1. sjldllds ;l;sf’;’;s بسم الله الرحمن الرحیم 1389 1 Isfahan Medical Faculty, Anatomical Sciences Department

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3. 1389Isfahan Medical Faculty, Anatomical Sciences Department 3 Figure 12.2b امام صادق(ع) فرمود: –به خدا قسم اگر مردم فضيلت واقعى «روز غدير» را مى‏شناختند، فرشتگان روزى ده‏بار با آنان مصافحه مى‏كردند و بخششهاى خدابه‏كسى‏كه‏آن روز را شناخته، قابل‏شمارش نيست.

4. 1389Isfahan Medical Faculty, Anatomical Sciences Department 4 Figure 12.2b Brain Stem 8 th Lecture Clinical points of Brain stem

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6. 1389Isfahan Medical Faculty, Anatomical Sciences Department 6 Review blood supply Vertebral Basilar Posterior cerebral Anterior spinal Posterior spinal PICA AICA Superior cerebellar Posterior communicating

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21. 1389Isfahan Medical Faculty, Anatomical Sciences Department 21 C-P angle An space in posterior cranial fossa bordered by: 1- superipr petrosal crest 2- lateral pons, interiorly 3- cerebellum, posteriorly

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27. 1389Isfahan Medical Faculty, Anatomical Sciences Department 27 Thank you

28. 1389Isfahan Medical Faculty, Anatomical Sciences Department 28 Lesions of Brain Stem

29. 1389Isfahan Medical Faculty, Anatomical Sciences Department 29 Lesions of cerebral hemispheres

30. 1389Isfahan Medical Faculty, Anatomical Sciences Department 30 Projection of Cerebral Hemispheres to Brain stem & Spinal cord Contra lateral projection of cerebral hemispheres to spinal cord Bilateral projection of cerebral hemispheres to Brain stem except two points: –Genioglossus –Lower 1/3 of the face muscles

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35. 1389Isfahan Medical Faculty, Anatomical Sciences Department 35 Facial pathway

36. 1389Isfahan Medical Faculty, Anatomical Sciences Department 36 Facial pathway

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40. 1389Isfahan Medical Faculty, Anatomical Sciences Department 40 Right abducent Palsy

41. 1389Isfahan Medical Faculty, Anatomical Sciences Department 41 What is your Diagnosis?

42. 1389Isfahan Medical Faculty, Anatomical Sciences Department 42 Left oculomotor PalsyLeft abducent Palsy

43. 1389Isfahan Medical Faculty, Anatomical Sciences Department 43 Hook & 3 pillars CN 7 closes & CN III pens

44. 1389Isfahan Medical Faculty, Anatomical Sciences Department 44 Ptosis or Droping of the eyelid

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46. 1389Isfahan Medical Faculty, Anatomical Sciences Department 46 Trochlear Palsy Produces elevation of eye; patients often bring down chin and tilt head away from affected eye to correct diplopia. TN is most commonly injured CN in head trauma; tumor, infection and aneurysm can also damage TN.

47. 1389Isfahan Medical Faculty, Anatomical Sciences Department 47 Trochlear Palsy

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55. 1389Isfahan Medical Faculty, Anatomical Sciences Department 55 Thank You

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58. 1389Isfahan Medical Faculty, Anatomical Sciences Department 58 Thank You

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61. 1389Isfahan Medical Faculty, Anatomical Sciences Department 61 BRAIN STEM LESIONS Unilateral brain stem lesions (Fig. 19.21, Fig. 19.22) may arise as a result of extrinsic compression of the brain stem by space occupying tumours (e.g. meningioma, acoustic neuroma or metastatic carcinoma) or may be caused by intrinsic disease (e.g. glioma, demyelination or stroke). The clinical syndrome is determined by the neuroanatomical site of the lesion.

62. 1389Isfahan Medical Faculty, Anatomical Sciences Department 62 At the segmental level, an ipsilateral cranial nerve palsy occurs. Below the level of the lesion, there is a contralateral loss of power and sensation in the limbs (corresponding to dysfunction of the decussating corticospinal and ascending sensory pathways), and ipsilateral incoordination of the limbs (as a result of the interruption of efferent and afferent cerebellar connections).

