Chapter 12

Brainstem 1: Surface Anatomy

&
Cranial Nerves
Brainstem is a compact stalk through which most information flowing
to and from the brain travels. Which 2 sensory systems do not have
primary relays in the brainstem?
Brainstem is also site of many important nuclei involved with cranial
nerve function, level of consciousness, cerebellar circuitry, muscle
tone, posture and important homeostatic control systems for respiration
and cardiac function.
Because of its compact architecture, even small lesions of brainstem can
affect multiple systems.
Brainstem: Ventral View
Brainstem: Dorsal View (Cerebellum removed)
Brainstem: Lateral View (Cerebellum removed)
Sensory & Motor Organization of the Cranial Nerves
Cranial Nerve 1: Olfactory Nerve
Anosmia (Olfactory Nerve)

Unilateral anosmia is rarely noticed by patients bcz contralateral side

functions normally. Each nostril must be tested separately.
Patients sometimes complain of loss of taste when it is actually olfaction
that is not functioning.
Head injury is a common cause of anosmia.
Viral infections can damage the olfactory epithelium
Intracranial lesions on the ventral surface of the frontal lobes commonly
cause olfactory deficits. Meningioma and metastasis are common
causes.
Tumors growing in this area often show few symptoms until they reach
large size. Foster-Kennedy syndrome, typically caused by
meningioma, includes anosmia, optic atrophy in one eye and
papilledema in the opposite eye.
Cranial Nerve II: Optic Nerve (covered in Chapter 11)

Cranial Nerves III, IV, VI: Oculomotor, Trochlear, &

Abducens (covered in detail in Chapter 13)
Oculomotor
Nucleus in midbrain
Innervates 4 extraocular muscles and functions in most eye movements
Contains parasympathetic axons from Edinger-Westphal nucleus
to ciliary ganglion which innervates pupillary constrictor muscles
and ciliary muscle of lens
Trochlear
Nucleus in midbrain
Nerve exits dorsal surface and crosses over
Moves eye medially and downward
Abducens
Nucleus in pons
Moves eye laterally
Cranial Nerve V: Trigeminal Nerve
Trigeminal ganglion
Ophthalmic, maxillary and mandibular divisions
Touch, pain, temp, proprioception for face, mouth,
anterior 2/3 of tongue, nasal sinuses & meninges
(supratentorial)
Muscles of chewing, tensor tympani muscle
Trigeminal Nuclear Complex
Extends from midbrain to upper cervical spinal cord
Mesencephalic, main (principal) sensory, and spinal nuclei
Mesencephalic nucleus: proprioception
Main nucleus: fine touch, dental pressure
Spinal nucleus: crude touch, pain, temperature
Trigemino-thalamic Pathway
Axons of main sensory nucleus neurons decussate in
rostral pons and ascends to terminate in the ventral
posterior medial nucleus of the thalamus
Axons of spinal nucleus of trigeminal follow similar path
VPM neurons project to face area of somatosensory cortex
Positions of Trigeminothalamic, Medial Lemniscus and
Spinothalamic Tracts at Level of Midbrain
Somatotopic Organization of the Spinal Trigeminal Nucleus
Mesencephalic Nucleus and Tract
Mesencephalic nucleus is only instance where primary sensory
neurons are in the CNS instead of peripheral ganglion
Proprioception from chewing muscles, tongue & extraocular muscles
Mesencephalic neuron axons project to the motor trigeminal nucleus
for jaw jerk reflex and function in monitoring motor function
Motor Functions of Trigeminal
Motor nucleus located adjacent to main sensory nucleus in pons
Innervates chewing muscles (masseter, temporalis, medial and
lateral pterygoid)
Tensor tympani muscle of middle ear
Upper motor neuron innervation is bilateral so unilateral motor
cortex or corticobulbar tract injury will not paralyze chewing
muscles
Trigeminal Nerve Disorders

1. Trigeminal neuralgia (tic douloureux) most common

Recurrent episodes of brief severe pain in the distribution of
V2 or V3
Cause unknown, possible pressure from blood vessel
Occurs in MS

2. Sensory Loss
Caused by damage to CN V by trauma, tumor metastasis,
herpes zoster, aneurysms of internal carotid, trigeminal
or vestibular schwannoma
Lesions of main sensory nucleus cause ipsilateral sensory loss
Causes include infarct, demyelination, or tumor

Lesions of trigeminal nucleus in pons or medulla often also involve

the adjacent spinothalamic tract producing ipsilateral sensory loss
in the face and contralateral loss of pain and temperature sense in
the body.
Cranial Nerve VII: Facial Nerve

Motor function: muscles of facial expression, stapedius muscle and

part of digastric muscle.
Parasympathetic function: innervation to lacrimal glands and salivary
glands except for parotid
Visceral sensory function: taste from anterior 2/3 of tongue
Somatosensory function: touch sensation from region near external
auditory meatus.
Facial Nucleus

