BRAINSTEM

Miss V. Bisetty
Department of Clinical Anatomy
School of Laboratory Medicine & Medical Sciences
College of Health Sciences
University of KwaZulu-Natal
BRAINSTEM
BRAINSTEM
BRAINSTEM
 BRAINSTEM
• Provides the main motor and sensory innervation to the face and neck via the cranial nerves
• Nerve connections of the motor and sensory systems from the main part of the brain to the rest of the body pass
through the brain

Brainstem contains:
• Corticospinal tract (in the pyramids of the medulla) - Motor
• Posterior column-medial lemniscus pathway - Fine touch, vibration sensation and proprioception
• Spinothalamic tract - Pain, temperature, itch and crude touch

Roles of the brainstem:

• Regulation of cardiac and respiratory function
• Regulation of the central nervous system, and is pivotal in maintaining consciousness
• Regulation of the sleep cycle
 MIDBRAIN: EXTERNAL ANATOMY

• Also known as the mesencephalon

• Most superior of the three regions of the brainstem.
• Acts as a conduit between the forebrain above and the pons and cerebellum below.
• Smallest of the three regions of the brainstem, measuring around 2cm in length.
• As it ascends, the midbrain travels through the opening in the tentorium cerebelli – Tentorial notch.

• Two main parts:

Ø Tectum – located posterior to the cerebral aqueduct
Ø Paired cerebral peduncles – located anteriorly and laterally.
Internally, the cerebral peduncles are further separated by the substantia nigra into the crus cerebri
(anterior) and the tegmentum (posterior).
 MIDBRAIN: EXTERNAL ANATOMY
• The tectum houses 4 rounded prominences - colliculi (collectively the
corpora quadrigemina) which sit directly inferior to the pineal gland.
• Colliculi are separated by the cruciform sulcus; there are two superior
and two inferior colliculi [Visual & Auditory reflexes, resp.].
• Extending laterally from each colliculi are the quadrigeminal
brachium:
Ø Superior quadrigeminal brachium forms a pathway between the
superior colliculus and the retina of the eye.
Ø Inferior quadrigeminal brachium conveys fibres from the lateral
lemniscus and inferior colliculus to the medial geniculate body.
• Inferior to the colliculi, the trochlear nerve (CN IV) emerges before
sweeping across to the anterior surface.
 MIDBRAIN: EXTERNAL ANATOMY

• The paired cerebral peduncles extend from the cerebral

hemispheres to converge as they meet the pons.
• They are separated anteriorly in the midline by the
interpeduncular fossa, the floor of which is termed the posterior
perforated substance (as many perforating blood vessels can be
identified).

• The oculomotor nerve (CNIII) is seen exiting from between the

peduncles while the optic tract runs around the superior border of
the midbrain.
 MIDBRAIN: INTERNAL ANATOMY
Level of the Inferior Colliculus
• The anterolateral surface of the midbrain houses the paired crus cerebri.

• Four fibre tracts run within the crus:

Ø Frontopontine fibres – located most medially.
Ø Corticospinal fibres – motor fibres from the
primary motor cortex.
Ø Corticonuclear tracts – motor fibres from the
primary motor cortex.
Ø Temporopontine fibres – located
posterolaterally.
 MIDBRAIN: INTERNAL ANATOMY
Level of the Inferior Colliculus
• Posteriorly is the substantia nigra – a pigmented nucleus
that separates the two regions of the cerebral peduncles.
• It is further broken down into the pars reticulata (anterior)
and pars compacta (posterior). [Motor control]

• The tegmentum is located posterior to the substantia

nigra.
• It is continuous with that found in the pons by the same
name.
• It is important to note that unlike the crus cerebri, the
tegmentum is continuous at the midline.
 MIDBRAIN: INTERNAL ANATOMY
Level of the Inferior Colliculus
• The cerebral aqueduct is a midline structure
surrounded by central gray matter – the periaqueductal
gray matter.

• Within this gray matter lies the mesencephalic nucleus

of the trigeminal nerve, as well as the trochlear
nucleus with its fibres continuing around the gray
matter to exit the midbrain.

• Anterior to this, the medial longitudinal fasciculus can

be seen.
 MIDBRAIN: INTERNAL ANATOMY

Level of the Inferior Colliculus

• The decussation of the superior cerebellar peduncles
can be seen centrally at this level with some reticular
formation lying lateral.

