BRAIN CME

ABBREVIATION KEY
CN cranial nerve
MLF medial longitudinal fasciculus
PICA posterior inferior cerebellar
artery
MSA multiple system atrophy
DTI diffusion tensor imaging

Primer of Brainstem Anatomy:

A Detailed Examination of Anatomy Received September 16, 2013;
accepted August 13, 2014.
From the Department of Radiology,

and Pathology Through MRI and DTI University of California Los

Angeles, Los Angeles, California.
Please address correspondence to
M. Fitzgibbons and N. Salamon Department of Radiology,
University of California Los
Angeles, 757 Westwood Blvd.,
Suite 1638, Los Angeles,
CA 90095-7437; e-mails:
mtzgibbons@mednet.ucla.edu;
nsalamon@mednet.ucla.edu
CME Credit
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ABSTRACT
We present a pictorial review of brain stem anatomy and vasculature at the level of the
midbrain, pons, and medulla by comparing multiple modalities, including MR imaging, dif-
fusion tensor imaging (DTI), color-coded presentation mapping, and diffusion tensor trac-
tography. This side-by-side comparison explored important nuclei and pathways, such as
the pyramidal tracts, transverse pontine fibers, medial longitudinal fasciculus, medial lem-
niscus, lateral lemniscus, and central tegmental tract. In addition, we introduced clinical case
examples, such as congenital anomalies, stroke, neoplasm, neurodegenerative disease, met-
abolic disease, and Wallerian degeneration. These clinical case examples helped solidify our
understanding of brain stem anatomy.

Learning Objectives: List brainstem tracts that can be elucidated with diffusion tractogra-
phy, and document their normal pathways.

INTRODUCTION ter understanding of the imaging findings

The anatomy of the brain stem is convo-
luted. It contains multiple nuclei and nu-
merous pathways, which are often difficult
to localize, even with conventional imaging
techniques, for example, MR imaging. The
recent development of diffusion tensor im-
aging (DTI) and diffusion tensor tractogra-
phy has aided the exploration of brain stem
anatomy by providing an understanding of
the directionality of axons. This pictorial
review sought to examine brain stem anat-
omy and vascular territories through a
side-by-side comparison of myelin-stained
specimen, MR imaging, DTI, and diffusion
tensor tractography. A precise knowledge
of brain stem anatomy contributes to a bet-
and clinical manifestations associated with
brain stem pathologies. Our exploration of
brain stem pathology included various
conditions, such as strokes, neurodegen-
erative diseases, congenital anomalies, and
neoplastic processes.
BRAIN STEM ANATOMY AND
VASCULATURE
MIDBRAIN
The midbrain, or mesencephalon, is lo-
cated below the diencephalon and is
broadly separated into 3 parts: the cerebral
peduncle, midbrain tegmentum, and tec-
tum. The cerebral peduncle occupies the

