Brainstem syndrome
Eponym/Name | Site/Localization | Cranial Nerves (CN) | Tracts/Nuclei | Key Signs/Features | Supply |
Weber | Medial Midbrain (Cerebral Peduncle) | III | Corticospinal tract | Ipsilateral CN III palsy (ptosis, mydriasis, eye down-and-out); Contralateral hemiplegia (UMN weakness). | P1 Posterior Cerebral Artery (PCA) |
Claude | Midbrain Tegmentum (Red Nucleus) | III | Red nucleus, Superior cerebellar peduncle, Brachium conjunctivum | Ipsilateral CN III palsy; Contralateral cerebellar ataxia and tremor. | P1 Posterior Cerebral Artery (PCA) |
Benedikt | Midbrain Tegmentum (Red Nucleus, III nucleus) | III | Red nucleus, Substantia nigra, III nucleus | Ipsilateral CN III palsy; Contralateral ataxia and involuntary movements (tremor, choreoathetosis). | P1 Posterior Cerebral Artery (PCA) |
Nothnagel | Midbrain Tectum (Tectal Plate) | Unilateral or Bilateral III | Superior cerebellar peduncles | Oculomotor palsy; Ipsilateral cerebellar ataxia. | ㅤ |
Parinaud | Dorsal Midbrain (Tectum/Pretectal Area) | ㅤ | ㅤ | Paralysis of upward gaze (supranuclear); Light-near dissociation; Retraction nystagmus. | ㅤ |
Raymond | Ventral Caudal Pons | VI | Corticospinal tract | Ipsilateral Abducens (CN VI) palsy; Contralateral hemiparesis/hemiplegia. | Basilar perforators |
Millard-Gubler | Caudal Ventral Medial Pons | VI, VII (fascicles) | Corticospinal tract | Ipsilateral Abducens (CN VI) palsy and Facial (CN VII) palsy (LMN); Contralateral hemiparesis/hemiplegia. | Basilar perforators |
Foville | Caudal Tegmental Medial Pons (PPRF) | VI nucleus, VII, PPRF | Corticospinal tract, Medial lemniscus, MLF | Ipsilateral gaze palsy (CN VI nucleus/PPRF) and Facial (CN VII) palsy; Contralateral hemiparesis. | Basilar perforators |
Raymond-Cestan | Rostral Dorsal Pons | (PPRF and VI nucleus) | Spinothalamic, Medial lemniscus, Corticospinal tract | Ipsilateral gaze palsy; Contralateral loss of all sensory modalities; Ataxia. | ㅤ |
Marie-Foix | Lateral Caudal Pons | ㅤ | Middle cerebellar peduncle, Corticospinal, Spinothalamic tracts | Ipsilateral cerebellar ataxia; Contralateral hemiparesis and pain/temperature loss. | Anterior Inferior Cerebellar Artery (AICA) |
Wallenberg (Lateral Medullary) | Lateral Medulla | Spinal V, IX, X, XI | Lateral spinothalamic tract, Descending sympathetic fibers, Nucleus ambiguus, Vestibular nucleus | Ipsilateral Horner's syndrome, ataxia, dysphagia/dysarthria (CN IX/X/XI), and facial pain/temp loss (CN V); Contralateral body pain/temp loss. | Posterior Inferior Cerebellar Artery (PICA) or Vertebral Artery (VA) |
Déjerine (Medial Medullary) | Medial Medulla | XII | Corticospinal (pyramid), Medial lemniscus | Ipsilateral tongue palsy (CN XII); Contralateral hemiparesis (pyramid) and proprioception/vibration loss. | Anterior Spinal Artery (ASA) / VA / Basilar Artery (BA) |
Babinski-Nageotte (Hemimedullary) | Hemimedullary Infarct | ㅤ | ㅤ | Combination of Wallenberg's and Déjerine's syndromes. | Vertebral Artery (VA) (proximal to PICA and spinal artery) |
Locked-in syndrome | Bilateral Ventral Pons | Bilateral VI/VII weakness, Lower CN (for aphonia) | ㅤ | Quadriplegia; Aphonia; Bilateral VI/VII weakness; Intact upgaze and blinking; Preserved consciousness. | Basilar perforators |
Non brainstem syndrome
Name | Localization | Tracts | Key Signs/Features | Supply |
