Brain stem lesions

Question 1

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 1

Medulla, mid olive.

Alternating hypoglossal hemiplegia with destruction of contralateral CST

1) Destruction of the hypoglossal nerve results in ipsilateral paralysis and atrophy of the tongue muscles
2) Destruction of the ipsilateral corticospinal tract results in contralateral spastic hemiplegia
3) Partial destruction of the contralateral corticospinal tract results in some degree of ipsilateral spastic paralysis

Question 2

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 2

Medulla, mid olive.

Right alternating hypoglossal hemiplegia

1) Destruction of the hypoglossal nerve results in ipsilateral paralysis of the muscles of the tongue, and atrophy of the ipsilateral muscles of the tongue
2) Destruction of the corticospinal tract at this level results in contralateral spastic hemiplegia

Question 3

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 3

Medulla at mid olive

Alternating Hypoglossal Hemiplegia and destruction of the ipsilateral Medial Lemniscus

1. Destruction of the ipsilateral hypoglossal nerve and the corticospinal tract (see above)
2. Destruction of the ipsilateral medial lemniscus results in contralateral loss of proprioception, 2-point tactile discrimination, and vibratory sensations from the body.

Question 4

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 4

“A6H+7”

Pons and the facial colliculus

Millard-Gübler’s Syndrome, Pons at facial colliculus

1) Includes the signs of alternating abducens hemiplegia plus a lesion of the VII nerve.
2) Destruction of the facial nerve results in ipsilateral facial palsy, loss of taste sensations from the anterior 2/3 of the tongue, decreased lacrimation, and hyperacusis.

Question 5

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 5

Pons at the facial colliculus

Alternating Abducent Hemiplegia, Pons at facial colliculus

1. Destruction of the abducens nerve results in an ipsilateral paralysis of lateral gaze, and/or internal strabismus.
2. Destruction of the corticospinal tract at this level results in contralateral spastic hemiplegia.

Question 6

What condition will be caused by a lesion in the shaded area?

Answer 6

Syndrome of Fovill “Al6+ML”

Pons at the facial colliculus

Syndrome of Foville

includes the signs of alternating abducens hemiplegia plus additional signs due to the dorsal extension of the lesion.

Destruction of the medial lemniscus results in contralateral loss of proprioception, 2-point tactile discrimination, and vibratory sensations from the body.

Destruction of the medial longitudinal fasciculus results in internuclear ophthalmoplegia. [see syndrome of the MLF in vestibular system].

Facial nerve may also be involved.

Destruction of the crossed corticobulbar fibers results in denervation of the ipsilateral nucleus ambiguus+ hypoglossal nucleus

Question 7

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 7

mid pons at level of trigeminal n.

Alternating Trigeminal Hemiplegia

Destruction of the trigeminal nerve results in an ipsilateral loss of all sensations from half of the face and scalp, and paralysis of the ipsilateral muscles of mastication.

Destruction of the corticospinal tract results in contralateral spastic hemiplegia.

Question 8

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 8

pons and the level of the trigeminal n.

Alternating Trigeminal Hemiplegia with a Dorsal Expansion

1. The signs of alternating trigeminal hemiplegia plus deficits associated with the involvement of more dorsally located structures
2. Destruction of the medial lemniscus results in a contralateral loss of proprioception and 2-point tactile discrimination from the body and limbs.
3. Destruction of the uncrossed corticobulbar fibers results in denervation of the contralateral cranial nerve nuclei.
   a. abducens nucleus
   b. 1⁄2 of facial nucleus results in a paralysis of the mimetic muscles on the lower half of the face (supranuclear facial palsy)
   c. hypoglossal nucleus
   d. nucleus ambiguus

Question 9

What is the name/location/results of the condition caused by a lesion in the shaded area?

Answer 9

Midbrain/Thalamus at Posterior Commissure

Alternating Oculomotor Hemiplegia (Weber’s Syndrome)

Destruction of the oculomotor nerve results in external strabismus, pupillary dilation and

complete ptosis.