76 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org

Fig 1. Midbrain at superior colliculus. (A) Myelin-stained specimen labeled with the major anatomic structures of the midbrain at the level of the
superior colliculus, including the pyramidal tract, substantia nigra, red nucleus, CN III nucleus, medial lemniscus, MLF, spinothalamic tract, and central
tegmental tract. (B) T2-weighted MR image of the midbrain, with an overlay of a functional map of the brain stem. (C) DTI at this level with labeling of
important anatomic landmarks.
anterior portion of the midbrain and gives the midbrain its
characteristic shape. Several tracts run in the cerebral pe-
duncle, including the frontopontine, pyramidal, and oc-
cipito-temporopontine tracts. The pyramidal tract passes
through the central portion of the cerebral peduncle. The
frontopontine tract passes medial and the occipito-tem-
poropontine tract lies lateral to the cerebral peduncle.
Posterior to the cerebral peduncle, the tegmentum con-
tains the bulk of the midbrain nuclei and tracts, such as the
substantia nigra, oculomotor nucleus, red nucleus, medial
longitudinal fasciculus (MLF), medial and lateral lemnis-
cus, and superior cerebellar peduncle decussation. The tec-
tum, or the quadrigeminal plate, is composed of the supe-
rior and inferior colliculi, which roughly divide the
midbrain into its upper and lower levels.1-6
Upper Midbrain
The red nucleus and substantia nigra dominate the histol-
ogy as the 2 pigmented nuclei at the level of the superior
colliculus (Fig 1). The red nucleus is a round, pigmented
nucleus, which is located centrally within the midbrain teg-
mentum. It is an integral part of the Guillain-Mollaret tri-
angle and connects to the inferior olivary nucleus by the
central tegmental tract. The substantia nigra is a 2-layer,
crescent-shaped structure located on each side of the mid-
brain, immediately posterior to the cerebral peduncle. It is
composed of the substantia nigra pars reticulata and the
substantia nigra pars compacta. Currently, these compo-
nents of the substantia nigra cannot be differentiated under
conventional imaging techniques.1,3-5 Decreased volume of
the substantia nigra has been associated in Parkinson dis-
ease, Huntington disease, and multiple system atrophy
(MSA).7 However, some studies contradict this theory that
the substantia nigra decreases in Parkinson disease.
The oculomotor nucleus is located immediately posterior
to the red nucleus in the midline between the MLF and the
periaqueductal gray. It is an ovoid structure composed of
the principal oculomotor nucleus, caudal central oculomo-
tor nucleus, nucleus of Perlia, and accessory oculomotor
nucleus of Edinger-Westphal.1 The neurons of the oculo-
motor nucleus extend their axons anteriorly through or
medial to the red nuclei. They exit the midbrain at the
interpeduncular cistern between the superior cerebellar ar-
tery and the posterior cerebral artery as the oculomotor
nerve or cranial nerve (CN) III. CN III continues through
the cavernous sinus, superior to the other cavernous CNs,
and along the lateral aspect of the cavernous internal ca-
rotid artery (ICA). It exits through the superior orbital fis-
sure and splits into the superior and inferior divisions.3,4,8,9
The superior division CN III innervates the superior rectus
and levator palpebrae muscles and the inferior division of
the CN III innervates the medial rectus, inferior rectus, in-
ferior oblique, and sphincter pupillae muscles. Compres-
sion of CN III by a posterior communicating artery aneu-
rysms typically causes pupil-involving CN III palsy, which
presents as diplopia, mydriasis, and ptosis. Microvascular
injury to the CN III leads to pupil-sparing CN III.10,11
Lower Midbrain
Caudally, at the level of the inferior colliculus (Fig 2), the
superior cerebellar peduncle decussation occupies the teg-
mental portion of the midbrain. These crossing fibers are
depicted in red as transverse fibers on DTI. The superior
cerebellar peduncles are located posteriorly in the upper
pons and serve as the main efferent pathway of the cerebel-
lum. The superior cerebellar peduncle fibers arise from the
dentate nucleus, decussate in the midbrain at the level of the
inferior colliculus, and continue to the contralateral red
nucleus in the upper midbrain. Thus, infarctions of the cen-
tral midbrain tegmentum cause ataxia and can be seen in
Claude and Nothnagel syndromes.1,10
The trochlear nucleus lies posterior to the superior cere-
bellar peduncle decussation, between the periaqueductal
gray and the MLF. The axons from the trochlear nucleus
course posteriorly and inferiorly around the cerebral aque-
duct. Once they cross the midline at the superior medullary
vellum, they exit as the trochlear nerve, or CN IV, along the
dorsal surface of the brain stem, just caudal to the inferior
colliculus. CN IV courses laterally through the ambient
cistern on gross anatomic specimens. However, its cister-
nal course is difficult to identify on imaging due to its
small diameter and the adjacent superior cerebellar ar-
tery and brachial branches of the precentral cerebellar
vein. CN IV innervates the superior oblique muscle, and
lesions that involve this nerve may lead to vertical diplo-
Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org 77
