BRAINSTEM

Kathleen R. Gibson, Ph.D. & Han Zhang, M.D.

THE BRAINSTEM IN CROSS SECTION

The student must now learn to distinguish the mesencephalon, pons, and medulla oblongata in
brainstem cross sections
.
Mesencephalon
In whole brains, the mesencephalon is characterized by two pairs of rounded elevations dorsally:
the superior and inferior colliculi; and a pair of ventral protuberances: the cerebral peduncles. A
cross-section of the mesencephalon can always be easily identified if the student learns to
recognize the cross-sectional appearance of the colliculi and peduncles. Below are sections of the
mesencephalon at two levels: the level of the superior colliculus (III cranial nerve) and the level of
the inferior colliculus (4th cranial nerve). Note the appearance of the colliculi in the dorsal portions of
the sections and the narrow ventricular cavity, the cerebral aqueduct which lies just beneath them.
Note also that the cerebral peduncles are easily recognized by the two diverging limbs which, on
their ventral-most portion contain darkly staining longitudinally running fibers, the basis pedunculi.
Just above the basis peduncli is a light nuclear area, the substantia nigra. The basis pedunculi
contains upper motor neurons descending from the neocortex to the brainstem and spinal cord,
while the substantia nigra produces dopamine. Other easily recognizable structures are the red
nuclei and the decussation of the superior cerebellar peduncles.

SUPERIOR COLLICULUS

CEREBRAL
AQUEDUCT
SUBSTANTIA
NIGRA
RED
NUCLEUS

BASIS
CEREBRAL PEDUNCULI
PEDUNCLE

MESENCEPHALON CRANIAL NERVE III LEVEL

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 INFERIOR COLLICULUS

CEREBRAL DECUSSATION SUPERIOR

AQUEDUCT CEREBELLAR PEDUNCLES

SUBS.
NIGRA
CEREBRAL
PEDUNCLE
BASIS
PEDUNCULI

MESENCEPHALON LEVEL OF NERVE IV

Pons
The ventral surface of the pons presents a large convex protuberance caused by the presence
of many transversely running fibers, the transverse pontine fibers, which eventually enter the
middle cerebellar peduncle. These fibers are easily recognized in cross-sections and are
clear indications that one is at the level of the pons. Interspersed among the transverse
pontine fibers are longitudinally running fiber bundles, the corticospinal, corticobulbar, and
corticopontine tracts. The superior and middle cerebellar peduncles are easily
recognizable in a cross-section of the pons, while the inferior cerebellar peduncle is seen at
upper medullary levels. Note also the cavity of the fourth ventricle at the level of the pons.

Superior cerebellar peduncle

4th V.

PONS
Middle cerebellar
peduncle

Transverse pontine
fibers Corticospinal fibers

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 4TH VENTRICLE

MIDDLE
CEREBELLAR
PEDUNCLE

TRANSVERSE
PONTINE FIBERS

CORTICOSPINAL
FIBERS

PONS LEVEL OF CRANIAL NERVE V

Medulla Oblongata
The medulla oblongata is directly continuous with the cervical spinal cord. As such, its more
caudal regions are similar in appearance to the spinal cord. More cranially the medulla
oblongata has its own distinctive appearance.

Upper Medulla Oblongata

Upper levels of the medulla oblongata are readily recognized by the appearance of the inferior
cerebellar peduncles dorsolaterally. The inferior olivary nucleus and the pyramids are also
prominent throughout most of the medulla.

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 4TH VENTRICLE

Inferior
cerebellar
peduncle

INFERIOR
OLIVARY
NUCLEUS

PYRAMID

MEDULLA OBLONGATA LEVEL OF CRANIAL NERVE IX

Lower Medulla Oblongata

In the lower medulla oblongata, the inferior cerebellar peduncles and inferior olivary nuclei are
no longer visible. The brain is demarcated dorsally by the nuclei gracilis and cuneatus and by
the pyramids ventrally. Internal arcuate fibers descend from the nuclei and cross to the
opposite side in the decussation of the medial lemniscus..

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 NUCLEI
GRACILIS & CUNEATUS

DECUSSATION OF MEDIAL
LEMNISCUS

CAUDAL MEDULLA
LEVEL OF DECUSSATION OF MEDIAL LEMNISCUS

Level of the decussation of the pyramids.

The transition between the spinal cord and the medulla oblongata is marked by an important
landmark, the decussation of the pyramids, which stands out as a dark ventral area
consisting of fibers from the pyramids that are crossing to the opposite side to form the lateral
corticospinal tract. The fibers that remain uncrossed form the ventral corticospinal tract.

LATERAL CORTICOSPINALTRACT

DECUSSATION
OF PYRAMIDS

LEVEL OF DECUSSATION OF PYRAMIDS

Cranial Nerve Columns and Nuclei

Six longitudinal columns of nuclei within the brain stem control the seven functional
categories of cranial nerves. Separate columns exist for five of these functions: GSA, GSE,

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SSA, GVE, and SVE. Two of the functions, SVA and GVA, are represented in a single
column. Each of these columns is subdivided into nuclei subserving specific cranial nerves
or their functional subcomponents. Concomitantly, each cranial nerve is associated with one
or more brain stem nuclei depending on its functions: i.e., if a cranial nerve has an SVE
component it will be associated with a nucleus in the SVE column, if it has a GSA
component as well, it will also be associated with a nucleus in the GSA column. (Table I lists
nuclei, functions, and associated cranial nerves. These are also discussed in detail
below.)

