1. Brain Stem Anterior View Posterior View 3 4 9,10,11 5 Adducent
Facial colliculus
7 & 8th 12
Striae Medullare

2. Case.1
A 55 year old overweight man was brought to the emergency room unconscious after he had collapsed while loading a truck.After he regained consciousness, an exam revealed a paresis of both right limbs with a Babinski sign on the right. The patient's tongue deviated to the left upon protrusion, and he had no vibratory sense on the right side of the body. These findings suggest.
A lesion in the medial medulla
A lesion in the medial pons
An infract PICA
A lesion in the lateral medulla

3. Case cont…2
A 35-year-old visits hospital because of severe headache. The patient says that the headache, which seems to be localized area behind his ears, it has been intermittent but persistent since he was involved in the baseball game while on his vacation. Shortly after he returned from his vacation, he made an appointment with his family physician because he was worried about the headache and the fact that he had developed noticeable clumsiness. When physician questioned, he mentioned unusual frequent bouts of nausea and vertigo. Physical examination reveals mild hoarseness of voice and some difficulty swallowing oral secretions. The left side of his face is affected by Horner’s syndrome, He has decreased sensitivity to light touch on the left side of his face, flattening of the left nasolabial fold, and paresis of the left soft palate. Finger to nose testing shows left sided Dysmetria. When asked to walk across the examining room, his gait is ataxic and he deviates to the left. There is diminished pain and thermal sensation on the right side. Reflexes are symmetric. There is no Babinski reflex, and the remainder of the motor and sensory examination is normal.

4. Case Cont….3
18. Which one of the following vessels should be the primary suspect?
Middle cerebral artery
Internal carotid artery at the cavernous sinus
Superior cerebellar artery
Posterior inferior cerebellar artery
Anterior communicating artery

5. Case cont…4
45 year-old women with a history of high blood pressure experienced a sudden onset of Dizziness, nausea, and vomiting. She was brought to the emergency room where a neurological Exam revealed horizontal nystagmus, dysphagia and hoarseness. Absent of gag reflex on the left. Alteration of taste sensations from the tongue. Analgesia and thermal anesthesia on the left side of the face . Analgesia and thermal anesthesia on the right side of the body. Homer’s syndrome and significant hearing loss on the left as compared to the right

6. Case cont…5
The dysphagia and hoarseness in this case are to due to lesion of which structure?
Dorsal motor nucleus of vagus
Nucleus solitarius
Nucleus ambigus
Inferior salivatory nucleus
Superior salivatory nucleus

7. Case cont 6….
The analgesia and thermal anesthesia on the left side of the face in this case most likely Resulted from a lesion of which structure?
The trigeminal nerve
The Mesencephalic nucleus of trigeminal
The principal (chief) nucleus of
The spinal tract of trigeminal
The trigeminal ganglia

8. Level
Nuclei
Midbrain
III, IV, mesencephalic V
Pons
V (main nucleus)
Caudal pons
VI, VII
Ponto-medullary junction
VIII
Medulla
N. of the descending tract of V. N. ambiguus N. tractus solitarius Motor X XII
Cervical cord XI

9. Medial Medullary Syndrome
Medial Medullary Syndrome/ Inferior Alternating Hemiplegia
(branches of anterior spinal artery occlusion)
contralateral hemiplegia of arm & leg
(pyramid—corticospinal fibers)
contralateral loss position sense, vibration, discriminatory touch
(medial lemniscus)
deviation of tongue to ipsilateral side when protruded; muscle atrophy
(CN XII hypoglossal nerve in medulla or CN XII nucleus)

10. Lateral medullary Syndrome (Wallenberg's)
contralateral body pain & temp loss
(anterolateral system/spinothalamic tract)
ipsilateral face pain & temp loss
(spinal trigeminal tract & nucleus)
dysphagia, soft palate paralysis, hoarseness, diminished gag reflex
(nucleus ambiguus, roots of 9th and 10th nerves)
ipsilateral Horner’s Syndrome (miosis, ptosis, anhydrosis)
(descending hypothalamospinal fibers)
nausea, diplopia, vertigo, nystagmus
(vestibular nuclei—CN 8)
ataxia to the ipsilateral side
(restiform body & spinocerebellar fibers)

11. Case 8..
65. A 46-year-old woman presents to her physician with "double vision" and is unable to adduct her right eye on attempted left lateral gaze. Convergence is intact. Both direct and consensual light reflexes are normal. Which of the following structures is most likely to be affected?
Left oculomotor nerve
Medial longitudinal fasciculus
Right abducens nerve
Right oculomotor nerve
Right trochlear nerve