Fig 2. Midbrain at inferior colliculus. (A) Myelin-stained specimen labeled with major anatomic structures of the midbrain at the level of the inferior
colliculus, including the pyramidal tract, superior cerebellar decussation, CN IV nucleus, medial lemniscus, MLF, spinothalamic tract, and central
tegmental tract. (B) T2-weighted MR image of the midbrain, with an overlay of a functional map of the brain stem. (C) DTI at this level, with labeling
of important anatomic landmarks.
pia and torsional diplopia as well as superior oblique
myokymia.1,4,6,9,12
The MLF is a white matter tract located between the
superior cerebellar peduncle decussation and the trochlear
nucleus. It occupies a similar location in the upper and
lower midbrain. The MLF interconnects the 6 ocular motor
nuclei, the bilateral CN III, IV, and VI, to coordinate con-
jugate horizontal eye movements, including saccades,
smooth pursuit, and vestibuloocular reflexes. The ascend-
ing tracts of the MLF arise from the paramedian pontine
reticular formation and terminate in the CN III, IV, and VI
nuclei. These fibers function in visual tracking.2,3,5
Input from the contralateral superior colliculus produces
a burst of excitatory activity in the paramedian pontine
reticular formation, which stimulates the ipsilateral CN VI
nucleus and lateral rectus muscle. Additional fibers cross
over to the other side through the MLF to excite the medial
rectus muscle and produce horizontal eye movements. The
connections between the MLF fibers and vestibular nuclei
produce the eye movements appropriate for changes in head
position. Lesions in the MLF may cause internuclear oph-
thalmoplegia, which can be seen in the setting of multiple
sclerosis or stroke.13 Posteriorly, the periaqueductal gray
surrounds the cerebral aqueduct and receives signals from
both the ascending anterolateral and trigeminal pathways
as well as the descending pathways for pain modulations. It
contributes to the complex function of the reticular forma-
tion and may be symmetrically involved in Wernicke en-
cephalopathy.14
The other key sensory pathways, such as the medial and
lateral lemnisci, are seen along the lateral aspect of the
midbrain tegmentum at the levels of the superior and infe-
rior colliculi. The lateral lemniscus relays auditory informa-
tion from the cochlear nerve to the inferior colliculus. The
medial lemniscus longitudinally carries sensory information
from the cuneate and gracile nuclei to ventral posterior
lateral nucleus of thalamus. The other motor pathways,
such as the central tegmental tract and spinothalamic tract,
are seen within the posterior midbrain tegmentum, lateral
to the MLF and posterior to the medial lemniscus.
78 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org
PONS
The pons is separated from the midbrain by the pontomes-
encephalic sulcus. Similar to the midbrain, the pons is di-
vided into the basis pontis and pontine tegmentum. The
basis pontis is the anterior component of the pons and con-
tains the pyramidal tracts, pontine nuclei, and the trans-
verse pontine fibers. The pontine tegmentum is posterior to
the basis pontis and contains many pathways, including the
medial lemniscus, lateral lemniscus, MLF, and central teg-
mental tract. At the level of the pons, 6 cerebellar peduncles
connect the brain stem to the cerebellum. The superior cer-
ebellar peduncles connect the cerebellum to the upper pons.
The middle cerebellar peduncles bridge the cerebellum to
the mid to lower pons.1,3-6 The attachment of the superior
and middle cerebellar peduncles roughly divides the pons
into an upper and lower segment.
Upper Pons: At the Level of the Superior Cerebellar
Peduncle
In the upper pons (Fig 3), the basis pontis contains the
longitudinally oriented pyramidal tracts and the horizon-
tally oriented transverse pontine fibers. The pyramidal
tracts occupy the anterolateral aspect of the basis pontis and
are indicated in blue on DTI. The transverse pontine fibers
form the horizontal band of red on DTI throughout which
multiple pontine nuclei are interspersed. These pontine nu-
clei receive input from the frontal, parietal, and temporal
lobes, and coalesce laterally along the margins of the lower
pons to form the middle cerebellar peduncles.1,6
In the central portion of the pontine tegmentum, the
reticular formation forms a rhomboid region, anterior to
the fourth ventricle. The reticular formation is an attenu-
ated network of neurons in the central brain stem, which
extends from midbrain to medulla. It is grossly organized
into three sectionsthe lateral, medial, and median zones.
The lateral group is formed of interneurons that are located
medial to the spinal trigeminal and solitary tract nuclei.
These interneurons coordinate simple reflexes and stereo-
typed movements facilitated by the CNs. The medial group
contains larger neurons, which bifurcate into ascending and
descending fibers that control posture, pain, autonomic
Fig 3. Upper pons. (A) Myelin-stained specimen labeled with the major anatomic structures of the upper pons at the level of the superior cerebellar
peduncles, including the pyramidal tract, transverse pontine bers, MLF, medial lemniscus, lateral lemniscus, spinothalamic tract, and central teg-
mental tract. (B) T2-weighted MR image of this level with an overlay of a functional map of the brain stem. (C) DTI at this level, with labeling of
important anatomic landmarks.