63. 1389 Isfahan Medical Faculty, Anatomical Sciences Department 63 The ipsilateral cranial nerve dysfunction reflects the segmental level of the lesion in the midbrain, pons and medulla. Midbrain lesions cause ophthalmoplegia, pupillary dilatation and ptosis (oculomotor nerve palsy) and impaired upward gaze (e.g. due to a pinealoma). Pontine lesions (e.g. an acoustic neuroma in the cerebellopontine angle) lead to ophthalmoplegia (abducens nerve lesion), loss of facial sensation and weakness of masticatory muscles (trigeminal nerve lesion), weakness of facial muscles (facial nerve lesion), deafness and vertigo (vestibulocochlear nerve lesion). Medullary lesions cause a ‘bulbar palsy', i.e. dysarthria, dysphagia and dysphonia, with wasting of the hemi-tongue and palate (glossopharyngeal, vagal and hypoglossal nerve lesions) and weakness and wasting of sternocleidomastoid and trapezius (accessory nerve lesion). In addition to this focal brain stem syndrome, blockage of the outflow of CSF from the fourth ventricle via the foramina of Magendie and Luschka (e.g. by extrinsic tumours) produces hydrocephalus, which is characterized by headache, papilloedema and progressive stupor and coma.

64. 1389Isfahan Medical Faculty, Anatomical Sciences Department 64 Bilateral destructive lesions of the brain stem are fatal if untreated, because of damage to ‘centres’ in the medulla that control respiration, heart rate and blood pressure. Impairment of the reticular activating system in the core of the brain stem leads to progressive impairment of consciousness, followed by stupor and coma. In this state of ‘brain stem death', life can only be supported artificially. This is the fate of all untreated expanding space-occupying lesions in the cranium (e.g. haematoma, abscess, tumour, whether extrinsic or intrinsic to the brain, and cerebral oedema). A space-occupying lesion within the unyielding skull raises the intracranial pressure directly and also indirectly by obstruction of CSF flow, which causes headache and papilloedema

65. 1389Isfahan Medical Faculty, Anatomical Sciences Department 65 The brain is distorted and displaced downward (rostro- caudally) within the skull and meningeal framework. The brain stem is vulnerable to compression at two critical sites, which are determined by the neuroanatomical relationship of the meningeal tentorium and foramen magnum to the cerebral hemisphere (supratentorial) and brain stem (infratentorial).

66. 1389Isfahan Medical Faculty, Anatomical Sciences Department 66 The downward displacement of the cerebral hemisphere leads to herniation of the ipsilateral medial temporal lobe (uncus) through the tentorial notch. There may be direct ipsilateral compression of the midbrain and emergent oculomotor and trochlear cranial nerves or contralateral compression of the upper brain stem by the abutting sharp edge of the tentorium. The ipsilateral posterior cerebral artery is vulnerable to compression at this site. Unilateral herniation is heralded by a progressive oculomotor nerve palsy (ophthalmoplegia, pupillary dilatation and ptosis), contralateral limb weakness, falling

67. 1389Isfahan Medical Faculty, Anatomical Sciences Department 67 اولین چیزی که از انسانها سؤال می شود، نمازهای پنج گانه است هر كه با مردم چنان رفتار كند كه دوست دارد آنها با او آنگونه رفتار كنند، عادل است. هر كه خدا را، آنگونه كه سزاوار اوست، بندگى كند، خداوند بیش ازآرزوها و كفایتش به او عطا مى كند در طلب دنیا معتدل باشید و حرص نزنید ، زیرا به هر كس هر چه قسمت اوست می رسد. دو چیز را خداوند در این جهان كیفر میدهد : تعدی ، و ناسپاسی پدر و مادر هرگاه دیدید که مردی باکی ندارد که چه می گوید و چه درباره اش گفته می شود،چنین کسی شریک شیطان است.