberg
• The lateral part of the medulla oblongata supplied by: the
posterior inferior cerebellar artery, which is usually a branch of
the vertebral artery
• Thrombosis of the arteries produces signs and symptoms:
dysphagia and dysarthria due to paralysis of the ipsilateral
palatal and laryngeal muscles (innervated by the nucleus
ambiguus); analgesia and thermoanesthesia on the ipsilateral
side of the face (nucleus and spinal tract of the trigeminal
nerve);
• vertigo, nausea, vomiting, and nystagmus (vestibular nuclei);
ipsilateral Horner syndrome (descending sympathetic fibers);
ipsilateral cerebellar signs—gait and limb ataxia (cerebellum or
inferior cerebellar peduncle); and contralateral loss of sensations
of pain and temperature (spinal lemniscus—spinothalamic tract)
 2. Medial Medullary Syndrome
• The medial part of the medulla oblongata is supplied by:
vertebral artery
• Thrombosis produces
signs and symptoms: contralateral hemiparesis (pyramidal tract),
contralateral impaired sensations of position and movement and
tactile discrimination (medial lemniscus), and ipsilateral paralysis
of tongue muscles with deviation to the paralyzed side when the
tongue is protruded (hypoglossal nerve).