The medulla oblongata not only contains many cranial

nerve nuclei that are concerned with vital functions (regulation of

heart rate and respiration),but it also serves as a conduit for the
passage of ascending and descending tracts connecting the spinal
cord to the higher centers of the nervous system.

These tracts may become involved in demyelinating

diseases, neoplasms, and vascular disorders.
 (1) Medial medullary syndrome

occlusion of vertebral artery medullary branch .

Ipsilateral to lesion

Structures involved Signs and symptoms

CN XII,hypoglossal,or nucleus Paralysis with atrophy of

half the tongue with deviation
to the paralyzed side when
tongue is protruded
Contralateral to lesion

Structures involved Signs and symptoms

Corticospinal tract Paralysis of UE and LE

Medial lemniscus Impaired tactile and

proprioceptive sense
 (2) Lateral medullary syndrome
(wallenburg’s syndrome)
occlusion of any of five vessels may be responsible—
vertebral, posterior inferior cerebellar, or superior, middle, or
inferior lateral medullary arteries
Ipsilateral to lesion

Structures involved Signs and symptoms

Descending tract and decreased pain and

nucleus of CN V,Trigeminal temperature sensation in
face

Ceraballum or cerebellar ataxia: gait and

inferior cerebellar peduncle limbs ataxia
Structures involved Signs and symptoms

Vestibular nuclei and connections vertigo, nausea,

vomiting, nystagmus

Descending sympathetic tract Horner’s syndrome( miosis,

ptosis, decreased sweating)

CN IX, Glossopharyngeal, and Dysphagia and dysphonia:

CN X,vagus, or nuclei paralysis of palatal and laryngeal
muscles, diminished gag reflex

Cuneate and gracile nuclei sensory impairment of Ipsilateral

UE,trunk,or LE
Contralateral to lesion

Structures involved Signs and symptoms

Spinal lemniscus-spinothalamic impaired pain and thermal

tract sense over 50% of body,
sometimes face
 The Pons situated in the posterior cranial fossa lying
beneath the tentorium cerebelli. It is related anteriorly to the
basilar artery, the dorsum sellae of the sphenoid bone, and the
basilar part of the occipital bone.

In addition to forming the upper half of the floor of the fourth

ventricle, it possesses several important cranial nerve nuclei
(Trigeminal, Abducent , Facial and Vestibulocochlear )
and serves as a conduit for important ascending and descending
tracts ( Corticonuclear, Corticopontine , Corticospinal , Medial
longitudinal fasciculus , and Medial , Spinaland lateral Lemnisci )
therefore, that tumors, hemorrhage,or infarcts in this area of the
brainstem produce a veriety of symptoms and signs.
(1)-MEDIAL INFERIOR PONTINE SYNDROME

Occlision of paramedian branch of basilar artery

Ipsilateral to lesion

Structures involved Signs and symptoms

Pontine center for lateral Paralysis of conjugate gaze to

gaze paramedian pentine side of lesion(preservation of
reticular formation(PPRF) convergence)

Vestibular nuclei and Nystagmus

connections
Structures involved Signs and symptoms

Middle cerebellar peduncle Ataxia of limbs and gait

CN VI(Abducens) or nucleus Diplopia on lateral gaze

Contralateral to lesion

Structures involved Signs and symptoms

Corticobulbar and corticospinal Paresis of face ,UE and

tract in lower pons LE

Medial lemniscus Impaired tactile and

proprioceptive sense over
50% of the body
(2)-LATERAL INFERIOR PONTINE SYNDROME

Occlusion of anterior inferior cerebellar artery, a branch of

the basilar artery.

Ipsilateral to lesion

Structures involved Signs and symptoms

CN VIII(Vestibular) or nucleus Horizontal and vertical

nystagmus,vertigo,nausea,
vomiting

CN VII(Facial )or nucleus Facial paralysis

Structures involved Signs and symptoms

Pontine center for lataral Paralysis of conjugate

gaze(PPRF) gaze to side of lesion

CN VIII(Cochlear )or nucleus Deafness,tinnitus

Middle cerebellar peduncle Ataxia

and cerebellar hemisphere

Main sensory nucleus and impaired sensation over

descending tract of fifth nerve face
Contralateral to lesion

Structures involved Signs and symptoms

Spinothalamic tract impaired pain and

thermal sense over half
the body
(3)-MEDIAL MIDPONTINE SYNDROME
Occlusion of paramedian branch of the mid-basilar artery