• Between the central gray matter and the substantia nigra

are four lemnisci. Moving anterior to posterior they are
the medial, spinal, trigeminal, and lateral lemnisci.

• At the very posterior pole, we find the tectum which, at

this level, contains the inferior colliculus.
 MIDBRAIN: INTERNAL ANATOMY
Level of the Superior Colliculus
• Much of the internal structure of the midbrain is
unchanged at this level and should be assumed present
unless mentioned hereafter.

• The central portion which previously was occupied by

the decussation of the superior cerebellar peduncles
now contains the large paired red nuclei with some
decussation of the rubrospinal tract occurring anterior
to this. [Muscle tone]
• The reticular formation now fans around the posterior
borders of the red nuclei.
 MIDBRAIN: INTERNAL ANATOMY

Level of the Superior Colliculus

• The trochlear nucleus is replaced with the oculomotor
nucleus while the oculomotor nerve projects anteriorly.

• The medial, spinal and trigeminal lemnisci are all

present in much the same location however the lateral
lemnisci does not reach to this level.

• The tectum now contains the superior colliculi rather

than the inferior colliculi. Edinger-
Westphal
nucleus
 CLINICAL SIGNIFICANCE
Substantia nigra and Parkinson's disease
• Parkinson’s disease is a slowly progressive
disorder that affects movement, muscle control,
and balance.
• Part of the disease process develops as cells are
destroyed in certain parts of the brain stem,
particularly the crescent shaped cell mass known
as the substantia nigra.
• Nerve cells in the substantia nigra send out fibers
to tissue located in both sides of the brain.
• There the cells release essential neurotransmitters
that help control movement and coordination.
 PONS

• Largest part of the brainstem, located above the medulla and below the midbrain.
• A group of nerves that function as a connection between the cerebrum and cerebellum (pons is Latin for
bridge).
• Develops from the embryonic metencephalon (part of the hindbrain, developed from the
rhombencephalon), alongside the cerebellum.

• A horseshoe-shaped collection of nerve fibres located in the anterior part of the posterior cranial fossa.
• Its anatomical relations are as follows:
Ø Posteriorly – the cerebellum, separated by the fourth ventricle.
Ø Inferiorly – the medulla oblongata.
Ø Superiorly – the midbrain lies immediately above the pons.
 PONS: EXTERNAL ANATOMY
Anterior/ Ventral Surface
• Marked by a bulging formed by the transverse
pontocerebellar fibres. These fibres wrap around the
otherwise vertically oriented brainstem. It measures
around 2.5 cm in adults.

• The basilar groove demarcates the midline of the ventral

MCP
surface and is where the basilar artery is located.

• The pontomedullary junction is an important anatomical

landmark defined by the angle between the lower border
of the pons and the superior border of the medulla.
 PONS: EXTERNAL ANATOMY
Anterior/ Ventral Surface
• Several cranial nerves originate from the ventral surface of
the pons:
Ø Cranial nerve V: trigeminal – originates from the lateral
aspect of mid pons
Ø Cranial nerve VI: abducens – originates from the
pontomedullary junction, close to the midline
Ø Cranial nerve VII: facial – originates from the
cerebellopontine angle, the more lateral aspect of the
pontomedullary junction.
Ø Cranial nerve VIII: vestibulocochlear – originates
laterally to the facial nerve.
 PONS: EXTERNAL ANATOMY

Posterior Surface
• Intimately related to the cerebellum and is connected
to it by the middle cerebellar peduncles.
• Removal of the cerebellum will reveal the underlying
fourth ventricle.
 PONS: EXTERNAL ANATOMY
Posterior Surface
• The floor of the fourth ventricle is composed of the dorsal
surface of the pons and the medulla.

