Brain brainstem and cerebellum

Beatriz Junqueira-Duarte Diagnostic Imaging PGY 1, University of Toronto

Outline
Topics:
Brainstem: Midbrain; Pons; Medulla oblongata; Cerebellum.

For each topic:

Anatomy; Images +/- Pathology; Cases.

Normal Anatomy

Pineal gld (with cyst) Midbrain Pituitary Midbrain tectum cerebellum

Pons

Cerebellar tonsils

Medulla

PATIENT HAD LEIOMYOSARCOMA!!!

Posterior fossa metastasis

Leiomyosarcoma

Brainstem

Brainstem
Conduit between:
Cerebral cortex; Cerebellum; Spinal cord;

Gray matter formations; 10/12 cranial nerves has

their nuclei in it: CN 3-4: Midbrain; CN 5-8: Pons; CN 9-12: Medulla;

White matter tracts.

Reticular formation
Tegmentum:
In all 3 segments; Functions: Complex motor patterns; Aspects of respiratory and
cardiovascular activity;

Regulation of
consciousness;

Reticular formation: Central core; CN nuclei; Ascending + descending

tracts.

Brainstem
Midbrain

Midbrain
Junction of the middle and
posterior cranial fossa;

Surrounds the cerebral

aqueduct: Connects the 3rd and 4th
ventricles.
midbrain

Left cerebral peduncle

Midbrain 3 major segments

Tectum
Aka, quadrigeminal plate: Superior colliculi pair; Inferior colliculi pair;

Tegmentum
White matter tract; Gray matter formation: Substancia nigra; Red nucleus; Periaqueductal gray
matter;

Cerebral peduncles
White matter tracts;

CN nuclei.

Midbrain
Tectum / Quadrigeminal plate
Dorsal surface of the midbrain; Colliculis:
4 rounded protuberances;

Superior colliculi pair:

Visual reflexes that coordinate
eye movements w movs/ of the head and neck;

Inferior colliculi pair:

Relay station for the auditory
pathway, providing auditory information to the thalamus.

Midbrain
Cerebral peduncles
Anterior to the cerebral aqueduct; White matter axons:

Corticospinal; Corticobulbar; Corticopontine; Cerebral cortex internal capsule cerebral peduncles pontine bulb medullary pyramids spinal cord.

Midbrain - Tegmentum
White matter tracts
Medial longitudinal
fasciculus: Oculomotor-vestibular;

Spinothalamic tract:
Somatosensory;

Central tegmental tract:

Motor.

Medial lemniscus:
Somatosensory;

Lateral lemniscus:
Auditory;

Midbrain Tegmentum
Gray matter formation
Substantia nigra:

Broad layer of cells

that contain melanin;

Production of
dopamin:

Control of
muscular reflexes.

Midbrain Tegmentum
Gray matter formation
Red nucleus:

Tract of motor nerve fibers; Relay station between

cerebellum and the cerebral hemispheres;

Contributes to coordination of
movs/ and sense of balance; Periaqueductal gray matter:

Surrounds the cerebral

aqueduct;

Receives sensory input that

conveys pain and temperature to the brain.

Midbrain

Midbrain
Oculomotor CN3
Superior colliculus level; Paramedian, anterior to
cerebral aqueduct;

Trochlear CN4
Inferior colliculus level; Paramedian, anterior to
cerebral aqueduct;

Motor nuclei consists of five

individual motor subnuclei that supply individual extraocular muscles;

Dorsal to medial longitudinal

fasciculus;

Edinger-Westphal
parasympathetic nuclei: Dorsal to CN3 nucleus in
periaquaductal grey;

CN4 fibers course posteriorly

around cerebral aqueduct, decussate in superior medullary velum;

CN3 fibers course anteriorly

through midbrain to exit at interpeduncular fossa.

CN4 exits dorsal midbrain

just inferior to inferior colliculus.

Cranial nerves - Midbrain

Midbrain
Blood supply
Small perforating branches
from: Basilar artery; Superior cerebellar artery; Posterior cerebral arteries.

Midbrain
Interpeduncular:
Anterior; CN3;

Adjacent CSF cisterns

Quadrigeminal plate:
Posterior; CN4.

Ambient (perimesencephalic):
Lateral; CN4;

What is seen in imaging?

CN3: level of superior colliculus, in interpeduncular fossa; CN4: level of inferior colliculus, seen dorsally and in ambient cistern as wraps around
midbrain;

Cerebral aqueduct: Signal varies due to flow artifact; CN nuclei and white matter tracts can be identified by typical location, but are not
resolved on imaging;

Substantia nigra
and red nucleus well seen.