Destruction of the corticospinal tract results in contralateral spastic hemiplegia.

Destruction of the substantia nigra may result in contralateral resting tremor.

Destruction of the uncrossed corticobulbar tract contralateral brainstem motor nuclear palsies, including supranuclear facial palsy.

Question 10

R side defects: facial palsy, loss of taste sensations from the anterior 2/3 of the tongue, decreased lacrimation, and hyperacusis. Internal strabismus.

L side: spastic paralysis

Answer 10

1. rightsided lesion @ Pons/facial colliculus on the Rig
   
   1. millard gubler syndrome
2. Millard-Gübler’s Syndrome, Pons at facial colliculus

1) Includes the signs of alternating abducens hemiplegia plus a lesion of the VII nerve.
2) Destruction of the facial nerve results in ipsilateral facial palsy, loss of taste sensations from the anterior 2/3 of the tongue, decreased lacrimation, and hyperacusis.

Question 11

paralysis and atrophy of the tongue muscles

tongue deviated to right

some L side spastic hemiplegia

complete R side spastic paralysis

Answer 11

lesion is in the rostral medulla, across both pyramids

Alternating hypoglossal hemiplegia with destruction of contralateral CST

1) Destruction of the hypoglossal nerve results in ipsilateral paralysis and atrophy of the tongue muscles
2) Destruction of the ipsilateral corticospinal tract results in contralateral spastic hemiplegia
3) Partial destruction of the contralateral corticospinal tract results in some degree of ipsilateral spastic paralysis

Question 12

atrophy and paralysis of tongue, deviates toward the right

contralateral spastic paralysis

Answer 12

lesion is at the Medulla, mid olive.

Right alternating hypoglossal hemiplegia

Question 13

atrophy/paralysis of tongue, deviates to the right

Spastic paralysis on left side of the body

loss of 2 pt tactile/proprioception on left sid of the body

Answer 13

lesion at Medulla at mid olive with dorsal extension

Alternating Hypoglossal Hemiplegia and destruction of the ipsilateral Medial Lemniscus

1. Destruction of the ipsilateral hypoglossal nerve and the corticospinal tract (see above)
2. Destruction of the ipsilateral medial lemniscus results in contralateral loss of proprioception, 2-point tactile discrimination, and vibratory sensations from the body.

Question 14

Patient experiences inhalation of food, water persistently without cough.

deviation of the uvula away from the affected nucleus

tongue deviates to the right, paralyzed

left lower quadrant paralysis

nystagmus in left eye

weak adduction in right eye

spastic paralysis on left side of body

loss of 2 pt tactile/proprio/vib on left side of body

internal strabismus

Answer 14

Pons at the facial colliculus

Syndrome of Foville

includes the signs of alternating abducens hemiplegia plus additional signs due to the dorsal extension of the lesion.

Destruction of the medial lemniscus results in contralateral loss of proprioception, 2-point tactile discrimination, and vibratory sensations from the body.

Destruction of the medial longitudinal fasciculus results in internuclear ophthalmoplegia. [see syndrome of the MLF in vestibular system].

Facial nerve may also be involved.

Destruction of the crossed corticobulbar fibers results in denervation of the ipsilateral nucleus ambiguus+ hypoglossal nucleus

Question 15

loss of all sensations from half of the face and scalp on L side

muscles of mastication reduced on L side

spastic hemiplegia R side

Answer 15

rightsided lesion @ mid pons @ level of trigeminal n.

Alternating Trigeminal Hemiplegia

Destruction of the trigeminal nerve results in an ipsilateral loss of all sensations from half of the face and scalp, and paralysis of the ipsilateral muscles of mastication.

Destruction of the corticospinal tract results in contralateral spastic hemiplegia.

Question 16

external strabismus, pupillary dilation,complete ptosis.

contralateral spastic hemiplegia.

resting tremor.

supranuclear facial palsy.

Answer 16

Midbrain/Thalamus at Posterior Commissure

Alternating Oculomotor Hemiplegia (Weber’s Syndrome)

Destruction of the oculomotor nerve results in external strabismus, pupillary dilation and

complete ptosis.