Location: pons caudal to trigeminal main sensory nucleus

Facial nerve axons loop dorsally around the abducens nucleus then
course ventrolaterally to exit the ponto-medullary junction
Motor cortex or corticobulbar tract lesions cause contralateral face
paralysis/weakness sparing the forehead
Lesions of facial nucleus/nerve cause ipsilateral paralysis of whole face.
Along the course of the facial nerve the geniculate ganglion has
primary sensory neurons for taste in the anterior 2/3 of the
tongue and somatic sensation for the external auditory meatus
Parasympathetic axons originate in the superior salivatory nucleus and
run to the sphenopalatine ganglion and submandibular
ganglion which contain neurons innervating glands in the nasal
passage, lacrimal glands, submandibular and sublingual glands
Taste Pathway
Taste sensory receptors in the taste buds innervated by primary sensory
neurons
Primary sensory neurons project to the rostral division of the nucleus
solitarius (gustatory nucleus); this nucleus also receives taste
input from posterior 1/3 of tongue traveling in CN IX & X
Nuc solitarius neurons project ipsilaterally into the midbrain where some
fibers decussate and terminate in VPM thalamus bilaterally
VPM thalamus projects to taste cortex located in the parietal operculum
and insula
Somatosensory axons from the external auditory meatus project to
the spinal trigeminal nucleus along with small number of
somatosensory axons from CN IX and X.
Facial Nerve Lesions 1
Upper motor neuron lesions spare forehead; lower motor neuron lesions
cause paralysis in upper and lower face.
Facial Nerve Lesions 2
Bell’s Palsy
All divisions of facial nerve are impaired acutely and then gradually
recover.
Cause unknown, but viral or inflammatory process suspected.
Unilateral upper and lower face paralysis
Patients often have pain near the ear
Hyperacusis common, as is dry eye
80% recover fully within 3 weeks
Some have residual weakness
Crocodile tears can result from aberrant regeneration of salivary
fibers to lacrimal gland
Brainstem lesions occasionally involve the facial nucleus or nerve
fascicles.
Corneal Reflex

Touching the cornea gently with cotton swab typically elicits a blink.
Afferent limb travels in the ophthalmic division of the trigeminal nerve
to the main sensory nucleus and spinal nucleus.
Efferent limb starts at the facial nucleus and travels in the facial nerve
to innervate the orbicularis oculi muscles that close the eye.
Lesions of trigeminal, facial nucleus or facial nerve may cause loss of
the corneal reflex.
Sensorimotor cortex lesions can also decrease corneal reflex on the
contralateral side.
The blink to threat response is carried in the optic nerve.
Cranial Nerve VIII: Vestibulocochlear Nerve
Auditory and vestibular sensation
Nerve emerges from ponto-medullary junction; cerebellopontine angle
Travels with facial nerve
Branches go to cochlea, saccule, utricle and semicircular canals
Vestibular and Cochlear Sensory Organs
Cochlea
Central Auditory Pathways
Tonotopic organization
Hair cells of organ of Corti
Primary sensory neurons in the spiral ganglion of cochlea
Dorsal and ventral cochlear nuclei
Bilateral projections
Superior olivary complex
Lateral lemniscus
Inferior colliculus
Medial geniculate body
Auditory cortex (41)
Brainstem Sections Through
Auditory Relay Areas
Lesions in Auditory Pathway

Auditory information ascends bilaterally after leaving the cochlea

so damage proximal to the cochlear nuclei do not cause unilateral
hearing loss.
However, more input ascends contralaterally than does so ipsilaterally.
During auditory seizures patients often report tones or roaring sounds
from the side opposite the cortical area involved in the seizure.
Efferent pathways from brainstem to cochlea can dampen sensitivity of
hair cells.
Reflex pathways from the cochlear nuclei project to CN V & VII
controlling stapedius and tensor tympani muscles that function to
dampen middle ear response to loud sounds.
Vestibular System: Semicircular Canals, Saccule and Utricle
Function in adjustment of posture, muscle tone, and eye position
in response to head movements.
Vestibular nuclei have connections with cerebellum, brainstem
motor and extrocular muscle control systems
Ascending vestibular pathway to cortex provides conscious
awareness of head position integrated with visual and tactile
spatial information.
Semicircular canals detect angular acceleration around 3 orthogonal
axes.
Saccule and utricle detect linear acceleration and head tilt.
Vestibular Pathways
Hair cells of semicircular canals, saccule & utricle
Superior and inferior vestibular ganglia
Superior, inferior, lateral and medial vestibular nuclei
Ventral posterior nuclear complex
Vestibular cortex probably in parietal lobe area 5
Important Vestibular System Ascending & Descending Tracts

1. Lateral vestibulospinal tract: extends throughout spinal cord and

functions in balance and extensor tone
2. Medial vestibulospinal tract: only projects to cervical spinal levels and
controls neck and head position muscles
3. Medial longitudinal fasciculus: connects vestibular nuclei and CN nuclei
III, IV, and VI; mediates vestibulo-ocular reflex
Hearing Loss