12. Case 9..
A patient with a bullet wound to the head is referred to you for neurological examination. Upon entering the hospital room you find the patient on a respiratory and cardiac monitor. You have difficulty arousing the patient and once awake you note the following: Right pupil is constricted; there is medial strabismus of the right eye and upon attempted right lateral gaze the left eye fails to adduct; loss of pain and temperature sensitivity on the right side of the face and left side of the body; deafness of the right ear; a pronounced intention tremor in the right arm and leg. The deep tendon reflexes on the right side are not as brisk as those on the left and there appears to be a complete facial paralysis on the right side.
The likely site for this lesion is:
The left internal capsule
The right caudal pons
The left cerebellar hemisphere
The left side of the midbrain at the level of the superior colliculus
The right side of the medulla at the level of the dorsal column nuclei

13. Pontine Syndromes
Medial Pontine Syndrome/ Middle Alternating Hemiplegia
(paramedian branches of basilar artery occlusion)
contralateral hemiplegia of arm & leg
(corticospinal fibers in basilar pons)
contralateral loss/decrease of proprioception,
vibration, discriminative touch
(medial lemniscus)
ipsilateral lateral rectus muscle paralysis
(abducens nerve fibers or nucleus—CN 6)
paralysis of conjugate gaze toward side of lesion
Medial Strabismus
(paramedian pontine reticular
formation/pontine gaze center)

14. Lateral Pontine Syndrome ).
  *note: combination of symptoms varies with caudal to rostral level of lesion*
ataxia, unsteady gait, fall toward side of lesion
(middle & superior cerebellar peduncles—caudal & rostral pons lesions)
vertigo, nausea, nystagmus, deafness, tinnitus, vomiting (vestibular & cochlear nerves and nuclei—CN 8)
ipsilateral paralysis of facial muscles (facial motor nucleus—CN 7—caudal pons lesions)
ipsilateral paralysis of mastication muscles (trigeminal motor nucleus—CN 5— midpontine lesions)
ipsilateral Horner’s Syndrome (descending hypothalamospinal fibers)
ipsilateral face pain & temp loss (spinal trigeminal tract & nucleus)
contralateral body pain & temp loss (anterolateral system/spinothalamic tract)
paralysis of conjugate gaze
(paramedian pontine reticular formation—mid to caudal pons lesions)
(Long circumferential branches of basilar artery occlusion)

15. Case 10
Jones likes to play golf. Usually he is a very competitive member of the team USA , but his game has been off lately. He has been unable to maintain his well-practiced grip on his favorite clubs (particularly with his right hand), causing the club to slip out of alignment as he begins his swing.
Additionally, as all great golfers know, maintaining visual contact with the ball is critical to accurate placement of the ball on the green. Jones has begun to complain that he sometimes sees two balls (double vision), and that occasionally he swings at the ‘wrong’ one. He has been unable to keep his eyes on the ball as he swings and he has not been able to watch it as it sails to its destination. Today has been particularly hot, and the entire team becoming fatigued as they near the final hole. It’s at this point that one of the partners who is a neurologist notices that Jone's left eye is crossed.
On further examination Neurologist noticed fallowing

16. Case 10
Left eye is crossed (diplopia); an inability to move the Left to the left.
He has Spastic paralysis of the right upper and right lower limb muscles.
His left side of the body seems to be functioning normal.

17. Case 7…
60 year old woman suddenly remarked that she was seeing double and felt a weakness in her left arm and leg. Her husband noticed that her right eyelid was drooping. At the hospital, she was awake, oriented, and articulate. Her visual fields were normal but here right eye deviated to the right. On attempted lateral gaze to the left only the left eye responded; only the left eye constructed in response to light. Upon smiling, there was a minor weakness on the left. The gag, corneal, and jaw jerk reflexes were normal as were the sensory examinations of the face and body. Motor strength was normal in the extremities on the right but reduced on the left especially in the arm where there was a heightened biceps reflex and resistance to passive stretch.
Where is the site of lesion?
a) Cerebellum
b) Substantia nigra
c) Mid brain
d) None of above.

18. At Superior colliculus

20. Medial Midbrain (Weber) Syndrome/ Superior Alternating Hemiplegia
(paramedian branches of P1 segment of PCA occlusion) 1.contralateral hemiplegia of arm & leg corticospinal fibers in crus cerebri) ipsilateral paralysis of eye movement, oriented down & out, pupil dilated & fixed (oculomotor nerve—CN 3) 2. Central Midbrain Lesion (Claude Syndrome) contralateral ataxia and tremor of cerebellar origin (red nucleus & cerebellothalamic fibers) 3. Benedikt Syndrome: includes both regions, both sets of symptoms from above

21. Cerebellum Classification Archicerebellum Paleocerebllum Neocerebellum
Classification by its Connections
Vestibulocerebellum
Spinocerebellum
cerebrocerebellum