Fig 4. Lower pons. (A) Myelin-stained specimen labeled with the major anatomic structures of the lower pons at the level of the middle cerebellar
peduncles, including the pyramidal tract, medial lemniscus, lateral lemniscus, MLF, spinothalamic tract, and central tegmental tract. (B) T2-weighted
MR image at this level, with an overlay of a functional map of the brain stem. (C) DTI at this level, with labeling of important anatomic landmarks.

function, and arousal. The median zone is formed by the
raphe nuclei, a group of serotonergic neurons, which send
axons to the forebrain and the spinal cord.1,2,4
The sensory pathways continue their course through the
pons. The medial lemniscus passes anterior to the superior
cerebellar peduncle, and the lateral lemniscus travels lateral
to the superior cerebellar peduncle. In the posterior tegmen-
tum, the MLF courses posterior to the reticular formation
and the central tegmental tract descends posterolateral to
the reticular formation. The central tegmental tract is an
extrapyramidal tract that connects the red nucleus to the
interior olivary nucleus and consists of 3 pathways: pallido-
olivary, rubro-olivary, and reticulo-olivary fibers.1,13 It is
one of the first regions to myelinate and demonstrates sen-
sitivity to severe asphyxiation of infants.15
Lower Pons: At the Level of the Middle Cerebellar
Peduncle
The lower pons (Fig 4) is also divided into the basis pontis
and the pontine tegmentum. Posteriorly, the middle cere-
bellar peduncles form the major afferent pathway between
the cerebrum, brain stem, and cerebellum. Its fibers origi-
nate along the anterolateral border of the basis pontis in the
upper pons and wrap around the lateral aspect of the lower
pons. The middle cerebellar peduncle axons run in the an-
teroposterior direction and are green on the DTI map. In
addition, CNs VII and VIII exit along the posterolateral
aspect of the basis pontis and pass through cerebellar pon-
tine angle and into the internal auditory canal.
MEDULLA
The medulla is the caudal portion of the brain stem (Figs 5,
6), which is separated from the pons by the pontomedullary
sulcus. On gross examination, the pyramidal tracts are vis-
ible along the ventral margins of the upper medulla and
decussate in the lower medulla at the bulbospinal level. The
inferior olivary nucleus complex is an olive-shaped nucleus
within the anterolateral medulla. It dominates the histo-
logic landscape of the upper medulla. This undulating com-
plex is composed of 3 nuclei, the principal, medial, and
dorsal nuclei, and plays a vital role in the Guillain-Mollaret
triangle.
The hypoglossal nucleus is immediately anterior to the
fourth ventricle. Multiple rootlets arise from this nucleus
and combine to form CN XII. Hypoglossal nerves cross the
lateral cerebellomedullary cistern and exit through the hy-
poglossal canal. CN XII innervates the genioglossus, hypo-
glossus, and styloglossus muscles. Lesions in the hypoglos-
sal nucleus cause deviation of the tongue toward the
ipsilateral side.1,5,8
The vagus nucleus is a complex set of nuclei located
along the posterolateral aspect of the upper medulla, lateral

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Fig 5. Medulla at the inferior olivary nucleus. (A) Myelin-stained specimen labeled with the major anatomic structures of the upper medulla at the level
of the inferior olivary nucleus, including the pyramidal tract, inferior olivary nucleus, MLF, CN X nucleus, CN XII nucleus, vestibular nucleus, and inferior
cerebellar peduncle. (B) T2-weighted MR image at this level, with an overlay of a functional map of the brain stem. (C) DTI at this level with labeling of
important anatomic landmarks.

Fig 6. Medulla at the pyramidal tract decussation. (A) Myelin-stained specimen labeled with the major anatomic structures of the lower medulla at the
level of the pyramidal tract decussation, including the CN/CF (cuneate nucleus/cuneate fasciculus), GN/GF (gracile nucleus/gracile fasciculus),
spinotrigeminal nucleus, and MLF. (B) T2-weighted MR image at this level, with an overlay of a functional map of the brain stem. (C) DTI at this level,
with labeling of important anatomic landmarks.

along the pontomedullary junction. There are multiple ves-

tibular nuclei, including the superior, medial, lateral, and
inferior vestibular nuclei. The vestibular nucleus contains
second-order neurons, which send information to the cere-
bellum, MLF, medial and lateral vestibulospinal tract, re-
ticular formation, and vestibular hair cells.1,3,5
At the pontomedullary junction, the inferior cerebellar
peduncles are the most caudal connections between the
brain stem and the cerebellum. The inferior cerebellar pe-
duncles border the rhomboid fossa and thus form part of
the margins of the fourth ventricle. The posterior spinocer-
ebellar tract, cuneocerebellar tract, and olivocerebellar
tracts are afferent fibers, which pass through the inferior
cerebellar peduncle to the cerebellum.6

Fig 7. Brain stem diffusion tensor tractography. (A, B) Anteroposterior
and lateral views of diffusion tensor tractography of the brain stem illus-
trate the pyramidal tracts in blue, transverse pontine bers in red, and
the middle cerebellar peduncles in green.
to the CN XII nucleus. The dorsal motor nucleus of the
vagus is located lateral to the hypoglossal nucleus and re-
ceives fibers from the hypothalamus, nucleus of the tractus
solitarius, and the main sensory nucleus of CN V. Lesions
that involve the dorsal motor nucleus of the vagus cause
swallowing difficulties.1,3,5
The vestibular nuclei can be found between the vagus
nucleus and the inferior cerebellar peduncle, extending
Neuronal Pathways
As we describe in the following section, multiple motor and
sensory tracts run through the brain stem. The complex
array of these tracts and their directionality can be visual-
ized with diffusion tractography (Fig 7).
Motor Pathway. The pyramidal tract is one of the main
descending pathways in the brain stem. The cell bodies of
these neurons originate from layer V of the motor cortex or
other nearby cortical areas. They descend through the pos-
terior third of the posterior limb of the internal capsule and
enter the brain stem via the central portion of the cerebral
peduncle (Fig 8). From there, the axons pass through the

