Brainstem Stroke Syndrome Spp t

7/25/2019 Brainstem Stroke Syndrome Spp t

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BRAINSTEM STROKE

SYNDROMES


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Discussion will contain

Basic neuro-anatomy of the rainstem from aclinician!s "ers"ecti#e

Details of the loo$ su""ly of the rainstem

%arious syn$romes cause$ y stro&e in#ol#in'the rainstem #essels

RULE OF FOUR ( a very simple way to

rememer #arious rainstem lesions)

*linical case e+am"les


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Located between the cerebrumand the spinal cord

Provides a pathway fortracts running between higher and lowerneural centers.

Consists of the midbrain, pons,andmedulla oblongata.

Brainstem

Midbrain

Pons

Medullaobongata


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Midbrain

Pons

Medulla

oblongata

%entral surface of rain stem


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Mi$rainCerebral

peduncles

,onsBasis pontis

Me$ulla

Ventral Lateral View


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,osterior circulation

Vertebral artery branchesPosterior inferior cerebellar Medulla, lower cerebellum

Basilar artery branches

Anterior inferior cerebellar Lower and middle pons, anteriorcerebellum

Superior cerebellar pper pons, lower midbrain, uppercerebellum

Posterior cerebral Medial occipital and temporal

cortex and subjacent white matter,

posterior corpus callosum, uppermidbrain

!halamoperforate branches !halamus

!halamogeniculate branches !halamus


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Brain stem arteries - anterior view

1 Posterior !erebral artery" #uperior !erebellar artery$ Pontine bran!%es o& t%e basilar artery' (nterior in&erior !erebellar artery) *nternal auditory artery+ Vertebral artery, Posterior in&erior !erebellar a- (nterior spinal artery

. /asilar artery


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MID-BRAIN STOKE

SYNDROMES


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Mi$rain


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Shortest brain stem,not more than

"cm in length,lies in the posterior cranial#ossa.#or descriptive purpose,divided into

$orsal tectum and right and left cerebral

Peduncles.%ach cerebral peduncles divide further

into ventral crus cerebri and a dorsal!egmentum by a pigmented lamina

& Substantia nigra'Cerebral peduncles contains(

)$escending fibers that go to thecerebellum via the pons

)$escending pyramidal tracts*unning through the midbrain is thehollow cereral a.ue$uct whichconnects the +rdandthventricles of the

brain.

Mi$rainCrus cerebri


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Basis "e$unculiSustantia ni'ra

*rus cereri

-cerebral peduncle

*ereral a.ue$uct


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Basis Te'mentum

Tectum

Ventral 0orsal Organiation


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!he roof of the a/ueduct - the tectumcontains the corpora /uadrigemina

" superior colliculi that control refle0movements of the eyes, head andnec1 in response to visual stimuli" inferior colliculi that control refle0movements of the head, nec1, andtrun1 in response to auditory stimuli

*or"ora .ua$re'emina

Superior colliculi larger and dar1er

than inferior colliculi,the difference

2n colour due to superficial neurons in

Superior colliculi

Superior and inferior colliculi

seperated by cruciform sulcus

#uperior!olli!uli

*n&erior

!olli!uli


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*nternal stru!tureansverse section of midbrainmmon to oth at inferior an$ su"erior colliculus/

2rus !erebri 3or basis pedun!uli4() Consists of fibres descending from cerebral corte0.

) 2ts medial one)si0th is occupied by coticopontine

fibres from frontal lobe,lateral one)si0th fibres

from temporal,occipital and parietal lobes,theintermediate two third by corticospinal and cortico)

nuclear fibres.

#ubstantia nigra () Present immediately behind and medial to basis

pedunculi.

) 2t appears dar1 as neuron within it contain pigment.