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 Brainstem cranial nerve nuclei

Eventually, you will be required to recognize all of the nuclei and columns on brainstem cross
sections. One key to locating these columns is to remember their positions with respect to each
other. Remember that in the spinal cord the columns were located in the following dorsal to
ventral order: GSA, GVA, GVE, GSE.

GSA
GVA
GVE

GSE
The brainstem folds in such a way that the columns which are dorsal in the spinal cord (GSA,
GVA) become lateral in the brainstem giving the following relative positions of the columns.

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Lower motor neuron nuclei cranial nerves.
Muscles of the head, like those of the body, are controlled by both upper and lower motor
neurons. Lower motor neurons lie within the brainstem and send their axons directly to
muscles. Upper motor neurons lie in higher neural processing centers including the neocortex
and influence the functions of the lower motor neurons.

In the spinal cord, lower motor neurons for the cranial nerves are found within the GSE column.
In the brainstem, they are found both within the GSE and the SVE columns.

Within the general somatic efferent (GSE) column are four nuclei.
1. The motor nucleus of the IIIrd nerve (oculomotor nucleus) contains lower motor
neurons for the medial, superior, and inferior rectus muscles, the inferior oblique muscle
and the levator levator palpebrae superioris.

2. The motor nucleus of the IVth nerve (troclear nucleus) contains lower motor neurons
for the superior oblique muscle of the eye.

3. The motor nucleus of the VIth nerve (abducens nucleus) contains lower motor
neurons for the lateral rectus muscle.

4. The hypoglossal nucleus contains lower motor neurons which innervate all extrinsic
and intrinsiic muscles of the tongue except for the palatoglossus.

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The special visceral efferent (SVE) column contains lower motor neurons to all of the muscles
derived from the branchial arches.
1. The motor nucleus of the trigeminal (V) nerve innervates the muscles of mastication, the
tensor tympani, the tensor veli palatini, the anterior digastric muscle, and the mylohyoid.

2. The motor nucleus of the facial nerve innervates the muscles of facial expression, the
stapedius muscle, the stylohyoid and the posterior digastric muscles.

3. The nucleus ambiguus contains lower motor neuron nuclei for the branchial arch
components of nerves (IX, X, and XI). This nucleus innervates the majority of the
muscles of the palate, the pharynx, and the larynx.

Sensory nuclei cranial nerves

The general and special visceral afferent column receives sensory fibers for taste and
general visceral sensibilities. Only a solitary nucleus, the nucleus solitarius, is found in
this column. The nucleus solitarius contains the second order afferent nuclei for all visceral
sensations except olfaction.

The special somatic afferent column contains cochlear and vestibular nuclei which are
second order afferent nuclei for the VIIIth cranial nerve.

The general somatic afferent column contains the second order afferent nuclei for all
general somatic sensation.
1. The mesencephalic nucleus of the trigeminal nerve contains first order afferent
nuclei for proprioceptive sensation of the face. This nucleus is the only first order
afferent nucleus within the central nervous system.

2. The main sensory nucleus of the trigeminal nerve contains second order afferent
neurons for fine touch and proprioception in the face.

3. The spinal nucleus of the trigeminal nerve contains second order afferent neurons for
pain, temperature, and light touch of the face. Most of these fibers are carried in nerve
V, but some fibers from VII, IX, and X which are sensory to the outer and middle ear also

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 reach this nucleus. This nucleus is directly continuous with the substantia gelatinosa of
the spinal cord.

The general visceral efferent (GVE) column contains preganglionic parasympathetic motor
nuclei.
1. The nucleus of Edinger-Westphal supplies preganglionic parasympathetic fibers to the
IIIrd nerve. These fibers mediate pupillary constriction.

2. The superior salivatory nucleus supplies preganglionic parasympathetic fibers via

nerve VII to the sphenopalatine and submandibular ganglia. Fibers from these ganglia
innervate the submandibular, and sublingual salivary glands, the lacrimal glands, and the
glands of the pharynx, palate, and nasal cavity.

3. The inferior salivatory nucleus supplies preganglionic parasympathetic fibers via the
IXth cranial nerve to the otic ganglion and parotid gland.

4. The dorsal motor nucleus of the vagus supplies preganglionic parasympathetic fibers
via the Xth cranial nerve to thoracic and abdominal viscera.

At this point, you should study the atlas and make sure that you can identify each of these
nuclei on brain stem sections.