80 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org

Fig 8. Motor pathway. Neurons in the precentral sulcus send their axons
down the posterior limb of the internal capsule, cerebral peduncle, ven-
tral pons, medullary pyramids, and decussates at the level of the foramen
magnum in the lower medulla.
central portion of the ventral pons to the anterior surface of
the medulla and form the medullary pyramids. Approxi-
mately 75%90% of these fibers cross at the pyramidal
decussation to form the lateral cortical spinal tract. Those
fibers that do not cross form the anterior cortical spinal
tract on both sides of the anterior medial fissure. A very few
numbers of fibers descend in the ipsilateral lateral
column.1-3,5
Pain-Temperature and Tactile-Proprioception. The sen-
sory pathway includes the spinothalamic tract and the pos-
terior column-medial lemniscus pathway. The spinotha-
Fig 9. Sensory pathway. Sensory information from the peripheral nerves
cross over to the contralateral spinal cord, ascend to the cuneate and
gracile nuclei, synapse onto the ventral posterior lateral nucleus of the
thalamus, and terminate at the sensory cortex.
lamic tract neurons ascend through the caudal medulla,
rostral pons, the rostral midbrain, and the ventral postero-
lateral nucleus of the thalamus (Fig 9). At the level of the
brain stem, these fibers also give off collateral connections
to the reticular formation. These spinothalamic tract fibers
transmit pain and temperature information. The posterior
column-medial lemniscus pathway carries tactile and pro-
prioceptive information. Axons from the posterior column
of the spinal cord synapse onto neurons in the gracile and
cuneate nuclei, which are organized somatotopically. Sec-
ondary neurons cross the midline at the caudal aspect of the
dorsal medulla and ascend through the dorsal brain stem as
Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org 81

Fig 10. Vestibular pathway. Sensory input from the vestibular nerve syn-
apses on the vestibular nucleus, located in the posterior portion of the
upper medulla. Axons from the superior and medial vestibular nucleus
(VN) form the afferent medial longitudinal bers. Reproduced with per-
mission from R. Nieuwenhuys, The Human Central Nervous System, NY:
Springer-Verlag; 2008.
the medial lemniscus to the ventral posterolateral nucleus of
the thalamus. Tertiary neurons arise from the ventral pos-
terolateral nucleus and extend their axons through the an-
terior limb of the internal capsule to the primary sensory
cortex.1-3,5
Auditory Pathway. The lateral lemniscus transmits audi-
tory information for sound localization and frequency
discrimination. Fibers from the cochlear nerve travel in
the anterior inferior aspect of the internal auditory canal,
enter the brain stem laterally at the pontomedullary junc-
tion, and synapse in the dorsal and ventral cochlear nu-
clei. Some second-order neurons cross the pontine mid-
line and terminate in the trapezoid body of the
contralateral lateral lemniscus. Other fibers pass to the
ipsilateral superior colliculus, through the lateral lemnis-
82 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org
Fig 11. Guillain-Mollaret triangle. The superior cerebellar peduncle con-
nects the dentate nucleus to the contralateral red nucleus in what is
called the dentatorubral tract. The central tegmental tract connects the
red nucleus to the ipsilateral inferior olivary nucleus.
cus. Third-order neurons from the lateral lemniscus pass
along the ventral pons and mid portion of the midbrain
to synapse onto the inferior colliculus. Fourth-order neu-
rons climb through the posterior limb of the internal
capsule to the medial geniculate nucleus of the thalamus
and ultimately terminate in the Heshl gyrus or transverse
temporal gyrus.1,2,5
Vestibular Pathway. The vestibular nuclei are located in the
dorsal pons and medulla in the floor of the fourth ventricle
(Fig 10). There are 4 vestibular nuclei: medial, lateral, su-
perior, and descending vestibular nuclei. The superior and
medial vestibular nuclei receive input from the semicircular
canals and send fibers to the MLF and oculomotor centers.
Together, they coordinate the vestibule-ocular reflex. The
lateral vestibular nucleus receives fibers from the semicircu-
lar canals and otolith organ, and is important for postural
reflexes. The descending vestibular nucleus receives fibers
from the otolith and sends projections to the cerebellum,
reticular formation, contralateral vestibular nuclei, and spi-
nal cord. These fibers are thought to integrate the vestibular
and central motor signals.1-3,5
Guillain-Mollaret Triangle. The dentate nucleus, red nu-
cleus, inferior olivary nucleus, and central tegmental
Fig 12. Vascular supply of the brain stem. (A) Myelin-stained specimen of the midbrain at the level of the superior colliculus labeled with the major
vascular territories. (B) Myelin-stained specimen of the midbrain at the level of the inferior colliculus labeled with the major vascular territories. (C)
Myelin-stained specimen of the upper pons labeled with the major vascular territories. (D) Myelin-stained specimen of the lower pons labeled with the
major vascular territories. (E) Myelin-stained specimen of the medulla at the level of the inferior olivary nucleus with the major vascular territories. (F)
Myelin-stained specimen of the lower medulla at the level of the pyramidal decussations labeled with the major vascular territories.

