Brainstem Syndromes

How To Use This Resource

This module is designed as an interactive review of the brainstem stroke
syndromes
It is intended to provide a top down approach taking you from a patient
who presents with a constellation of syndromes and allowing you to work
out the anatomic localization
It is meant to be run in Power Point and has animations that should allow
you to work through the case scenarios

Learning Objectives
Review the neuroanatomical structures including cranial
nerve, relay nuclei, and tracts that within the brainstem.
Review the vascular supply of the brainstem.
Be able to describe the key clinical features of the common
brainstem syndromes reviewed in these cases.
Be able to localize lesions within the brainstem based on
presenting signs and symptoms in a clinical case.

Outline
Case 1: A 32 year old waitress presenting with nausea, vertigo, and ataxia.
Case 2: A 72 year old male presenting with right-sided weakness and
slurred speech.
Case 3: A 58 year old accountant presenting with slurred speech, difficulty
walking, left sided weakness and horizontal diplopia.
Case 4: A 75 year old woman presenting with double vision, weakness,
tremor, and involuntary movements.
Case 5: A 60 year old woman found unresponsive by her daughter.

Vignette 1: Presentation and Exam

A 32 year old waitress without significant past medical history presented
to the emergency room with dizziness and nausea. Her symptoms started
this morning. While working at I-HOP, where she will often walk with a
heavily laden tray crooked between her neck and shoulder, she noted that
she was bumping into tables and chairs and listing to the right. She also
felt as though the room was spinning.
On examination:
MS: Awake, alert, and mildly distressed. Oriented to person, place, and time.
CN: Her speech is fluent but hoarse and there was rotary nystagmus to the left, pupils
were reactive but the left was smaller than the right and the left corneal reflex was not
present.
Motor: No adventitious movements noted. Normal bulk and tone. Power 5/5
throughout.
Sensory: Sensation to pain diminished in the right leg and the left face. Dorsal touch and
proprioception intact.
Reflexes: Mildly decreased on the left and normal on the right.
Cerebellum: Mild dysmetria on finger to nose on the left.
Gait: When she attempted to stand she fell to the left and was unable to walk.

Vignette 1: Sign and Symptom Localization

Signs and Symptoms
1.
2.
3.
4.
5.
6.
7.
8.

Vertigo, nausea, vomiting, nystagmus

Impaired Taste
Impaired gag
Hoarseness and dysphagia
Horners (ptosis, miosis, anhydrosis)
Ataxia
Loss of pain/temp to face
Loss of pain/temp to body

Localization
1.
2.
3.
4.
5.
6.
7.
8.

Vestibular Nuclei (ipsi)

Nucleus / Tractus Solitarius (ipsi)
Dorsal Motor of the Vagus (ipsi)
Ventral Motor of the Vagus (aka Nucleus
Ambiguus) (ipsi)
Sympathetic Fibers (ipsi)
Inferior Cerebellar Peduncle (ipsi)
Spinal Nucleus of V (ipsi)
Anterolateral System (contra)

Vignette 1: Neurologic Localization

1.

Vestibular Nuclei

2.

Nucleus / Tractus Solitarius

3.

Dorsal Motor of the Vagus

4.

Ventral Motor of the Vagus

(aka Nucleus Ambiguus)

1.

Sympathetics

2.

Inferior Cerebellar Peduncle

3.

Spinal Nucleus of V

4.

Anterolateral System

Lateral Medullary Syndrome

The most common of the brainstem lesion syndromes
Often the vignette will describe a young person with vascular injury from
repetitive head / neck movements
Caused by an occlusion of PICA (Posterior Inferior Cerebellar Artery)
Characteristic features are nausea / vomiting, vertigo, unilateral ataxia,
and Horners syndrome, loss of pain and temp (body contra, face ipsi)
Symptom Summary

Vascular Localization

Vignette 2: Presentation and Exam

A 72 year old male presented to the emergency room with sudden onset
weakness on the right side of the body noted while at Starbucks. His wife
noted that he was somewhat difficult to understand with a garbled or
slurred quality to his speech.
On examination:
MS: Awake, alert, and in mild distress. Oriented to person, place, and time. Speech was
notable for poor articulation especially with T sounds.
CN: Pupils and eye movements normal. Face symmetric. No nystagmus. The tongue
protruded to the left.
Motor: No adventitious movements. Reduced muscle tone. Dense, right hemipareis
which seemed more pronounced distally. Left normal.
Sensory: Impaired sensation to touch / proprioception on the right side of the body.
Reflexes: Brisk on the right. Otherwise normal.
Cerebellum: No clear dysmetria.
Gait: He was able to stand and walk but did so hesitantly with a mild ataxia.

Vignette 2: Sign and Symptom Localization

Signs and Symptoms
1.
2.
3.
4.
5.
6.

Slurred Speech
Tongue Protruding to Left
Hemiparesis
Brisk Reflexes on Right
Hemisensory Loss to Touch / Proprioception
Gait Ataxia

Localization
1.
2.
3.
4.
5.
6.