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 CRANIAL NERVES AND ASSOCIATED BRAIN STEM NUCLEI
SUMMARY TABLE

Number Name Components Function Brain Stem Nuclei

I Olfactory SVA Smell Connects directly to
olfactory cortex
II Optic SSA Vision Lateral geniculate body,
superior colliculus
III Oculomotor GSE Motor all extrinsic eye Oculomotor nucleus
muscles except (motor nucleus of 3rd
superior oblique and nerves)
lateral rectus
GVE Motor to pupillary Nucleus of Edinger-
constrictor and ciliary Westphal
muscles
IV Trochlear GSE Motor to superior Trochlear nucleus
oblique muscle of eye (nucleus of nerve IV)
V Trigeminal SVE Motor to muscles of Motor nucleus of
mastication, trigeminal
mylohyoid, anterior
digastric, tensor
palatine and tensor
tympani
GSA Somatosensation Main sensory nucleus,
from face-oral cavity spinal nucleus of
trigeminal,
mesencephalic nucleus
VI Abducens GSE Motor to lateral rectus Abducens nucleus
muscle to eye (nucleus of VIth nerve)
VII Facial GVE Motor to Superior salivatory
submandibular, nucleus
sublingual, lacrimal
and lingual glands
SVE Motor to muscles of Facial nucleus (motor
facial expression, nucleus of nerve VII)
stylohyoid, posterior
digastric and
stapedius muscles
GSA Somatosensation Spinal nucleus of
from skin of ear trigeminal
SVA Taste from anterior Nucleus solitarius
two-thirds of tongue
VIII Auditory SSA Hearing and Cochlear nuclei,
or vestibular sensation vestibular nuclei medial
Vestibulocochlear geniculate body, inferior
colliculus

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 TABLE (Continued)

IX Glossopharyngeal GVE Motor to parotid gland Inferior

salivatory
nucleus
SVE Motor to stylopharyngeus muscle Nucleus
ambiguus
GSA Sensory from external ear Spinal nucleus
of trigeminal
GVA Visceral sensation posterior one-third Nucleus
of tongue, upper pharynx, carotid solitarius
body, and middle ear cavity
SVA Taste from posterior one-third of Nucleus
tongue solitarius
X Vagus GVE Motor to smooth muscle of gut, Dorsal motor
smooth muscle of respiratory system, nucleus of
cardiac muscle vagus
SVE Motor to all pharyngo-laryngeal Nucleus
muscles except stylopharyngeus and ambiguus
to all muscles of soft palate except the
tensor palatine
GSA Somatosensation from external Spinal nucleus
auditory canal and skin near ear of trigeminal
GVA Ordinary sensibility from visceral Nucleus
structures solitarius
SVA Taste from epiglottis Nucleus
solitarius
XI Spinal accessory SVE Motor to sternocleiodmastoid and Nucleus
trapezius muscles ambiguus
XII Hypoglossal GSE Motor to all instrinsic and extrinsic Hypoglossal
tongue muscles except the nucleus
palatoglossus

Cranial nerves motor systems

Lower motor neurons for the cranial nerves lie in the nuclei of the SVE and GSE columns.
Fibers travel with the cranial nerves to their final destinations. General symptoms of lower
motor neuron damage to cranial nerve nuclei include ipsilateral flaccid paralysis and atrophy of
the affected muscles and diminished reflexes. Specific symptoms usually correspond to lower
motor neuron symptoms of damage to the cranial nerves themselves. Thus, damage to the
motor nucleus of the trigeminal will produce ipsilateral paralysis and atrophy of the muscles of
mastication, and the jaw will deviate to the affected side. Damage to the facial nucleus will
produce ipsilateral atrophy and paralysis of the muscles of facial expression. The patient will
have difficulty raising the eyebrow, closing the eye, pursing the lips, whistling and smiling on the

12
ipsilateral side. The corneal reflex will be absent on the ipsilateral side. Damage to the
nucleus ambiguus will result in paralysis of the vocal cord and an accompanying hoarse voice
and deviation of the uvula away from the side of the lesion. The cough and gag reflexes will be
lost. Damage to the oculomotor nucleus will result in lateral strabismus, diplopia, ptosis, and
poverty of eye movement. Damage to the abducens nucleus will cause medial strabismus.
Damage to the hypoglossal nucleus will produce paralysis of the tongue on the ipsilateral side.
The ipsilateral tongue will be shrunken and wrinkled and will deviate to the side of the lesion.

Upper motor neuron fibers for the head and neck lie in descending corticobulbar,
corticopontine and corticomesencephalic tracts. These tracts which are comparable in
function to the corticospinal tracts, all arise in the cortex or other higher brain centers and are
named according to the brain stem level at which they terminate. Those fibers providing upper
motor neuron control for mesencephalic nuclei terminate in the mesencephalon and are named
corticomesencephalic tracts; those providing upper motor neuron control for pontine nuclei are
termed corticopontine tracts; and those for the nuclei of the medulla are termed corticobulbar
tracts. These longitudinally running fiber tracts are part of one continuous system which
descends from the cortex via the internal capsule to the basis pedunculi of the mesencephalon.
When they reach the pons, the fibers are separated by the transverse pontine fibers into
bundles of corticopontine, corticobulbar and corticospinal tracts. The corticospinal fibers again
coalesce into one bundle, the pyramids, in the medulla oblongata. Some fibers then cross in
the decussation of the pyramids to become the lateral corticospinal tracts, while others remain
the uncrossed ventral corticospinal tracts.

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 Corticomesencephalic tract

Corticopontine tract

Corticobulbar tract

Lateral corticospinal tract

Ventral corticospinal tract

One of the most difficult problems in diagnosis is that of differentiating between upper motor neuron
and lower motor neuron lesions of the cranial nerves. As each muscle receives only ipsilateral (same
sided) innervation from the lower motor neurons in the cranial nerves, lesions of lower motor neurons
in both cranial and spinal nerves always cause paralysis on the same side as the lesion. Lower
motor neuron lesions in cranial nerve motor nuclei are also usually ipsilateral.