• There are some important anatomical landmarks here:

Ø The medial eminence marks the midline of the floor.
Ø The facial colliculus is a bulging formed by the fibres of
the facial nerve looping around the abducens nucleus.
Ø The stria medullaris of the fourth ventricle is a bundle of
nerve fibres crossing transversely from the lateral aspect
into the midline. They mark the posterior border between
the pons and the medulla.
 PONS: EXTERNAL ANATOMY

Posterior Surface
• The angle formed at the junction of the pons, medulla,
and cerebellum is another anatomical landmark and is
named cerebellopontine angle.
• Here, the cerebellar flocculus, the ventricular choroid
plexus and the emerging CNs VII and VIII surround
the lateral apertures of the fourth ventricle (the foramen
of Luschka).
 PONS: INTERNAL ANATOMY
• Comprised of two major components – the ventral pons and
the tegmentum.
Ø Ventral pons contains the pontine nuclei, which are
responsible for coordinating movement. Fibres from the
pontine nuclei cross the midline and form the middle
cerebellar peduncles on their way to the cerebellum.
Ø Tegmentum is the evolutionarily older part of the pons
which forms part of the reticular formation – a set of nuclei
found throughout the brainstem that are responsible
for arousal and attentiveness. Damage to this part of the
pons may result in anosognosia for hemiplegia, where
patients are unaware of their paralysis.
 PONS: INTERNAL ANATOMY
• The rest of the pons is made up of tracts passing through the pons including:
Ø Descending corticospinal tracts – responsible for voluntary motor control of the body.
Ø Descending corticobulbar tracts – responsible for voluntary motor control of face, head and neck.
Ø Ascending medial lemniscus tracts – responsible for fine touch, vibration and proprioception.
Ø Ascending spinothalamic tracts – responsible for pain and temperature sensation
 PONS: INTERNAL ANATOMY
CRANIAL NERVE NUCLEI IN THE PONS
• Mid pons: the chief or pontine nucleus of the trigeminal nerve sensory nucleus (V)
• Mid pons: the motor nucleus for the trigeminal nerve (V)
• Lower down in the pons: abducens nucleus (VI)
• Lower down in the pons: facial nerve nucleus (VII)
• Lower down in the pons: vestibulocochlear nuclei (vestibular nuclei and cochlear nuclei) (VIII)

• The functions of these four nerves include sensory roles in hearing, equilibrium, and taste, and in facial
sensations such as touch and pain ; as well as motor roles in eye movement, facial expressions, chewing,
swallowing, and the secretion of saliva and tears.

• A urinary control centre (pmc) is also found in the upper pons

 MEDULLA OBLONGATA

• Most inferior of the three brainstem regions.

• Continuous above with the pons and below with the spinal cord.
• Houses essential ascending and descending nerve tracts as well as brainstem nuclei.

• Conical in shape, decreasing in width as it extends inferiorly.

• It is approximately 3cm long and 2cm wide at its largest point.
• The superior margin of the medulla is located at the junction between the medulla and pons, while the
inferior margin is marked by the origin of the first pair of cervical spinal nerves. This occurs just as the
medulla exits the skull through the foramen magnum.
MEDULLA OBLONGATA: EXTERNAL ANATOMY

ANTERIOR SURFACE
• Several structures on the anterior surface of the medulla
– three fissures/sulci, the pyramids, the olives, and five
cranial nerves.

• In the midline of the medulla is the anterior median

fissure, which is continuous along the length of the
spinal cord. However, it is interrupted temporarily by
the decussation of the pyramids.
• Lateral to the midline, two sulci – the ventrolateral
sulcus and the posterolateral sulcus.
MEDULLA OBLONGATA: EXTERNAL ANATOMY
ANTERIOR SURFACE
• Pyramids - paired swellings found between the anterior
median fissure and the ventrolateral sulcus.
• Olives – paired swellings located laterally to the pyramids
– between the ventrolateral and posterolateral sulci.

• Arising from the junction between the pons and medulla

is the abducens nerve (CN VI).
• Extending out of the ventrolateral sulcus is the
hypoglossal nerve (CN XII).
• In the posterolateral sulcus, three more cranial nerves join
the medulla (CN IX, CN X, and CN XI).
MEDULLA OBLONGATA: EXTERNAL ANATOMY
POSTERIOR SURFACE
• The posterior surface is largely obstructed from view and is
relatively devoid of features. The cerebellum must be removed
to view posterior surface.

• Midline structure – the posterior median sulcus –continuous

below as the posterior median sulcus of the spinal cord.
• Above, the sulcus ends at the point in which the fourth ventricle
develops.