Common causes (unilateral): disorders of external auditory canal,

middle ear, cochlea, 8th nerve, or cochlear nuclei.
Auditory pathways ascend bilaterally proximal to the cochlear nuclei.
Conductive hearing loss caused by problem in external auditory canal
or in middle ear.
Sensorineural hearing loss caused by damage to cochlea or 8th nerve.
Tuning fork in air outside ear tests sensorineural hearing; tuning fork
on mastoid bone tests conductive hearing; normals hear better
with air conduction than bone conduction.
Common causes of conductive hearing loss include accumulation of
ear wax, otitis, tympanic membrane perforation and otosclerosis.
Causes of sensorineural hearing loss include exposure to loud sounds,
meningitis, ototoxic drugs, head trauma, viral infections, aging,
Meniere’s disease, tumors and rarely infarct.
Most common tumor is the acoustic neuroma, which is actually a
schwannoma and typically originates where the 8th nerve enters the
brainstem.
Symptoms include unilateral hearing loss, tinnitus (ringing in the ear)
and unsteadiness.
Trigeminal is often also affected as tumor spreads, leading to facial pain
and sensory loss.
With large tumors additional deficits may occur due to compression of
cerebellar and corticospinal pathways causing ipsilateral ataxia and
contralateral hemiparesis.
Trigeminal neuroma is also somewhat common.
Schwannomas of the other cranial nerves are very rare.
Dizziness & Vertigo

Dizziness is a general term used by patients with a number of different

conditions.
Vertigo is a spinning sensation of movement and is more closely linked
with vestibular disease.
Vertigo can be caused by damage to vestibular pathways anywhere
from the labyrinth to the parietal cortex.
Most cases of vertigo are caused by peripheral disorders, fewer by CNS
disorders.
CNS disorder can often be detected by looking for diplopia or other visual
changes, somatosensory changes, weakness, dysarthria, ataxia, or
impaired consciousness.
Cranial Nerve IX: Glossopharyngeal Nerve

Motor function: stylopharyngeus muscle which elevates pharynx during

talking and swallowing and participates in gag reflex.
Motor neurons are in the nucleus ambiguus.
Parasympathetic function: innervation of parotid salivary gland.
Preganglionic neurons in inferior salivatory nucleus; postganglionic
neurons in the otic ganglion
Somatic sensory function: sensation from middle ear, external auditory
meatus, pharynx and posterior 1/3 of tongue.
Primary sensory neurons in the inferior and superior glossopharyngeal
ganglion which projects to the spinal nucleus of the trigeminal.
Visceral sensory function: taste from posterior 1/3 of tongue.
Primary sensory neurons in the inferior glossopharyngeal ganglion
project to rostral nucleus solitarius
Visceral sensory function: chemoreceptors and baroreceptors in carotid
body.
Primary sensory neurons in the inferior glossopharyngeal ganglion
project to caudal nucleus solitarius.
Cranial Nerve X: Vagus Nerve

Motor function: pharyngeal muscles (swallowing) & laryngeal muscles

Motor axons from the nucleus ambiguus.
Parasympathetic function: innervation of heart, lungs, digestive tract
down to the splenic flexure.
Motor neurons in the dorsal motor nucleus of vagus in the medulla.
Somatic sensation function: sensation from pharynx, meninges,
external auditory meatus
Primary sensory neurons in inferior and superior vagal ganglia that
project to the spinal nucleus of the trigeminal
Visceral sensory function: taste from epiglottis and pharynx.
Primary sensory neurons in the vagal ganglia that project to
the rostral nucleus solitarius
Visceral sensory function: from chemoreceptors and baroreceptors
in the aortic arch, cardiorespiratory system and digestive tract.
Primary sensory neurons are in vagal ganglia that project to
the caudal nucleus solitarius
Cranial Nerve XI: Spinal Accessory Nerve

Motor function: sternomastoid and upper trapezius muscles

Motor neurons found in lateral intermediate zone of C1-C5/C6 spinal
cord segments; axons leave cord lateral surface, ascend and join
together forming spinal accessory nerve.
Sternomastoid muscle functions in turning head (left muscle turns head
right).
Trapezius muscle functions in elevating shoulder.
Cranial Nerve XII: Hypoglossal Nerve

Motor function: intrinsic and extrinsic tongue muscles.

Motor neurons in hypoglossal nucleus near midline in medulla.
Upper motor neurons in inferior part of motor cortex.
In UMN injury tongue will deviate away from the lesion; in LMN injury
tongue will deviate toward the side of the injury.
Disorders of CN IX, X, Xi, and XII

Damage to these nerves/nuclei is most commonly a CNS injury.

Hoarseness is most often due to vagus injury. Nucleus ambiguus
can be damaged in a lateral medullary infarct.
Dysarthria is abnormal articulation of speech and can occur from injury
to CN V, VII, IX, X, or XII or UMN ; common causes are
infarct and MS damaging UMN pathways.
Dysphagia is impaired swallowing and can occur following injury to
CN IX, X or XII or UMN injury.
Brainstem nuclei involved in laughing and crying include CN VII, IX, X,
and XII. Lesions of corticobulbar paths in the subcortical white
matter can cause pseudobulbar affect in which patients exhibit
uncontrollable outbursts of laughing or crying with no
accompanying emotions.