Upper motor neuron innervation is more complicated. Examine, for a moment, voluntary
movements in your own body. Note that it is extremely easy to move the right hand without
moving the left hand or to move one foot without the other. Now attempt to contract only one
side of your diaphragm or one side of your anal sphincter. You will probably find this extremely
difficult, if not impossible. In general, muscle groups that move independently of similar
muscles on the opposite side of the body have unilateral innervation from the contralateral
cortex only. Muscles that always work in unison with the similar muscles of the opposite body
side receive bilateral innervation from both the contralateral and the ipsilateral cortex. Those
muscles which receive innervation only from the contralateral cortex will suffer severe upper

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motor neuron symptoms if these upper motor neurons are disrupted at any portion of the upper
motor neuron pathway. Those muscles which are innervated by both cortical hemispheres will
suffer only temporary weakness if the upper motor neuron pathway is disrupted on one side.
The lesion must be bilateral to cause permanent damage to these muscles.

Now examine the muscles of your head. Try to move one eye at a time. Very few people can do
this. The extrinsic eye muscles work in unison and are bilaterally innervated. Upper motor
neuron paralyses of the extrinsic eye muscles are rare. Most paralyses of the eye muscles are
lower motor neuron in type. However, damage to the frontal eye fields or the horizontal gaze
center in the pons will produce a paralysis of conjugate gaze, that is, a loss of the ability to
move both eyes simultaneously towards the opposite side of the lesion. The muscles of
mastication fall between the two extremes of bilateral, symmetrical movement and unilateral,
asymmetrical action. Thus, the muscles of mastication are bilaterally innervated by the upper
motor neurons. Unilateral upper motor neuron lesions will not cause permanent paralysis, only
temporary weakness. All unilateral permanent paralyses of the muscles of mastication are
lower motor neuron in type.

Now test the muscles innervated by nerve VII. Raise one eyebrow. Many people find this
difficult. The frontalis muscle is bilaterally innervated. Close one eye. People vary in their
ability to do this. The orbicularis oculi muscles are bilaterally innervated, but not to the same
extent as the frontalis. Retract one corner of your mouth. The muscles which retract the lips
are unilaterally innervated. Upper motor neuron lesions of nerve VII may be readily
differentiated from lower motor neuron lesions of that nerve by remembering the above facts.
Lower motor neuron paralysis will affect all muscles innervated by nerve VII on the ipsilateral
side of the face. The patient will be unable to raise his eyebrow, close his eye, or retract his lip
on that side. In upper motor neuron lesions, the ability to raise the eyebrow will be unaffected
on the side of the lesion. The eye may close, but weakly. Major effects will be below the orbit in
the mouth region. The lip will not retract on the affected side, the mouth will droop toward the
affected side and the nasolabial fold will be diminished on that side. Most upper motor neurons
of cranial nerve VII are contralateral.

Can you contract of your palate, of your pharynx, or of your vocal cords? The muscles
innervated by nerves IX and X are bilaterally innervated. Unilateral paralysis of the muscles
innervated by these nerves is nearly always lower motor neuron in type.

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The tongue is intermediate between the extremes of unilateral and bilateral innervation. A
unilateral upper motor neuron lesion will cause a mild, transient paresis of tongue.

Lesions in certain parts of the brainstem can affect both upper motor neurons to the limbs and
lower motor neurons associated with specific cranial nerves. For example, a lesion in the
ventral medulla oblongata can affect both the pyramids and the emerging hypoglossal nerve. In
this case, the patient will have an ipsilateral lower motor neuron paralysis of the tongue and an
upper motor neuron paralysis of the contralateral arm and leg. Lesions that produce lower
motor symptoms of a cranial nerve of one side combined with contralateral upper neuron
lesions of the extremities are termed alternating hemiplegias. Lesions in the pons can
produce alternating hemiplegias affecting the trigeminal or facial nerves. Lesions in the
mesencephalon can produce an alternating hemiplegia of the oculomotor nerve resulting in
ipsilateral lateral strabismus, ptosis, inability to constrict the pupil, loss of corneal reflex and
contralateral hemiplegia. This constellation of symptoms is termed Webers syndrome.

LESIONS PRODUCING ALTERNATING HEMIPLEGIAS

BRAIN STEM SENSORY PATHWAYS

Audition and Vestibular Sense
Cranial nerve VIII provides for hearing and vestibular function. Auditory fibers leave this nerve
to synapse in the dorsal and ventral cochlear nuclei of the medulla oblongata. From here
some fibers pass directly to the lateral lemniscus. Others first synapse in the superior olivary
nucleus and the nucleus of the trapezoid body prior to joining the lateral lemniscus. Fibers in
the lateral lemniscus synapse in the inferior colliculus. From the inferior colliculus fibers pass
to the medial geniculate body of the thalamus and from there via the internal capsule to the

16
primary auditory cortex. Vestibular impulses synapse with vestibular nuclei of the medulla.
Ascending pathways to the cortex are poorly understood. Definitive vestibular connections are
made with the brain stem motor nuclei of the extraocular muscles. These connections permit
the eyes to remain focused on a visual stimulus when the head and body are moving. The
vestibular system also sends fibers to the cerebellum for aid in control of body posture.