Ipsilateral to lesion

Structures involved Signs and symptoms

Middle cerebellar peduncle Ataxia of limbs and gait

Contralateral to lesion

Structures involved Signs and symptoms

Corticobulbar and corticospinal tract Paralysis of face,UE and

LE

Pontine center of lateral gaze Deviation of eyes

(4)-LATERAL MIDPONTINE SYNDROME

Occlusion of short circumferential artery

Ipsilateral to lesion

Structures involved Signs and symptoms

Middle cerebellar peduncle Ataxia of limbs

Motor fibers or nucleus of Paralysis of muscles of

CN V(trigeminal) mastication

Sensory fibers or nucleus of Impaired sensation over

CN V (trigeminal) side of face
(5)-MEDIAL SUPERIOR PONTINE SYNDROME
Occlusion of paramedian branches of upper basilar artery

Ipsilateral to lesion

Structures involved Signs and symptoms

Superior or middle Cerebellar ataxia

cerebellar peduncle

Medial longitudinal fasciculus Internuclear ophthalmoplegia

Contralateral to lesion

Structures involved Signs and symptoms

Corticobulbar and corticospinal tract Paralysis of face,UE and

LE
(6)-LATERAL SUPERIOR PONTINE SYNDROME

Occlusion of superior cerebellar artery,a branch of

the basilar artery.

Ipsilateral to lesion

Structures involved Signs and symptoms

Middle and superior cerebellar Cerebellar ataxia of limbs

peduncles,superior surface of and gait, falling to side of
cerebellum,dentate nucleus lesion

Vestibular nuclei Dizziness,nausea,vomiting

Horizontal nystagmus
Structures involved Signs and symptoms

Descending sympathetic fibers Horner’s syndrome:

miosis,ptosis,decreased
sweating on opposite side
face

Uncertain Paresis of conjugate

gaze(ipsilatereal),Loss of
optokinetic nystagmus
Contralateral to lesion

Structures involved Signs and symptoms

Spinothalamic tract Impaired pain and

thermal sense of
face,limbs and trunk

Medial lemniscus(lateral portion) Impaired touch,

Vibration,and position
sense,more in LE than
UE (tendency to
incongruity of pain and
touch deficits)
 The midbrain forms the upper end of the narrow stalk of
brainstem.
As it ascends out of the posterior cranial fossa through the
relatively small rigid opening in the tentorium cerebelli,it is
vulnerable to traumatic injury.
It possesses two important cranial nerve nuclei
(Oculomotor and trochlear), reflex centers(the colliculi),and the
Red nucleus and substantia nigra, which greatly influence motor
function and the midbrain serves as a conduit for many important
ascending and descending tracts.
As in other parts of the brainstem,it is a site for
tumors,hemorrhage,or infercts that will produce a wide variety of
symptoms and signs.
1)-PARINAUD’S SYNDROME

Lesion location Midbrain dorsum

Structures involved Quadrigeminal plate region;

pretectum;periaqueductal gray matter

Clinical findings Impaired upgaze;convergence

retraction nystagmus;dilated pupils
with light near dissociation

Comment Usually due to mass lesion in the

region of the posterior third
ventricle,most often pinealoma, or due
to midbrain infarction
2)-WEBER’S SYNDROME

Lesion location Midbrain base

Structures involved CN III ,fibers’cerebral peduncle

Clinical findings Ipsilateral CN III palsy’

contralateral hemiparesis

Comment Usually vascular

3)-BENEDIKT’S SYNDROME

Lesion location Midbrain tegmentum

Structures involved CN III fibers,Red nucleus,CST,SCP

Clinical findings Ipsilateral CN III palsy’contralateral

hemiparesis with ataxia,hyperkinesis
and tremor “rubral tremor”

Comment Usually vascular

4)-CLAUDE’S SYNDROME

Lesion location Midbrain tegmentum

Structures involved CN III fibers; Red nucleus; SCP

Clinical findings Ipsilateral CN III palsy; contralateral

ataxia and tremor(rubral tremor)

Comment Usually vascular