Destruction of the corticospinal tract results in contralateral spastic hemiplegia.

Destruction of the substantia nigra may result in contralateral resting tremor.

Destruction of the uncrossed corticobulbar tract contralateral brainstem motor nuclear palsies, including supranuclear facial palsy.

Question 17

Rightsided paralysis of muscles of mastication

Rightsided loss of pain/temp/proprioception/2 pt tactile

Rightsided spastic paralysis

Leftsided sided lower quadrant paralysis

Loss of gag reflex

Tongue deviates to the right

Answer 17

pons at the level of the trigeminal n.

CNV, ML, CBT (VI, XII, Nuc Ambig)

Alternating Trigeminal Hemiplegia with a Dorsal Expansion

1. The signs of alternating trigeminal hemiplegia plus deficits associated with the involvement of more dorsally located structures
2. Destruction of the medial lemniscus results in a contralateral loss of proprioception and 2-point tactile discrimination from the body and limbs.
3. Destruction of the uncrossed corticobulbar fibers results in denervation of the contralateral cranial nerve nuclei.
   a. abducens nucleus
   b. 1⁄2 of facial nucleus results in a paralysis of the mimetic muscles on the lower half of the face (supranuclear facial palsy)
   c. hypoglossal nucleus
   d. nucleus ambiguus

How well did you know this?

Question 18

Answer 18

CPA syndrome

Question 19

Answer 19

CPA syndrome

Question 21

Answer 21

1. Right Millard Gubler Syndrome
2. Pons and the facial colliculus (caudal pons)
3. Takes out CN 6 and 7

Question 22

Answer 22

Right Weber’s Syndrome

Question 23

Answer 23

Right Benedikt’s syndrome

Question 24

Answer 24

Brown Sequered syndrome

Question 25

Answer 25

spinal shock injury

Question 26

Parinaud Syndrome

Answer 26

1. dorsal midbrain syndrome
2. patient reports difficulty looking up
3. may have blurred distant vision caused by accommodative spasm.
4. tetrad of findings in the dorsal midbrain syndrome

• (1) loss of upgaze, which usually is supranuclear
• (2) normal to large pupils with light-near dissociation (loss of the pupillary light reaction with preservation of the response to a near stimulus) or pupillary areflexia
• (3) convergence–retraction nystagmus, in which the eyes make converging and retracting movements during attempted upward saccades
• (4) lid retraction (Collier sign).

Question 27

Paniaurd’s syndrome

Answer 27

The location of the lesion causing the upgaze paresis of the dorsal midbrain syndrome is the posterior commissure and its interstitial nucleus

presence of the full syndrome implies a lesion of the dorsal midbrain (including the posterior commissure), bilateral lesions of the pretectal region, or a large unilateral tegmental lesion.

Question 28

Acoustic neuroma

Answer 28

Acoustic neuroma

1. a benign neoplasm of the eighth cranial nerve
2. arising from the Schwann cells in the sheath of the vestibular nerve branch and protruding into the cerebellopontine angle
3. Should be considered for any recent onset unilateral oto-vestibular symptom

Question 29

Acoustic Neuromas

Answer 29

1. Large tumors that are causing severe neurologic symptoms (eg, ataxia, mental confusion, dysphagia, sudden unilateral hearing loss, or severe rotational vertigo) or affecting vital functions should be evaluated for treatment immediately
2. Treatment options include observation and microsurgery, as well as adjunctive therapies (eg, hearing aids) to relieve symptoms of postsurgical complications

Question 30

Acoustic neuroma

Answer 30

1. Symptoms most commonly arive from compression of the acoustic branch of cranial nerve VIII, the trigeminal nerve [cranial nerve V], and the facial nerve [cranial nerve VII]) and depend on which cranial nerve is being compressed
2. Most common symptom is unilateral hearing loss, usually in the form of speech discrimination in the early stages and high-frequency loss later on
3. Other symptoms include tinnitus, balance disturbances, trigeminal neuralgia, fullness in the ear, headache, facial numbness, and tingling or pain