Somatosensation Cranial Nerves V, VII, IX, and X

Although the trigeminal nerve controls most somatosensation from the oral cavity and facial
regions, cranial nerves VII, IX, and X also contribute to somatosensation from the region of the
ear. In addition, some pain from blood vessels in the head may be mediated by the
sympathetic nervous system instead of by the cranial nerves.

Pain, Temperature and Light Touch

First order cell bodies for pain, temperature and light touch lie in peripheral ganglia of following
nerves: V, VII, IX, and X. In each case after entering the brain stem, a central process travels
upwards or downwards a few segments and then enters the spinal tract of the trigeminal
nerve. This small tract lies lateral to the spinal nucleus and is functionally equivalent to
Lissauers tract of the spinal cord. The first order neuron then synapses in the spinal nucleus
of the trigeminal nerve (nucleus caudalis). This nucleus which is found in the medulla and
lower pons is directly continuous with the substantia gelatinosa of the spinal cord and similar to
it in function. From cranial to caudal, the spinal nucleus is divided into three subnuclei: the
nucleus oralis, the nucleus interpolaris and the nucleus caudalis. Pain and temperature for
most of the facial region are mediated by the nucleus caudalis, that for the teeth by the nucleus
interpolaris. Within the nucleus caudalis, the skin and oral cavity are represented by an onion
skin pattern. Those regions nearest the lip are represented in the anterior portion of the
nucleus. Those nearest the ear in the posterior portion. This onion skin pattern corresponds
to the dermatomes of the limbs and trunk.

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 Second
order fibers
emerge from
the spinal
SPINAL
nucleus,
NUCLEUS OF
TRIGEMINAL
cross to the
opposite side
of the brainSKIN
ONION
PATTERN
stem and ascend to the thalamus in the trigeminal lemniscus (ventral trigeminothalamic tract). As
is the case for the spinal nerves, cranial nerves mediate both fast and slow pain. Slow pain pathways
terminate in the thalamus. Third order afferents for the fast pain system ascend from the thalamus to
the somatosensory cortex. Descending fibers from higher brain centers are apparently able to control
the intensity of pain perception in the facial region just as they do for the remainder of the body.

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Lesions in the peripheral nerves, spinal nucleus of the trigeminal or spinal tract of the trigeminal
produce ipsilateral loss of pain, temperature, and light touch. Lesions in the trigeminal
lemniscus, somatosensory portion of the internal capsule or somatosensory cortex produce
contralateral loss. Lesions in the dorsolateral medulla can damage the spinal nucleus and
tract of the trigeminal and the lateral spinothalamic tract simultaneously. In this case, the patient
will have an alternating analgesia. There will be an ipsilateral loss of pain and temperature
sensation in the face and a contralateral loss on the opposite body.

ALTERNATING
ANALGESIA

Fine Touch
Fine touch of the face and oral cavity is mediated primarily by the trigeminal nerve. Cell bodies
of the first order afferent neurons lie in the trigeminal ganglion and synapse in the main
sensory nucleus of the trigeminal nerve. From here most second order afferent fibers cross to
the contralateral side and travel in the trigeminal lemniscus (ventral trigeminothalamic tract)
to the thalamus. Others travel to the thalamus ipsilaterally in the dorsal trigeminothalamic
tract. Third order afferents pass from the thalamus to the somatosensory cortex. Lesions in the
trigeminal nerve or main sensory nucleus produce ipsilateral loss of fine touch sensation.
Lesions in the trigeminal lemniscus, thalamus, internal capsule or cortex produce contralateral
loss.

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Proprioception
A peculiarity of the proprioceptive system of the head and neck is that the first order afferent cell
bodies lie within the brain rather than within the peripheral ganglia. First order afferent
proprioceptive fibers, (presumably from all cranial nerves carrying motor impulses), travel in the
mesencephalic tract of the trigeminal nerve. Their cell bodies lie in the mesencephalic
nucleus. This is the only brain stem nucleus containing first order afferent cell bodies. From the
mesencephalic nucleus, fibers travel to the main sensory nucleus of the trigeminal. Second
order afferents of the proprioceptive system emerge from this nucleus. Some cross to the
opposite side and travel to the thalamus in the trigeminal lemniscus (ventral
trigeminothalamic tract). Others travel to the thalamus in the ipsilateral dorsal
trigeminothalamic tract. Pure proprioceptive defects of the head and neck region are rare.
Note that the trigeminal lemniscus carries contralateral second order fibers for fine touch,
proprioception, pain, temperature and light touch.

