Brainstem Syndrome

Brain stem vascular syndromes

1. Weber’s syndrome: CN 3 palsy (pupil sparing) + contralateral hemiparesis
2. Benedikt’s syndrome: Weber’s plus red nucleus - CN 3 palsy + contralateral hemiparesis + contralateral hyperkinesis, ataxia, intention tremor; Remember: Weber + red nucleus
3. Millard Gubler: CN 6 + CN 7 + contralateral hemiplegia
4. Wallenberg’s syndrome: (PICA + vertebral) spinal trigeminal tract of CN 5 + inferior cerebellar peduncle + descending sympathetic tract + ventral spinocerebellar tract + CN 9 and 10 fibers + lateral and ventral spinothalamic tract + solitary nucleus + cuneate and gracile nucleus + vestibular nuclei (NOTE: no weakness in the contralateral arm or leg)
   1. Hoarseness, dysphagia
   2. Ipsilateral vocal cord paralysis
   3. Loss of gag reflex (CN 9 is the afferent limb of the gag reflex and CN 10 is the efferent limb)
   4. Vertigo
   5. Oscillopsia (swaying side to side)
   6. Facial analgesia
   7. Horner’s
   8. Ipsilateral loss of taste
   9. Ipsilateral arm, trunk, leg numbness
   10. Contralateral pain and temperature loss
   11. Remember: Vocal PATHetic HOG with Vertigo (vocal cord, pain and temp, analgesia, taste, Horner’s, hoarseness, oscillopsia (sensation of things moving back and forth in horizontal plane), gag, vertigo)
5. Avellis syndrome: (tegmentum of the medulla) paralysis of soft palate and vocal cord + contralateral hemianesthesia
   1. Note: posterior portion of brain stem has mostly sensory tracts + CN 9 and 10
   2. NOTE: palatal myoclonus is due to a lesion in the dentatorubroolivary circuit
6. Jackson syndrome: Avellis + ipsilateral tongue paralysis
7. Medial medullary syndrome: (occlusion of basilar paramedian branches) ipsilateral hemiparalysis of tongue + contralateral arm and leg hemiparesis
8. Claude syndrome: (brachium conjunctivum) cerebellar ataxia + crossed CN III palsy
   1. Note: crossed CN III = innervation of superior rectus; levator palpebrae has both crossed and uncrossed
   2. Remember: Claude, Crossed, Conjunctivum, CN 3
9. Dysarthria-clumsy hand syndrome – facial weakness and severe dysarthria and dysphagia that occur in conjunction with a clumsy or paretic hand; usually due to a lacunar infarct of the basis pontis supplied by the basilar artery
10. Top o’ the basilar syndrome: abulia (absence of initiative) + Parinaud’s + CN III palsy
    1. Remember: PA 3 (Parinaud’s, Abulia, CN 3)
11. Nothnagel syndrome: unilateral or bilateral CN III + cerebellar ataxia; Remember Benedikt - hemiplegia
12. Parinaud’s syndrome: loss of upward gaze + mydriasis (dilated pupil) + loss of convergence + loss of pupillary light reflex + lid retraction + nystagmus retractorius
    1. Note: due to crossing of the fibers for upward gaze rostrally and posteriorly between the ri MLF nuclei that are interrupted before descending to the CN III nuclei
    2. Remember UPMC (Upward gaze, Pupillary reflex (plus dissociated light-near response), Mydriasis, Convergence)
13. Brain stem syndromes of non-vascular type
    1. Foster-Kennedy – lesions at the base of the frontal lobe with symptoms of ipsilateral optic atrophy, ipsilateral anosmia, and contralateral papilledema
    2. Devic’s syndrome – optic neuritis and myelitis
    3. Leber’s optic atrophy – caused by mitochondrial DNA mutation and usually causes a centrocecal scotoma

http://wiki.cns.org/wiki/index.php/Brain_stem_vascular_syndromes