- neuromelanin


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Me$ial mi$rain syn$rome 0"arame$ian ranchesof u""er asilar an$ "ro+imal "osterior cereral arteries1

ON SIDE O2 3ESION

Eye 4$own an$ out4secon$ary to uno""ose$action of fourth an$ si+thcranial ner#es5 with

$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbers

ON O,,OSITE SIDE

,aralysis of face5 arm5

an$ le'/ Corticobulbarand corticospinal tractdescending in cruscerebri


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3ateral mi$rain syn$rome 0syn$rome of small "enetratin' arteries arisin' from"osterior cereral artery1

On si$e of lesion


$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbersand/or third nervenucleus

On si$e o""osite lesion

6emiata+ia5hy"er&inesias5 tremor/Red nucleus,dentatorubrothalamicpathway


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Mi$ rain syn$romes


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Me$ial mi$rain syn$rome 0"arame$ian ranchesof u""er asilar an$ "ro+imal "osterior cereral arteries1

ON SIDE O2 3ESION


$ilate$ an$ unres"onsi#e"u"il/ Third nerve fbers

ON O,,OSITE SIDE

,aralysis of face5 arm5

an$ le'/ Corticobulbarand corticospinal tractdescending in cruscerebri


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,ontine syn$romes


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,ons


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,ons

!he pons shows a conve0 anterior surface with prominent transversely running fibres.

!hese fibres collect to form bundles,the

middle cerebellar peduncles.

!he anterior surface of pons is mar1ed in the

midline by a shallow groove,the sulcus

basilaris which lodges the basilar artery.

,ons

s

Sulcus basilaris


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Subdivided into ventral and dorsal part

3entral part of the pons contains

Pontine nuclei:

*ecieves corticopontine fibres from frontal,

temporal,parietal and occipital lobes of

cerebrum

!he efferent fibres form the transverse fibresof pons.

Vertically running corticospinal and

corticopontine fibres.

ransversely running fibres arising in

pontine nuclei

Pontine nuclei


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!he dorsal part of the pons may be regarded as

continuation of the part of the medulla behind the

pyramids.

Superiorly continous with the tegmentum of the

midbrain.

4ccupied predominately by reticular formation

Posterior surface help to form floor of fourth

ventricle

The dorsal part is bounded laterally by inferior

cerebellar peduncle in the lower part of the pons

and superior cerebellar peduncle in upper part.

Dorsal "art of "ons

DORSA3 ,ART

Midpons

!pper pons


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Me$ial inferior "ontine syn$rome 0occlusion of "arame$ian ranch of asilar artery1

On si$e of lesion

,aralysis of con7u'ate 'a8e tosi$e of lesion 0"reser#ation ofcon#er'ence1/ Center orconjugate lateral gaze(R!"

Nysta'mus/ #estibular nucleus

Ata+ia of lims an$ 'ait/ 3i&ely

middle cerebellar peduncle Di"lo"ia on lateral 'a8e/

$bducens nerve

On si$e o""osite lesion

,aralysis of face5 arm5 an$ le'/Corticobulbar and corticospinal

tract in lower pons Im"aire$ tactile an$

"ro"rioce"ti#e sense o#er one-half of the o$y/ %ediallemniscus


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3ateral inferior "ontine syn$rome 0occlusion of anterior inferior cereellar artery1

On side o& lesion

6ori8ontal an$ #ertical nysta'mus5#erti'o5 nausea5 #omitin'5 oscillo"sia/#estibular nerve or nucleus

2acial "aralysis/ &eventh nerve

,aralysis of con7u'ate 'a8e to si$e oflesion/ Center or conjugate lateral gaze

Deafness5 tinnitus/$uditory nerve orcochlear nucleus

Ata+ia/ %iddle cerebellar peduncle andcerebellar hemisphere

Im"aire$ sensation o#er face/

'escending tract and nucleus fth nerve

On side opposite lesion

Im"aire$ "ain an$ thermal sense o#erone-half the o$y 0may inclu$e face1/&pinothalamic tract


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Me$ial mi$"ontine syn$rome0"arame$ian ranch of mi$asilar artery1

On side o& lesion

Ata+ia of lims an$ 'ait0more "rominent inilateral in#ol#ement1/

ontine nuclei On side opposite lesion

,aralysis of face5 arm5 an$le'/ Corticobulbar and

corticospinal tract %ariale im"aire$ touch

an$ "ro"rioce"tion whenlesion e+ten$s "osteriorly/

%edial lemniscus


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3ateral mi$"ontine syn$rome 0shortcircumferential artery1