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 PROPRIOCEPTION
HEAD

FINE TOUCH AND PROPRIOCEPTION BODY AND HEAD COMPARED

Taste and General Visceral Sensation Cranial Nerves VII, IX, and X
Taste sensation (SVA) for the anterior two thirds of the tongue is carried by the seventh nerve,
for the posterior one third by the ninth nerve and for the epiglottis by the tenth. General visceral
sensation (GVA) for the posterior palate, posterior one third of the tongue and oral pharynx is
provided by cranial nerve nine; that for the laryngopharynx, larynx, thoracic and abdominal
viscera by nerve X. Cell bodies for both SVA and GVA functions lie in the peripheral ganglia of

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the superficial nerves. Within the brain, all SVA and GVA fibers from nerves VII, IX, and X follow
the same pathways. All first order afferents for either taste or general visceral sensation
descend in the tractus solitarius to the nucleus solitarius. The pathways for second order
afferents are uncertain but are thought to emerge from the nucleus solitarius and then travel in
close association with the ipsilateral trigeminal lemniscus, possibly in the central tegmental
tract, to synapse in the thalamus. Third order afferents travel from the thalamus to the
neocortex, including the insula.

BRAIN STEM CROSS SECTIONS

All structures that the student is required to identify on the Atlas photographs have now been
named. Please assure that you can identify each of the following brain stem structures.

Level of Lower Medulla

GSA column Spinal tract of trigeminal
Spinal nucleus of trigeminal Lateral spinothalamic tract
Nucleus gracilis Medial lemniscus
Nucleus cuneatus Pyramids

Level of Cranial Nerves X and XII

GVA nucleus solitarius GSA spinal nucleus of V
GVE dorsal motor nucleus of vagus SVE nucleus ambiguus
GSE hypoglossal nucleus Nerves X and XII
SSA Cochlear nuclei Inferior olivary nucleus

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Level of Cranial Nerve IX
GVA nucleus solitarius GSA spinal nucleus of V
GVE inferior salivatory nucleus SVE nucleus ambiguus
Nerve IX
Inferior cerebellar peduncle
Nerve VIII

Level of VI and VII Cranial Nerves

GVE superior salivatory nucleus* GSA spinal nucleus of trigeminal
Nerves VI and VII trapezoid body
SVE motor nucleus of VII middle cerebellar peduncle
Corticospinal tracts
Note that nerve VII loops around the nucleus of VI before leaving the brain stem.
* Although present at this level, this nucleus is not visible.

Level of Cranial Nerve V

GSA main sensory nucleus medial lemniscus and trapezoid body
SVE motor nucleus of V mesencephalic nucleus
Vth nerve transverse pontine fibers
Corticospinal tracts

Level of IVth Nerve

GSE fourth nerve nucleus Inferior colliculus
Nerve IV cerebral aqueduct
Substantia nigra
Medial, lateral, and trigeminal lemnisci
Basis pedunculi

Level of Nerve III

GVE Edinger-Westphal nucleus medial, lateral and trigeminal lemnisci
GSE motor nucleus of III nerve Red nucleus
Nerve III Superior colliculus
Mesencephalic nucleus Basis pedunculi
Substantia nigra

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CRANIAL NERVE REFLEXES
Two types of reflexes found in the spinal cord are also found in the cranial nerves: stretch
reflexes and superficial reflexes. In addition, the cranial nerves mediate many visceral and
special reflexes.

Stretch Reflexes Jaw Jerk Reflex

The primary stretch reflex of the cranial nerves is the jaw jerk reflex. This reflex consists of
rapid closure of the jaws upon tapping the middle of the chin or the lower teeth. Like spinal
stretch reflexes, the jaw jerk is mediated by a simple two neuron reflex arc. Both sensory and
motor limbs of this reflex arc are carried in the mandibular division of the trigeminal nerve.
Proprioceptive fibers travel from the mandibular division to the mesencephalic tract. First order
afferents lie in the mesencephalic nucleus. From the nucleus, descending fibers connect with
the motor nucleus of V. An absence of the jaw jerk reflex usually indicates a lesion in the
mandibular nerve, but may indicate a lesion in the mesencephalic nucleus or in the motor
nucleus of the trigeminal.

Superficial Reflexes
The corneal reflex is the primary superficial reflex of the facial region. With the patient staring
straight ahead, cotton is applied to the lateral cornea in such a manner that the patient cannot
see it. A blink results in both eyes. The sensory limb of this reflex is carried by the ophthalmic
division of V and synapses in the spinal nucleus. From the spinal nucleus, fibers are sent to the
motor nucleus of the seventh nerve on both sides. Absence of blinking in both eyes

24
subsequent to corneal stimulation usually indicates damage to the ophthalmic division of V. If
blinking occurs in one eye, but not the other, the seventh nerve or nucleus is lesioned on the
side of the absent reflex.

Visceral and Other Special Reflexes

Gag Reflex - Gagging is elicited by touching the posterior oral pharynx with a tongue depressor.
The sensory limb of this reflex is cranial nerve IX, the motor limb X. From cranial nerve IX,
fibers travel to the nucleus solitarius. Interneurons are found within the medulla. Motor
impulses originate in the nucleus ambiguus. Loss of the gag reflex usually indicates a lesion in
IX, or X, but may result from lesions in the nucleus solitarius or the nucleus ambiguus.

Cough Reflex Irritation of the larynx, trachea or bronchi results in coughing. Both sensory
and motor limbs of the cough reflex are carried by the vagus nerve. Afferent impulses travel to
the nucleus solitarius. From there, special connections are made to the respiratory center of the
reticular formation of the medulla to bring about forced expiration. The nucleus ambiguus
provides motor innervation to laryngeal muscles; spinal motor nuclei provide it to the diaphragm.
A loss of the cough reflex usually reflects damage to the vagus nerve, but may result from
damage to the medulla.