Less commonly, the vagus nerve (cranial nerve X) and the glossopharyngeal nerve (cranial nerve IX) are affected, resulting in dysphagia

In severe cases, compression of the brainstem leads to obstruction of cerebrospinal fluid and elevated intracranial pressure, which may cause fever, vomiting, and visual problems

Large tumors may exert severe pressure on the brainstem and cerebellum, affecting vital functions

Question 31

Answer 31

1. Lesion of the Nucleus Ambiguus and the Spinal Lemniscus
   
   1. Destruction of the nucleus ambiguus results in dysphagia, dysarthria, hoarseness, paresis of the ipsilateral palatal muscles
   2. Destruction of the spinal lemniscus results in contralateral loss of pain and temperature sensations from the body
   3. Lesion may extend medially to include the medial lemniscus and the solitary nucleus
   4. a. Destruction of the medial lemniscus results in contralateral proprioceptive/2-point tactile hemianesthesia of the body.

b. Destruction of the solitary nucleus results in an ipsilateral anesthesia of the palate and pharynx, and loss of taste sensations from 1⁄2 of the tongue and pharynx (gag reflex).

Medulla at the olive

Question 32

Answer 32

Cerebellopontine Angle (CPA) Syndrome
One of the most common tumors of the posterior cranial fossa in adults is the **acoustic neurinoma.** As the tumor enlarges it **compresses the lateral aspect of the pons, cerebellum and medulla.**

1. Destruction of the vestibulocochlear nerve results in deafness and vestibular disturbances.
2. Destruction of the facial nerve results in Bell’s palsy.
3. Alternating Hemianalgesia refers to the ipsilateral loss of pain and temperature

sensations from the face and the contralateral loss of pain/temperature sensations from the body

Destruction of the descending tract of V results in ipsilateral loss of pain/temperature sensations from the face.

Destruction of the spinal lemniscus results in contralateral hemianalgesia of the body

4. Involvement of the cerebellar peduncles results in some degree of ipsilateral cerebellar ataxia, intention tremor, dysmetria and dysdiadochokinesia.

Question 33

Answer 33

Cerebellopontine Angle (CPA) Syndrome

One of the most common tumors of the posterior cranial fossa in adults is the acoustic neurinoma. As the tumor enlarges it compresses the lateral aspect of the pons, cerebellum and medulla.

1. Destruction of the vestibulocochlear nerve results in deafness and vestibular disturbances.
2. Destruction of the facial nerve results in Bell’s palsy.
3. Alternating Hemianalgesia refers to the ipsilateral loss of pain and temperature

sensations from the face and the contralateral loss of pain/temperature sensations from the body

Destruction of the descending tract of V results in ipsilateral loss of pain/temperature sensations from the face.

Destruction of the spinal lemniscus results in contralateral hemianalgesia of the body

4. Involvement of the cerebellar peduncles results in some degree of ipsilateral cerebellar ataxia, intention tremor, dysmetria and dysdiadochokinesia.

Question 34

Answer 34

1. Parinaud’s Syndrome is due to a lesion of the superior colliculus,
2. apparently it contains a center for controlling upward gaze. Therefore, the principal sign of this syndrome is paralysis of upward gaze.
3. Parinaud’s syndrome may be due to
   
   1. a. pineal tumor
   2. b. varix of the great vein of Galen.
4. lesions may also destroy the posterior commissure and a concomitant loss of the consensual light reflex.

Question 35

Unilateral lesions of the VPM and VPL nuclei

Answer 35

1. contralateral hemianesthesias:
   
   1. Loss of pain and temperature on the opposite side of the face and body;
   2. Proprioception and tactile discrimination from the contralateral body
   3. Proprioception, tactile discrimination and taste sensations from the ipsilateral head.