On side o& lesion

Ata+ia of lims/ %iddlecerebellar peduncle

,aralysis of muscles of

mastication/ %otor fbersor nucleus o fth nerve

Im"aire$ sensation o#ersi$e of face/ &ensory fbersor nucleus o fth nerve


Im"aire$ "ain an$ thermalsense on lims an$ trun&/&pinothalamic tract


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Me$ial su"erior "ontine syn$rome 0"arame$ian ranchesof u""er asilar artery1

On side o& lesion

*ereellar ata+ia 0"roaly1/&uperior and/or middlecerebellar peduncle

Internuclear o"hthalmo"le'ia/%edial longitudinal asciculus

Myoclonic syn$rome5 of "alate5"haryn+5 #ocal cor$s5res"iratory a""aratus5 face5oculomotor a""aratus5 etc)/ central tegmental bundle)


,aralysis of face5 arm5 an$ le'/Corticobulbar and corticospinaltract

Rarely touch5 #iration5 an$"osition are a9ecte$0arm:le'1/

%edial lemniscus


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Rt internuclearo"hthalmo"le'ia


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One an$ a half syn$rome

RT 3T


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3ateral su"erior "ontine syn$rome 0syn$rome of su"erior cereellar artery1

On side o& lesion

Ata+ia of lims an$ 'ait5 fallin' to si$eof lesion/ %iddle and superiorcerebellar peduncles, superior suraceo cerebellum, dentate nucleus

Di88iness5 nausea5 #omitin'; hori8ontalnysta'mus/ #estibular nucleus

,aresis of con7u'ate 'a8e 0i"silateral1/

ontine contralateral gaze Miosis5 "tosis5 $ecrease$ sweatin'

o#er face 06orner


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MED=33A

OB3ON>ATA


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Medulla is broad above ,5oins with pons narrow below, continous with spinal cord

Length is about +cm, width is about "cm

at its upper end

Surfaces shows series of fissuresAnterior median fissurePosterior median fissure

Medulla oblongata

Most inferior region of the brain stem.

Becomes the spinal cord at the level ofthe foramen magnum.

E5ternal stru!ture o& medulla


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%entral surface of me$ulla olon'ata contains,yrami$ele#ation etween anterior me$ian

an$ anterolateral sulcus2orme$ $ue to $ecussation of corticos"inal ?res)

,yrami$

Oli#e

Oli#eO#al swellin' etween anterolate "osterolateral sulcus5half an inc lon',ro$uce$ y lar'e mass of 'ray

matter calle$ inferior oli#ary nucleus

E5ternal sur&a!e o& medulla


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Anterior me$ian ?ssure

,yrami$

Anterolateral ?ssure

Oli#e


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Medial medullary syndrome 0occlusion of #erteral artery or of ranch of #erteral orlower asilar artery1

On side o& lesion

,aralysis with atro"hy ofone-half half the ton'ue/*psilateral twelth nerve

On side opposite lesion ,aralysis of arm an$ le'5

s"arin' face; im"aire$tactile an$

"ro"rioce"ti#e senseo#er one-half the o$y/Contralateral pyramidaltract and medial

lemniscus


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3ateral me$ullary syn$rome 0occlusion of any of ?#e #essels maye res"onsile@#erteral5 "osterior inferior cereellar5 su"erior5 mi$$le5 or inferior lateral me$ullary arteries1

On side o& lesion

,ain5 numness5 im"aire$ sensation o#erone-half the face/ 'escending tract andnucleus fth nerve

Ata+ia of lims5 fallin' to si$e of lesion/+ncertainrestiorm body, cerebellarhemisphere, cerebellar fbers,spinocerebellar tract ("

Nysta'mus5 $i"lo"ia5 oscillo"sia5 #erti'o5nausea5 #omitin'/ #estibular nucleus

6orner

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Brainstem Stroke Syndrome Spp t