25. Inputs of the cerebellum

28. Main Connections of the Vestibulocerebellum
Vestibular
Organ
Floculonodular
Lobe
Vermis
VESTIBULAR NUCLEUS
vestibulospinal tract
MLF
FASTIGIAL
NUCLEUS
lower motor neuron
ARCHICEREBELLUM
LMN

29. Main Connections of the Paleocerebellum
RED NUCLEUS
NUCLEUS
INTERPOSITUS
rubrospinal
tract
Inferior
Olivry
Nucleus
ANTERIOR
LOBE
PARAVERMAL
ZONE
lower motor neuron
PALEOCEREBELLUM
SPINAL CORD
spinocerebellar tract

30. Main Connections of the Neocerebellum
CEREBRAL
CORTEX
THALAMUS
DENTATE
NUCLEUS
pyramidal
tract
Pontine
Nucleus
POSTERIOR
LOBE
CEREBELLAR
HEMISPHERE
lower motor neuron
NEOCEREBELLUM
LMN

31. Pyramidal Tract and Associated Circuits
upper motor neuron
UMN
Cerebellum
BASAL
GANGLIA
pyramidal tract
lower motor neuron
UMN

32. Functions Of Cerebellum
 Maintenance of Equilibrium
- balance, posture, eye movement
 Coordination of automatic movement of
walking and posture maintenance
- posture, gait
 Adjustment of Muscle Tone
 Motor Leaning – Motor Skills
 Cognitive Function

33. Cerebellum Disorders Ataxia: incoordination of movement
- decomposition of movement
- dysmetria, post-pointing
- dysdiadochokinesia(Adidydakokinesia)
- rebound phenomenon of Holmes
- gait ataxia, truncal ataxia, titubation
Intention Tremor
Hypotonia, Nystagmus

34. Cerebellum Disorders Archicerebellar Lesion: medulloblastoma
Paleocerebellar Lesion: gait disturbance
Neocerebellar Lesion: hypotonia, ataxia, tremor

35. Case 1…..
A patient delays initiation of movement, displays an uneven trajectory in moving her hand from above her head to touch her nose, and is uneven in her attempts to demonstrate rapid alternation of pronating and supernating movements of the hand and forearm. Which of the following regions most likely contains the lesion?
Hemispheres of the posterior cerebellar lobe
Flocculonodular lobe of the cerebellum
Vermal region of the anterior cerebellar lobe
Fastigial nucleus
Ventral spinocerebellar tract

36. The classic appearance of a patient with a lesion of the cerebellar hemispheres is one in which voluntary and skilled movements are affected. They are uncoordinated, and there are errors in the range, force, and direction of movement. The relationships between the cerebellum and the motor regions of the cerebral cortex have been disrupted. Lesions of other regions, such as the flocculonodular lobe, vermal region of the anterior cerebellar cortex, or fastigial nucleus, produce different symptoms (disturbances of balance and nystagmus associated with the flocculonodular lobe and vermal regions, disturbances of muscle tone associated with the anterior cerebellar cortex). Although pure lesions limited to the ventral spinocerebellar tract have not been reported, it is likely that such a lesion could not account for the symptoms indicated in this question. Information carried by this tract concerns activity of Golgi tendon organs of muscles of the lower limbs.

37. Case 2…..
As a result of a dysfunction in development, a 4-year-old boy has difficulty
walking and maintaining balance. It is later determined that there is
significant loss of neurons in the cerebellum that disrupts the neuronal
organization of the cerebellar glomerulus. Which of the following best
characterizes this glomerulus?
Mossy fiber terminals, Golgi axons, and axon terminals of granule cells
Climbing fiber terminals, Golgi axons, and granule cell dendrites
Mossy fiber terminals, Purkinje cell axons, and granule cell dendrites
Mossy fiber terminals, Golgi and granule cell dendrites, and Golgi cell axon terminals
Climbing fiber terminals, Golgi cell dendrites, Purkinje cell dendrites, and axon terminals of parallel fibers

38. Case 3….. Fastigial nucleus Vermal region Cerebellar hemsipheres
A 55-year-old male had been complaining about his having difficulty
in coordinating the use of his arms in meaningful ways. For example, when
examined by a neurologist, the patient was unable to move his finger
Accurately to his nose from his side when requested to do so but instead
Would undershoot or overshoot the target. He also had difficulty in making
Rapid alternating rotational movements of the hand. The neurologist believed
that the patient was suffering from a disorder that resulted in a lesion of a
region of the cerebellum or structures related to it. Which of the following
regions most likely contained this lesion?
Fastigial nucleus
Vermal region
Cerebellar hemsipheres
Inferior cerebellar peduncle
Vestibular nuclei

39. The answer is c. This patient presented with a disorder associated with a lesion of the cerebellar hemisphere. This region of the cerebellar cortex is linked anatomically and functionally with the cerebral cortex. Its linkage is through the dentate nucleus, whose axons project to the VL thalamic nucleus, which in turn, project to the motor and premotor regions of the cerebral cortex. This feedback is essential for producing smooth, accurate movements of the limbs that are Well coordinated. Loss of such feedback thus results in the deficits seen in this patient. Other regions listed in this question bear no relation to this disorder but relate to other functions such as balance, modulation of muscle tone and posture.