Hypogloasal Nucleus
Hypoglossal Nucleus (ipsilateral)
Corticospinal Tract (contralateral)
Corticospinal Tract (contralateral)
Medial Lemniscus (contralateral)
Medial Lemniscus (contralateral)

Vignette 2: Neurologic Localization

1. Hypoglossal Nucleus

2. Medial Lemniscus

3. Corticospinal Tract

Medial Medullary Syndrome (Dejerine)

Caused by occlusion of the anterior spinal artery at the level of the medulla
Constellation of tongue weakness on one side and body weakness on the
other side, with loss of discriminative touch / proprioception contralateral to
the side of the lesion.
Vascular Localization

Vignette 3: Presentation and Exam

A 58 year old accountant presented to the emergency room with acute
onset slurred speech which started during an important business meeting.
Coincident with the slurred speech, the patient noted difficulty walking,
left sided weakness and horizontal diplopia.
On examination:
MS: Awake, alert, mildly distressed. Slightly sleepy. Mild dysarthria.
CN: EOM exam was notable for a right abducens nerve palsy, PERRL, right facial
weakness. Tongue protrudes to midline.
Motor: Normal tone and no adventitious movement. Pronounced weakness of the left
arm and leg. Right are normal.
Sensory: Decreased sensation to touch and proprioception on the left.
Reflexes: Intact.
Cerebellum: Mild difficulty with finger to nose on the right.
Gait: Able to stand but requires support on the left (paretic side). The feet are widely
spaced. Could not walk.

Vignette 3: Sign and Symptom Localization

Signs and Symptoms
1.
2.
3.
4.
5.

Dysarthria
Facial Weakness (entire face)
Decreased Touch and Proprioception
Arm and Leg Weakness
Dysmetria

Localization
1.
2.
3.
4.
5.

Facial Motor Nucleus

Facial Motor Nucleus (ipsi)
Medial Lemniscus (contralateral)
Corticospinal Tract (contralateral)
Pedunculopontine Fibers

Vignette 3: Neurologic Localization

1.

Facial Motor Nucleus

2.

Facial Motor Nucleus

3.

Medial Lemniscus

4.

Corticospinal Tract

5.

Pedunculopontine Fibers

Medial Pontine Syndrome (Millard-Gubler)

Medial pontine syndromes are relatively common
Caused by occlusion of the Paramedian Pontine Perforating branches of
Basilar Artery
Symptom Summary

Vascular Localization

Vignette 4: Presentation and Exam

A 75 year old woman presents to the emergency room after abruptly

developing double vision while at a church B-I-N-G-O function. The onset of
symptoms was sudden and she noted horizontal more than vertical double
vision. When she tried to touch her stamper, she had difficulty reaching for it
and noted weakness in the right arm. When she attempted to stand, she had
difficulty supporting herself and immediately sat back down. During the
ambulance ride she noted a tremor in the right arm.

On examination:

MS: She appears pleasant but quite nervous. There is no dysarthria.

CN: She has a dilated pupil on the left with deviation of the left eye up and slightly out.
Movements of the right eye are normal. The remainder of her cranial nerves are normal.
Motor: She has weakness in the right arm and leg but not face.
Sensory: There is impaired touch and proprioception on the right in the arm and leg.
Reflexes: Brisk and symmetric throughout with down/down toes.
Cerebellum: She has gross limb ataxia on the right noted more proximally than distally with a
tremor on finger to nose.
Gait: She is able to stand with support and has a wide-stance but refuses to walk.

Vignette 4: Sign and Symptom Localization

Signs and Symptoms
1.
2.
3.
4.
5.

Oculomotor Paralysis
Dilated Pupil
Impaired Sensation (touch/pressure)
Limb Ataxia
Hyperkinesia and Tremor

1. Hemiparesis

Localization
1.
2.
3.
4.
5.

Cranial Nerve III (ipsi)

Cranial Nerve III (ipsi)
Medial Lemniscus (contra)
Red Nucleus via Rubrospinal Tract (contra)
Red Nucleus via Central Tegmenral Tract
(contra)

6.

Cerebral Peduncle (contra)

Vignette 4: Neurologic Localization

1. Cranial Nerve III
2. Cerebral Peduncle
3. Medial Lemniscus
4. Red Nucleus

Benedikt and Weber Syndromes

Occlusion of the paramedian penetrating arteries of the basilar and posterior cerebral artery
Benedikt and Webers are quite similar resulting from lesions in the same general location.
The difference is exactly which structures are affected and which symptoms predominate:

Weber hemiparesis predominate and less tremor (a more ventral lesion)

Benedikt hemiparesis and tremor (a more dorsally extending lesion)

Symptom Summary

Vascular Localization

Vignette 5: Presentation and Exam

A 60 year old woman was found unresponsive on her bedroom floor by
her daughter who called 911. When EMS arrived, she was intubated and
brought to the ED where she was comatose with tachycardia,
hypertension, and tachypnea. Her daughter did offer a history of bouts of
vertigo, ataxia, and double vision over the last two weeks.
On examination:
MS: Comatose and intubated.
CN: Pupils were anisocoria with the left being 4 and right 3 neither of which were very
reactive. The left eye was deviated out and down. Other brainstem reflexes were intact.
Motor: Decerebrate posturing to pain in all four extremities.
Sensory: Decerebrate posturing to pain in all four extremities.
Reflexes: Reflexes were increased on the right with an up-going right toe.
Cerebellum: Unable to assess.
Gait: Unable to assess.

Vignette 5: Sign and Symptom Localization

Signs and Symptoms

Vision Loss
Memory Disturbance
Oculomotor Palsy
Peduncular Hallucinosis (somnolence,
delirium, vivid visual hallucinations)
Ataxia

Localization
1.
2.
3.
4.
5.

Visual Cortex
Medial Thalamus
Cranial Nerve III
Midbrain Reticular Formation
Cerebellum

Top of the Basilar Syndrome

Embolus lodged in the distal basilar artery
Causes occlusion of multiple vascular territories
Vascular Localization

Outline
Case 1: Lateral Medullary Syndrome (Wallenberg)
Case 2: Medial Medullary Syndrome (Dejerine)
Case 3: Pontine Syndrome
Case 4: Midbrain Syndromes (Benedikt and Weber)
Case 5: Top of the Basilar Syndrome