Question 36

Déjerine-Roussy Syndrome

Answer 36

Thalamic Syndrome

1. usually due to thrombosis of the posterior choroidal or thalamogeniculate branches of the posterior cerebral arteries.
2. variety of signs and symptoms:
3. state of constant spontaneous pain without appropriate external stimulus; diffuse
4. Modification of emotional control
5. Patient exhibits extreme mood swings from laughter to sobbing within short periods of time.
6. May also involve contralateral hemihypalgesia (“crawling ant” sensations), hemiparesis, homonymous hemianopia, or auditory deficits.

Question 37

Answer 37

1. Lateral Medullary Syndrome (Wallenberg’s syndrome or Syndrome of the Posterior Inferior Cerebellar Artery (PICA))
2. Destruction of the spinal lemniscus results in contralateral hemianalgesia
3. Destruction of the descending tract of V results in ipsilateral loss of pain and temperature
4. sensations from the face
5. Alternating Hemianalgesia refers to the ipsilateral loss of pain and temperature
6. sensations from the face and the contralateral loss of pain/temperature sensations from
7. the body
8. Destruction of the glossopharyngeal and vagus nerves
9. Destruction of the nucleus ambiguus
10. Destruction of the solitary nucleus results in ipsilateral loss of visceral sensations and
11. reflexes from the palate and pharynx; ipsilateral loss of taste sensations from 1⁄2 of the
12. tongue and pharynx
13. Destruction of the spinocerebellar tracts may result in asynergia or hypotonia
14. Irritation of the vestibular nuclei may result in nystagmus.

Question 38

Altnernating hemianalgesia

Answer 38

2 kinds we should note. So, if someone has loss of pain/temp from face and opposite side of body, there are two patterns:

1. CPA syndrome

alternating hemianalgesia + Deafness vestibulochocchlear problems

equilibrium problems + +Romberg sign + ataxia + deafness

2. Wallenburg Syndrome/Lateral Medullary Syndrome/Syndrome of PICA

Alternating hemianalgesia + dysphagia/issues with throat (from involvement of nucleus ambiguus) and the hemianalgesia results from Descending nucleus of V and Spinal Lemniscus

Question 39

Patient complains of feeling like ants are crawling all over them non-stop.

Answer 39

Dejerine-Roussy Syndrome, thalamic syndrome

Question 40

CN III palsy, loss of 2 pt tactile/proprio, loss of pain and temp of upper extremities.

Question 41

Identify A, B, C, D

Answer 41

B: Red nucleus, lesions may cause resting tremor

A: Substantia Nigra, lesions may cause resting trempor

C: Lemniscal system: SL most posterio-laterally; trigeminal lemniscus next to it, and ML more medio-anteriorily

D: Black stipling fibers coming from the superior cerebellar peduncle, lesions result in intention tremor

Depicted is a Benedikt’s syndrome: CN III palsy, loss of P/T, Proprio/2PT.T/Virbatory sen. If it involves cerebellar tegmentum, will show choriform movements/intention tremors. If it involves substantia nigra, will involve resting tremors too.

Question 42

1. external strabismus, pupillary dilation, complete ptosis. contralateral loss proprioception & 2-point tactile discrimination from body + limbs.
2. ipsilateral oculomotor palsy. contralateral tremors, ataxia, choreiform movements. Some spasticity.
3. external strabismus, pupillary dilation and complete ptosis. contralateral spastic hemiplegia. resting tremor. nuclear palsies, supranuclear facial palsy.

Answer 42

1 is a benedikts: shows lemniscal involvement (sensory) and motor deficits in addition to CN III palsy

Weber’s vs Benedikt’s syndrome

Weber’s syndrome is a midbrain lesion with CBT involvement: almost all signs are motor related. CN III palsy, Uncrossed CBT palsies (supranuclear facial palsy for example); involvement of substantia nigra and the Red Nucleus will cause resting tremors and/or choreaform movement; cerebellar peduncle involvement will cause ataxi. CST involvement will cause contralateral spasticity.

Benedikt’s syndrome will cause both motor deficits related to CNIII, CST, red nucleus+substantia nigra (chorea movement, ataxia, resting tremors), but ALSO sensory deprivations because of lemniscal involvement (SL, TL, ML).