Vomiting Reflex Both sensory and motor limbs of the vomiting reflex are mediated by cranial
nerve X. In addition to the muscles of the gastrointestinal tract and glottis, the diaphragm and
abdominal muscles also function during vomiting. Hence, spinal nerves also mediate this reflex.
Consequently, a vomiting center is located in the reticular formation of the medulla to coordinate
this response. Loss of the vomiting reflex may signify damage to the vagus nerve or brain stem.

Salivary Reflexes Salivation occurs as a reflex response to taste. Usually the facial nerve
and nucleus solitarius serve as the afferent limb of this reflex. The superior and inferior
salivatory nuclei and cranial nerves VII and IX are the motor limb. Loss of salivation can
indicate damage to any of these structures.

Pupillary Light Reflex When light is flashed in the eye, the pupils of both eyes constrict. The
afferent limb of this reflex passes from the optic nerve to the pretectal region of the midbrain (a
region just rostral to the superior colliculus). From here fibers are sent to the Edinger-Westphal
nucleus. This nucleus sends preganglionic parasympathetic fibers via nerve III to the ciliary

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ganglion. From the ganglion, postganglionic fibers pass to the pupil. The response in the
directly stimulated eye is the direct reflex. The response in the opposite eye is the
consensual reflex. In lesions of the optic nerve the direct reflex is abolished in the blind eye
and the consensual in the opposite eye. Lesions of the oculomotor nerve abolish both direct
and consensual responses on the side of the lesion (paralyzed eye). Response in the opposite
eye remains normal. Absence of light reflexes can also indicate malfunction of the midbrain.

Pupillary Accommodation Reflex When the eyes focus on a near object, the pupils constrict.
This complex reflex requires participation of the occipital cortex. Sensory fibers ascend from the optic
nerve to the lateral geniculate body to the visual cortex and from there to visual association cortex.
Descending fibers proceed to the superior colliculus which sends impulses to the Edinger-Westphal
nucleus. The final limb of the reflex travels with the oculomotor nerve to the ciliary ganglion and from
there to the pupil. Lesions at any point in this pathway destroy the accommodation reflex.

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Argyll-Robertson Pupil The pupil constricts in response to accommodation but not in response
to light. This results from a midbrain lesion and is usually symptomatic of neurosyphillis.

CLINICAL SYNDROMES OF THE HEAD AND NECK REGION

Trigeminal Neuralgia Consists of very severe lightning-like pains in one or more branches of
nerve V. These begin abruptly and stop suddenly. The pains are usually initiated by touching a
trigger zone, which may be located on the lip, face, gum or tongue. Trigeminal neuralagia
usually affects adults over age 40. In most cases the cause is unknown. Trigeminal neuralgia,
however, may be symptomatic of multiple sclerosis, neurosyphillis or other neurologic disease,
particularly if it is bilateral, occurs in a young patient, or in conjunction with other neurologic
signs. Histologic examination generally reveals preferential destruction of large type A fibers in
the trigeminal nerve or roots. Hence, the lesions somewhat resemble those of tabes dorsalis in
that large tactile fibers which may exert an inhibitory role in pain perception are degenerated.
Trigeminal neuralgia may be treated by drugs including diphenylhydantoin and
carbamazepine.

Bells Palsy is a lower motor neuron lesion of the VIIth nerve which produces symptoms of VIIth
nerve paralysis on one side of the face. It may result from chilling of the face, middle ear
infections, tumors, fractures, infectious diseases or, occasionally, a misplaced dental injection.

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Usually the palsy clears spontaneously. Bells palsy must be differentiated from upper motor
lesions of cranial nerve VII which result from stroke, tumor, or other cranial diseases. In upper
motor neuron lesions, only the muscles of the lower half of the face are afflicted. Whereas in
lower motor lesions, the forehead and eye muscles are affected as well as those of the mouth. A
special type of Bells palsy results from the Ramsey-Hunt Syndrome. This is a Herpes zoster
infection of the geniculate ganglion (sensory ganglion of nerve VII). It is signified by a vesicular
eruption of the external ear, Bells palsy, and loss of taste in anterior 2/3 of the tongue.

Glossopharyngeal Neuralgia consists of severe lightning-like pains which start in the throat
and radiate to the auditory tube. Pain may be initiated by coughing, swallowing, or clearing the
throat.

Herpes Zoster of the Vth Nerve is usually limited to one division of the Vth nerve, most
commonly, the ophthalmic. The first symptom is pain followed by vesicular eruptions. The
greatest danger is that the cornea may be seriously damaged. Sometimes, Herpes zoster is
followed by trigeminal neuralgia.

Trismus refers to spasm of the masseter muscle resulting in pain accompanied by difficulty in
opening the jaw. In extreme cases it may lead to lock-jaw. Although bilateral trismus can
indicate tetanus if accompanied by other muscle spasms, trismus most often is a reflex spasm
resulting from pain or disease in the region of the teeth.

Amyotrophic lateral sclerosis is a systemic disease which often first manifests itself in the
head and neck region. The patient may experience difficulty in chewing or swallowing
secondary to muscular atrophy or paralysis.