Déjerine-Roussy syndrome (Thalamic Pain Syndrome) | Thalamus | ㅤ | Contralateral hemisensory loss; Contralateral hemibody pain (chronic pain). | P1 Posterior Cerebral Artery (PCA) |
STN | Subthalamic Nucleus (STN) | ㅤ | Contralateral hemiballismus (large, flinging, involuntary movements). | P1 Posterior Cerebral Artery (PCA) |
Bilateral Occipital Lobe (Cortex) | ㅤ | Visual agnosia (cortical blindness with denial of blindness). | Bilateral P2 PCA/Top of Basilar | |
Balint syndrome | Bilateral Parieto-Occipital Lobe (Cortex) | ㅤ | Bilateral loss of voluntary eye movements; Bilateral optic ataxia (inability to guide hand by sight); Asimultagnosia (inability to perceive the visual field as a whole). | Bilateral P2 PCA |
Top of Basilar syndrome | Bilateral Rostral Midbrain & Posterior Thalamus | ㅤ | Ophthalmoplegia; Behavioral abnormalities; Somnolence/hallucinations; Usually no motor deficit. | Basilar Artery |
Basilar artery associated deficits
Location | Supply | Syndrome | Symptoms/signs |
Top of the BA | Midbrain, thalamus, and mesial temporal lobes and occipital lobes | Top of the basilar | Somnolence, peduncular hallucinosis, convergence nystagmus, skew deviation, oscillatory eye movements, Collier's sign (retraction and elevation of eyelids), vertical gaze paralysis |
Mid-BA | Lateral and medial pons | Lateral mid-pontine syndrome | Ipsilateral loss of facial sensation and motor function of the trigeminal nerve, ipsilateral dysmetria |
ㅤ | ㅤ | Medial mid-pontine syndrome | Ipsilateral dysmetria, contralateral arm and leg weakness and gaze deviation |
Pontine paramedian perforators | Anteromedial pons | Dorsal mid-pontine syndrome | Ipsilateral nuclear facial palsy, horizontal gaze palsy, and contralateral arm and leg weakness |
Short pontine circumferential arteries | Anterolateral pons | Superior medial pontine syndrome | Ipsilateral intranuclear ophthalmoplegia, palatal, facial, pharyngeal and/or ocular myoclonus, dysmetria, contralateral arm and leg weakness, ocular bobbing |
Proximal BA | Lower pons | Locked-in syndrome | Quadriplegia, horizontal gaze paralysis, bifacial, paralysis, and tongue and mandibular weakness |
Specific arterial conditions
Disease associated with PICA
- Wallenberg (lateral medullary) syndrome
- Tumours
- Meningiomas blood supply
- Petroclival meningiomas
- Branch of meningohypophyseal trunk (ICA)
- Subarcuate artery branch AICA
- Medial clival artery br. Of cavernous carotid
- Jugular branch of occipital artery
- Jugular branch of ascending pharyngeal artery
- Foramen magnum meningiomas
- Branches from V3 segment (anterior meningeal artery
- Posterior meningeal artery branch of VA if posteriorly located
- Hypoglossal branch of occipital artery
- Hypoglossal branch of ascending pharyngeal artery
- Aneurysms
- All 4 below can be associated with an extradural haematoma:
- Calvarial haematoma
- Middle meningeal vein
- Middle meningeal artery
- Venous sinuses
- Blister aneurysms typically arise from the dorsomedial wall of non-branching parts of the ICA, although more rarely they may arise at other anterior and posterior circulation sites
- Anterior choroidal artery-Clinical
- Use to be ligated to tx Parkinson's in the past
- Aneurysm: located superior/superiorlaterally to origin of anterior choroidal artery
- Stroke → Anterior choroidal artery syndrome: (3H)
- Hemisensory loss
- Hemiplegia
- Homonymous hemianopia
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