Fig 13. Medial longitudinal fasciculus syndrome. Axial T2 (A) and dif-
fusion-weighted images (B) through the midbrain illustrate restricted
diffusion and faint T2 hyperintensity in a region of the right MLF.
tract are vital components of the triangle of Guillain
and Mollaret, which allows for motor learning. The
dentate nucleus (Fig 11) sends information through the
superior
cerebellar peduncle and superior cerebellar peduncle de-
cussation to the contralateral red nucleus. This informa-
tion then travels downward through the central tegmen-
tal tract to the inferior olivary nucleus, where
comparisons between the intended and achieved move-
ments are made. Based on this discrepancy, correcting
movements are made through the climbing cerebellar fi-
bers. Other fibers from the red nucleus end in the ventral
lateral nucleus of the thalamus. Fibers from the inferior
olivary nucleus cross the midline and pass through the
inferior cerebellar peduncle on their way to the dentate
nucleus.1,4
Fig 14. Dysarthria clumsy hand syndrome. Axial T2 (A) and diffusion-
weighted images (B) through the upper pons depicts restricted diffusion
and T2 hyperintensity in the left ventral pons in the region of the corti-
cospinal tract and transverse pontine bers.
Vascular Supply
The vertebrobasilar system supplies blood to the brain
stem. The vertebral arteries originate as the first branches of
the right and left subclavian arteries, and may be unequal in
size as they ascend in the transverse foramina. The intra-
dural segments of the vertebral arteries give off the posterior
inferior cerebellar arteries (PICA). Occasionally, the PICAs
can originate from the vertebral artery below the level of the
foramen magnum. At the level of the pontomedullary junc-
tion, the right and left vertebral arteries join to form the
basilar artery. The penetrating paramedian and circumfer-
ential perforator branches arise from the dorsal aspects of
the basilar artery. The superior cerebellar artery and poste-
rior cerebral artery are seen at the distal portion of the
basilar artery.1

Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org 83

Fig 15. Wallenberg syndrome. Axial T2 (A) and diffusion-weighted im-
ages (B) through the upper medulla shows restricted diffusion and T2
hyperintensity in the left posterolateral medulla in the region of the spi-
nothalamic tract, vestibular nuclei, spinotrigeminal tract, and inferior
cerebellar peduncle.
Fig 16. Dejerine syndrome. Axial T2 (A) and diffusion-weighted images
(B) through the upper medulla shows restricted diffusion and T2 hyper-
intensity in the left medial medulla, in the region of the medial lemniscus
and hypoglossal nucleus.
At the level of the midbrain (Fig 12A, -B), there are 4
vascular territories, including the anteromedial, anterolat-
eral, lateral, and posterior territories. The anteromedial
vascular territory vessels arise from the posterior cerebral
artery at the interpeduncular fossa. The anterolateral ves-
sels originate from the posterior cerebral artery or the an-
terior choroidal artery. The lateral territory vessels arise
from the collicular, choroidal, or PICA. The posterior zone
is supplied by the superior cerebellar, collicular, and the
posteromedial choroidal arteries.
At the level of the upper pons (Fig 12C), there are 4
vascular territories, including the anteromedial, anterolat-
eral, lateral, and posterior territories. In the lower pons (Fig
12D), there are 3 vascular territories, including the antero-
medial, anterolateral, and lateral territories. The anterome-
dial region is supplied from the pontine perforating arteries,
which arise from the basilar artery. The anterolateral seg-
mental arteries arise from the AICA at the pontomedullary
sulcus. The lateral zone vessels originate from the lateral
pontine perforators, AICA, or the superior cerebellar
artery.1
At the level of the medulla oblongata (Fig 12E, -F), there
are 4 vascular territories including the anteromedial, an-
84 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org
Fig 17. MSA. (A) DTI images of the lower pons at the level of medial
cerebellar peduncles demonstrate atrophy of the transverse pontine -
bers (red), and middle cerebellar peduncles. (B, C) T2-weighted MR im-
ages of the lower pons at the level of the middle cerebellar peduncles
demonstrate the hot cross bun sign typically seen within the pons. (D)
T2-weighted image at the level of the basal ganglia demonstrates T2
hyperintensity in the left lateral putamen.
terolateral, lateral, and posterior territories. The anterome-
dial and anterolateral vascular territory originates from the
anterior spinal artery, inferiorly, and from the vertebral
artery, superiorly. The lateral territory blood supply arises
from the PICA and the posterior territory arises from the
posterior spinal artery.1,5,6
PATHOLOGY
After a detailed review of brain stem anatomy and vascula-
ture, we reviewed a few general cases to illustrate the im-
portance of functional anatomy and the role that DTI plays.
Strokes
Infarctions of the brain stem typically have good clinical-
anatomic correlation. For example, an infarction that in-
volves the posterior midline midbrain leads to MLF syn-
drome, characterized by ipsilateral downward gaze and
vertical eye movement paralysis (Fig 13).13 Dysarthria-
clumsy hand syndrome occurs when an infarction involves
the cortical spinal tract and ventral transverse pontine fi-
bers. This lesion leads to mild ipsilateral clumsiness without
frank weakness and contralateral dysmetria, dysrhythmias,
and dysdiadochokinesia as well as truncal and gait ataxia
(Fig 14).
Wallenberg syndrome, also known as lateral medullary
syndrome, occurs when an infarction in the posterolateral
medulla involves the spinothalamic tract, central tegmental
tract, inferior cerebellar peduncle, vestibular nuclei, and
spinotrigeminal nucleus. The symptoms include ataxia, loss
of pain and temperature sensation (ipsilateral face or con-
Fig 18. Progressive supranuclear palsy. (A) Axial DTI image through the midbrain at the level of the inferior colliculi demonstrates absence of the
superior cerebellar decussation. (B) Axial DTI image through the level of the upper pons demonstrates the presence of normal transverse pontine
bers and atrophy of the superior cerebellar peduncles. (C) Axial T2-weighted MR imaging through the midbrain, at the level of the inferior colliculi,
demonstrates decreased anteroposterior diameter of the midbrain. (D) Axial T2-weighted MR imaging through the upper pons demonstrates atrophy
of the superior cerebellar peduncles. (E) Sagittal T1-weighted image through the brain stem depicts the decreased anteroposterior diameter of the
midbrain, which produces a hummingbird appearance to the brain stem.

tralateral body), vertigo, dysphagia, dysarthria, and nystag-
mus. In addition, Horner syndrome is found in 91% of
these patients. Wallenberg syndrome is often seen in the
setting of vertebral artery dissections (Fig 15).16
Dejerine syndrome, also called medial medullary syn-
drome, is a rare infarction in the medial medulla, which
involves the medullary pyramid, medial lemniscus, and hy-
poglossal nerve. These infarctions are typically due to oc-
clusion of the anterior spinal artery. The symptoms include
contralateral upper and lower extremity weakness, vibra-
tory and proprioceptive sensory loss, ipsilateral tongue
weakness, and atrophy (Fig 16).16
Neurodegenerative Disorders
MSA is a sporadic, adult-onset, progressive neurodegenera-
tive disease that leads to neuronal loss and gliosis of the
inferior olives, pons, cerebellum, substantia nigra, locus
coeruleus, striatum, and intermediolateral column of the
spinal cord. The types of MSA include MSA with parkin-
sonism, MSA with cerebellar predominant features, and
Shy-Drager syndrome with autonomic failure. In MSA, ax-
ial T2-weighted images demonstrate the hot cross bun
sign or a cross-shaped hyperintensity in the pons, which is
created by selective loss of myelinated transverse pontocer-
ebellar fibers in the pontine raphe (Fig 17). In approxi-
mately 80% of cases, it can be difficult to clinically differ-
entiate from Parkinson disease and even respond to
levodopa during its initial stages. DTI can help discriminate
between MSA and Parkinson disease based on apparent
diffusion coefficient. In addition, the middle cerebellar pe-
duncle width is significantly reduced in patients with MSA
compared with those with Parkinson disease. The hot cross
bun sign is not specific for MSA, however, and also may be
seen in patients with spinocerebellar ataxia.17,18
Progressive supranuclear palsy is a rare neurodegenera-
tive disease characterized by neuronal loss in the midbrain
tegmentum, substantia nigra, red nucleus, and globus pal-
lidus. The signs and symptoms include supranuclear verti-
cal gaze palsy, pseudobulbar palsy, dystonic rigidity of the
neck and upper extremities as well as frequent falls. As with
MSA, progressive supranuclear palsy is clinically difficult to
differentiate from Parkinson disease and imaging plays a vital
role in its diagnosis. On sagittal T1-weighted images, the brain
stem takes on the appearance of a hummingbird due to the
reduced number of superior cerebellar peduncle decussation
fibers, which decreases the anteroposterior diameter of the
midbrain (Fig 18). Axial T1-weighted images of the upper
pons also demonstrate atrophy of the superior cerebellar pe-
duncles. DTI also clearly shows loss of the superior cerebellar
peduncle decussation in the midbrain.19
Transneuronal Degeneration
Inferior olivary hypertrophy is a form of transneuronal de-
generation caused by a lesion in the Guillain-Mollaret tri-
angle. For example, focal hemorrhage in the pontine teg-
mentum that involves the central tegmental tract leads to T2
hyperintensity in the anterior medulla, which represents
edema and atrophy of the downstream ipsilateral inferior
olivary nucleus (Fig 19). These patients rarely present with
palatal myoclonus but are often asymptomatic.20
Congenital
Joubert syndrome is a rare, autosomal, recessive, congenital
disorder with symptoms, including hypotonia, ataxia, devel-
opmental delay, mental retardation, irregular breathing, and
ocular motor apraxia. Axial MR images of brain stem dem-
onstrate elongated superior cerebellar peduncles and a deep
interpeduncular cistern (Fig 20). The DTI sections clearly dem-
onstrate loss of the corticospinal tract decussation.21
Horizontal gaze palsy and progressive scoliosis is a rare,
autosomal recessive mutation of the ROBO3 gene, which

Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org 85


Fig 19. Inferior olivary hypertrophy. (A) Axial T2-weighted MR imaging
at the level of the upper pons demonstrates hemorrhage (*) in the left
pontine tegmentum in the region of the left central tegmental tract. (B)
Axial T2-weighted image through the upper medulla demonstrates a
normal inferior olivary nucleus at the time of hemorrhage. (C) The
6-month follow-up T2-weighted MR imaging at the level of the upper
pons demonstrates expected evolution of the blood products. (D) The
6-month follow-up axial T2-weighted MR imaging at the level of the in-
ferior olivary nucleus demonstrates T2 hyperintensity and enlargement
of the left inferior olivary nucleus due to transneuronal degeneration.
From Ref. 21, reproduced with permission. American Society of
Neuroradiology.
Fig 20. Joubert syndrome. (A) Axial T1-weighted MR imaging at the level
of the upper pons demonstrates the elongated superior cerebellar pe-
duncles (SCP), which produce the characteristic molar tooth sign seen in
Joubert syndrome. (B) Axial DTI at the level of the pontomesencephalic
pontomedullary junction demonstrates deepening of the interpeduncu-
lar cistern and elongated, horizontally oriented SCP bers, as indicated
by the green color.
leads to horizontal gaze palsy and progressive scoliosis, as
its name implies. Axial and sagittal MR images of the brain
stem demonstrate flattening of the basis pontis, hypoplasia
of the pontine tegmentum, and the split pons sign. DTI
demonstrates the absence of midpontine transverse pontine
fibers and loss of the corticospinal tract decussation.22
Neoplasm
Brain stem gliomas are a heterogeneous group of tumors,
most commonly found in children. The most common brain
86 Neurographics 2016 March/April; 6(2):76 87; www.neurographics.org
stem glioma is a diffuse pontine glioma. Other lower grade
tumors include juvenile pilocytic astrocytomas, ganglioglio-
mas, and oligogliomas. The presenting symptoms of brain
stem tumors are variable, but typically include ataxia, CN
palsies, long tract signs, and hydrocephalus. On MRI, these
diffuse pontine gliomas are T1 hypointense, heteroge-
neously T2 hyperintense, ill-defined masses with minimal
enhancement.23 They cause thickening of the corticospinal
tracts and transverse pontine fibers, which appear on DTI as
thickening of the vertically oriented blue tracts and trans-
versely oriented red bands, respectively. These tumors also
displace the other tracts that run craniocaudally through
the brain stem.
CONCLUSION
The brain stem is a complex structure that contains multiple
nuclei and tracts that are vital to our everyday activities but
that are not well understood. A detailed understanding of
the brain stem may be attained through a comparison of
myelin-stained specimens, MR images, and DTI images.
This knowledge of functional brain stem anatomy and vas-
cular territories plays a critical part in accurately describing
brain stem lesions and in understanding the dysfunction
that they cause.
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