Horners Syndrome Lesions of the sympathetic trunk, often subsequent to lung cancer, result
in Horners syndrome. The ipsilateral pupil is constricted, ptosis occurs; the skin is reddened
and exhibits loss of sweat.

CASE HISTORIES

1. A 46 year old man complained to his dentist that he was having trouble chewing.
Examination disclosed atrophy and complete paralysis of the left temporal and masseter
muscles. When he opened his jaw, it deviated to the left. He could not move it forcefully to the
right. He had no motor or sensory deficits involving other cranial or spinal nerves. The jaw jerk
reflex was absent.

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 a. What nerve is involved?

b. What side?

c. Is the lesion upper or lower motor neuron?

2. A 42 year old man visited a dentist complaining of difficulty in chewing and articulating his
dentures. The dentist readjusted the dentures and sent the patient on his way.

Unbeknownst to the dentist, the patient also suffered from back pain and weakness and
fasciculations of the muscles of the limbs. These symptoms had been diagnosed as nervous
tension. The patients problems persisted, and several months later, he again visited the
dentist. This time marked fasciculations and atrophy of the tongue were noted. The patients
bite was extremely weak and his mouth tended to hang open. The dentist referred the patient to
a neurologist who noted that the patient had many hyperactive reflexes, coupled with marked
degeneration and weakness of muscles throughout the body.

a. The hyperactive reflexes suggest what kind of lesion?

b. The muscle atrophy is suggestive of what kind of lesion?

c. What disease combines these two types of lesion?

3. A 46 year old woman awakened one morning with her face drawn to one side. Examination
disclosed that on the right side she could not wrinkle her forehead, close her eye, smile, or
wrinkle the skin of her neck. The left side of her face moved normally. There was no problem
with hearing or taste.

a. What nerve is involved?

b. What is the name of this syndrome?

4. A 76 year old patient complains of severe pain in his face. His symptoms have existed for
four months. His wife claims that he is irascible and impossible to live with. He has very brief,
shock-like episodes of unbearable pain which run from the side of his cheek down to the tip of
the jaw on the right side only. All motor and sensory functions of the cranial nerves are normal,
but the patient will not allow the examiner to test sensation over the right lower jaw because he

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fears pain. He neither brushes his right mandibular teeth, nor attempts to chew on the right
side, because to do so causes unbearable pain.

a. What peripheral nerve is involved?

b. What side?

c. What branch?

d. What is the name of this syndrome?

5. A patient awakes one morning to find the left half of his face paralyzed. Painful vesicles are
also found in the left external ear. Testing reveals loss of taste in the anterior two thirds of the
tongue on the left.

6. When the dentist inadvertently touches the patients posterior palate, the patient suffers
paroxysms of pain in the throat.

7. A patient awakes one morning to find painful vesicular eruptions over his forehead and
cornea.

8. A patient bothered by persistet cough and loss of weight exhibits the following symptoms. 1)
constriction of the left pupil 2) ptosis of the left eye 3) reddening and loss of sweat in the left
face.

9. A patient has the following symptoms: his left shoulder droops and his chin is deviated to the
left and cannot be turned toward the right. The left tongue is wrinkled and exhibits
fasciculations. When protruded his tongue deviates to the left.

a. What cranial nerves were damaged?

b. On what side?

10. A patient exhibits shortness of breath and hoarseness. When asked to say Ah his uvula
deviates to the right.

a. What cranial nerve is damaged?

b. On what side?

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11. An elderly woman awakens one morning to find she cannot smile or purse her lips on the
left. Movements of the forehead and eye, however, are normal.

a. What nerve is malfunctioning?

b. Is this malfunctioning likely to be upper motor neuron or lower motor neuron in type?

12. A patient slowly develops deafness in the left ear, vertigo, and nystagmus. What nerve is
diseased?

13. A patient develops blindness in the left eye accompanied by loss of both direct and
consensual light reflexes. What nerve is damaged?

14. A patient has a slowly developing bitemporal hemianopsia. Where is the lesion?

15. A patient has a ptosis, a lateral strabismus, a dilated pupil, and a general lack of movement
in the left eye. Both direct and consensual light reflexes are absent in the left eye. What nerve
is damaged?

16. A patient suffers from vertigo and from deafness in the left ear. What nerve is damaged?

VI ANSWERS TO CASE HISTORIES

1. Lesions of motor division of left trigeminal nerve. Lower motor neuron lesion.

2. Upper neuron lesion, lower motor neuron lesion. Amyotrophic lateral sclerosis.

3. Seventh nerve, Bells palsy.

4. Trigeminal neuralgia, right mandibular division.

5. Herpes zoster of geniculate ganglion resulting in Bells palsy. Ramsey-Hunt syndrome.

6. Glossopharyngeal neuralgia.

7. Herpes zoster of the ophthalmic division of nerve V.

8. Horners syndrome probably secondary to lung cancer.

9. Eleven and twelve on the left.

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10. Vagus on left.

11. Left facial nerve, upper motor neuron lesion.

12. Auditory nerve, cranial nerve VIII.

13. Left optic.

14. Optic chiasm.

15. Left Third nerve.

16. Left cranial nerve VIII.

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