• Lateral from the midline - the fasciculus gracilis and fasciculus

cuneatus, separated by the posterior intermediate sulcus.
MEDULLA OBLONGATA: INTERNAL ANATOMY
• Divided into two regions: the open and the closed medulla.
• This distinction is made based on whether the CSF-containing cavities are surrounded by the medulla
(closed medulla) or not (open medulla).
• The medulla becomes open when the central canal opens into the fourth ventricle.
• Anteriorly we can see the paired lumps representing the pyramids which are separated by the anterior
median fissure.
• Centrally, the central canal can be seen as it rises to form the fourth ventricle in the final cross section.
MEDULLA OBLONGATA: INTERNAL ANATOMY
LEVEL OF THE DECUSSATION OF THE PYRAMIDS
• Major decussation point of the descending motor fibres.
Roughly 75% of motor fibres housed within the pyramids cross
diagonally and posteriorly, and continue down the spinal column
as the lateral corticospinal tracts.

• At this level, the central portion of the medulla contains gray

matter, while the outer portions consist of white matter. The
posterior white matter contains the fasciculus gracilis and the
more lateral fasciculus cuneatus.
• Corresponding portions of gray matter extend to these regions
and are the nucleus gracilis and nucleus cuneatus respectively.
MEDULLA OBLONGATA: INTERNAL ANATOMY

LEVEL OF THE DECUSSATION OF THE PYRAMIDS

• Unchanged from the spinal cord, the spinocerebellar tracts
(posterior and anterior) are located laterally, with the lateral
spinothalamic tract situated between them.
• The large trigeminal nucleus and tracts can be found
posterior to these tracts. This is a continuation of the
substantia gelatinosa of the spinal cord.
MEDULLA OBLONGATA: INTERNAL ANATOMY

LEVEL OF DECUSSATION OF THE MEDIAL

LEMNISCUS
• Centrally, the hypoglossal nucleus and medial
longitudinal fasciculus are seen.
• Moving laterally, the nucleus ambiguous can be seen.
• Between this structure and the pyramids is the inferior
olivary nucleus.
MEDULLA OBLONGATA: INTERNAL ANATOMY

LEVEL OF THE OLIVES

• Shows significant change in structure both.
• The central canal has now expanded into the fourth
ventricle and as such makes this region the open
medulla.

• The large inferior olivary nucleus is responsible for

the external expansion of the olives.
• The related medial and dorsal accessory olivary
nuclei can be seen medial and posterior to this
structure respectively.
MEDULLA OBLONGATA: INTERNAL ANATOMY

LEVEL OF DECUSSATION OF THE MEDIAL

LEMNISCUS
• This level marks the sensory decussation occurs of
the medial lemniscus.
• Lateral to the medial lemniscus, the trigeminal
nucleus and spinal tract can once again be seen, as
can the spinocerebellar tracts and the lateral
spinothalamic tract. Similarly, the posterior structures
are much the same at this level.
MEDULLA OBLONGATA: INTERNAL ANATOMY

LEVEL OF THE OLIVES

• The large inferior cerebellar peduncles come into
view and are surrounded by multiple nuclei.
• The two vestibular nuclei (medial and inferior) are
both found towards the midline while the two cochlear
nuclei are found somewhat above and below the
peduncles.
• Now a much smaller structure, the trigeminal tract and
nucleus is seen adjacent to the peduncle.
MEDULLA OBLONGATA: INTERNAL ANATOMY
LEVEL OF THE OLIVES
• Nucleus ambiguous remains as is while the hypoglossal nucleus has
migrated with the central canal posteriorly, joined by the medial
longitudinal fasciculus.
• An additional cranial nucleus comes into view lateral to the
hypoglossal – the dorsal vagal nucleus. Moving further lateral, the
nucleus of tractus solitarius comes into view.

• Centrally, the medial lemniscus hugs the midline posterior to the

pyramids, as does the tectospinal tract.

• Between the peduncle and the olivary nuclei resides the lateral
spinothalamic tract and the more lateral anterior spinocerebellar tract.
 BLOOD SUPPLY

Midbrain: basilar artery and its branches

Most of pons: pontine arteries, branches of the basilar artery

Smaller part: anterior inferior cerebellar artery and the superior cerebellar artery

Medulla oblongata: anterior spinal, the posterior spinal, the posterior inferior cerebellar, the anterior
inferior cerebellar, and vertebral arteries.
 THANK YOU!
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