40. Case 4…..
A man presents with a wide-based, ataxic gait during his attempts at walking. He is also unsteady, sways when standing, and displays a tendency to fall backward or to either side in a drunken manner. In which of the following structures is a lesion most likely located?
Hemispheres of the posterior cerebellar lobe
Anterior limb of the internal capsule
Dentate nucleus
Anterior lobe of the cerebellum
Flocculonodular lobe of the cerebellum

41. Answer is E Since the flocculonodular lobe receives and integrates inputs from the vestibular system, it is understandable why lesions that disrupt this integrating mechanism for vestibular inputs would result in difficulties in maintaining balance. Indeed, this is a classic feature of lesions of the Flocculonodular lobe but is not associated with lesions in the hemispheres of the posterior lobe, the anterior limb of the internal capsule, or the dentate nucleus, which are functionally linked to the frontal lobe. Lesions of the anterior lobe also do not affect mechanisms of balance.

42. Case 5…..
A 25-year-old man, who began to have difficulty in walking, is examined by a neurologist and neurosurgeon. They conclude that a tumor is compressing upon the lateral aspect of his spinal cord, affecting primarily the spinocerebellar tracts. Which of the following structures is the principal region within the cerebellum that receives these fibers?
Anterior lobe
Posterior lobe
Flocculonodular lobe
Fastigial nucleus
Dentate nucleus

43. Horizontal eye movement
Generated from horizontal gaze center in PPRF which is connected to ipsilateral 6th nerve nucleus.
From 6th CN nucleus internuclear neurons cross midline and pass to contralateral MLF to innervate medial rectus in the 3rd nerve complex
Stimulation of PPRF on one side causes a conjugate movement of the eyes to the same side.

44. Vertical eye movements
Generated from vertical gaze center ( rostral interstitial nucleus of the MLF ) which lies in midbrain.
rostral interstitial nucleus of medial longitudinal fasciculus (riMLF) is a portion of the medial longitudinal fasciculus which controls vertical gaze.

45. medial longitudinal fasciculus (MLF)
It yokes the CN nuclei III and VI together, and integrates movements directed by the gaze centers (frontal eye field) and information about head movement.
it is an integral component of saccadic eye movements as well as Vestibulo-ocular reflex
Lesions of the MLF produce internuclear ophthalmoplegia. Lesions to the MLF are very common manifestations of the disease Multiple sclerosis ,where it presents as nystagmus and occasionally diplopia .

46. PPRF lesion gives rise to ipsilateral horizontal gaze palsy with inability to look in the direction of lesion.
MLF lesion gives rise to INO

47. Left INO Straight eyes in primary position. Defective left adduction.
Ataxic nystagmus of the right eye in right gaze.
Convergence is intact
Vertical nystagmus on attempted upgaze.

48. SUPRANUCLEAR DISORDERS OF
EYE MOVEMENT
1. Horizontal gaze palsies
Internuclear ophthalmoplegia
Combined internuclear and PPRF
(‘one-and-a-half syndrome’)
MLF
2. Vertical gaze palsies
Parinaud dorsal midbrain syndrome
Progressive supranuclear palsy

49. Internuclear ophthalmoplegia
Lesion involving left MLF
Normal left gaze
Defective left adduction and ataxic
nystagmus of right eye
Convergence intact if lesion discrete
Important causes
Demylination - usually bilateral
Vascular disease
Tumours of brainstem

50. ‘One-and-a-half syndrome ’
Combined lesion of left MLF and PPRF
Defective left adduction
Ipsilateral (left) gaze palsy
Normal right abduction with ataxic
nystagmus

51. Parinaud dorsal midbrain syndrome
Supranuclear upgaze palsy
Normal downgaze
Large pupils with light-near dissociation
Convergence weakness
Lid retracton (Collier sign)
Convergence-retraction nystagmus
Important causes
In children: aqueduct stenosis, meningitis and pinealoma
In young adults: demylination, trauma and a-v malformations
In elderly: vascular accidents and posterior fossa aneurysms

52. Progressive supranuclear palsy
( Steele-Richardson-Olszewski syndrome )
Affects elderly
Pseudobulbar palsy
Initially involves downgaze
Extrapyramidal rigidity
Gait ataxia
Dementia
Subsequent defective up and
horizontal gaze