Midbrain
Coronal T2-weighted MRI:

1, Lateral ventricle; 2, Cingulate gyrus; 3, Corpus callosum; 4, Superior temporal gyrus; 5, Middle temporal gyrus; 6, Inferior temporal gyrus; 7, Spinal cord; 8, Medulla; 9, Pons; 10, Red nucleus; 11, Thalamus.

Brainstem
Pons

Pons
Between midbrain and
medulla oblongata;

Posterior to the clivus* and

anterior to the cerebellum;

Literally means bridge; Relay signals between the

spinal cord, cerebral and cerebellar cortices;

4th ventricle:
Between dorsal pons/upper
medulla and cerebellum.

*Basilar occipital bone w sphenoid bone.

Pons 2 major segments

Ventral (anterior) pons:
Aka, pontine bulb or belly; White matter axons:

Corticospinal; Corticobulbar; Corticopontine; Cerebral cortex internal capsule cerebral peduncles pontine bulb medullary pyramids spinal cord.

Dorsal tegmentum:
White matter tracts; CN nuclei; Continuous with:
Midbrain tegmentum
superiorly;

Medullary tegmentum
inferiorly.

Pons tegmentum
White matter tracts
Medial longitudinal
fasciculus: Oculomotor-vestibular;

Spinothalamic tract:
Somatosensory;

Central tegmental tract:

Motor;

Medial lemniscus:
Somatosensory;

Trapezoid body:
Auditory.

Lateral lemniscus:
Auditory;

Pons tegmentum
Trigeminal CN5
Nucleus located throughout
brainstem and upper cord;

Abducent CN6
Nucleus located in pontine
tegmentum near midline, anterior to fourth ventricle;

Bulk of motor, main sensory

and mesencephalic nuclei located in pons.

Axons of facial nerve (CN7)

loop around abducens nucleus creating a bulge in floor of fourth ventricle, the facial colliculus.

Pons tegmentum
Facial CN7
CN7 has three main nuclei
within pons: Motor; Superior salivatory; Solitary tract;

Vestibulocochlear CN8
CN8 has cochlear and
vestibular nuclei: Vestibular nuclei beneath
lateral recess along floor of fourth ventricle (rhomboid fossa);

Located in ventrolateral
aspect of tegmentum of lower pons.

Dorsal and ventral cochlear

nuclei on lateral surface of inferior cerebellar peduncle (restiform body).

Cranial nerves - Pons

Pons
Cerebellopontine angle (CPA).

Pons
Rhomboid fossa of the 4th ventricle:
Rostral half is formed by dorsal surface of the pons

What is it?
1 2
pons

Pons
Adjacent CSF cisterns
Prepontine cistern:
Anterior; CN5 & 6;

CPA cistern:
Lateral; CN7 & 8.

Pons
Blood supply
Medial branches of:
Superior cerebellar arteries; Perforating branches of
basilar artery.

What is seen in imaging?

CN root entry and exit zones visualized:

CN5 root entry zone at mid lateral pons; CN6 exit anteriorly at pontomedullary junction; CN7 exit lateral brainstem at pontomedullary junction; CN8 enters post. to CN7 at pontomedullary junction;

CN nuclei not resolved on conventional imaging; Specific white matter tracts can be identified by typical
location, but are not resolved on imaging;

Cerebellopontine angle (CPA): junction between pons

and cerebellum.

Prepontine meningioma
DURAL-BASED MASS!!!

Brainstem
Medulla Oblongata

Medulla Oblongata
From pons to foramen
magnum, where it continues as the spinal cord;

All fiber tracts between the

brain and the spinal cord;

Inferior 4th ventricle:

Posterior to the medulla;

Centers that control:

HR, BP and RR.

Medulla Oblongata
Anterior median fissure; Posterior median fissure; Two symmetric halves.
medulla Cerebellar tonsils cerebellum

Medulla Oblongata

Junction of medulla with cervical spinal cord

Medulla Oblongata
2 major segments
Ventral (anterior) medulla
Pyramidal tract; Olive.

Tegmentum (posterior)
White matter tracts; CN nuclei.

Medulla Oblongata ventral

Pyramids
Either side of ant. median fissure; Corticospinal tract:
Voluntary motor control;

Corticobulbar tract; Inferior decussation of

pyramids; Cerebral cortex internal capsule
cerebral peduncles pontine bulb medullary pyramids spinal cord.

Medulla Oblongata ventral

Olives
Lateral surface of the
medulla oblongata;

Rounded oval prominence; Nuclei involved in:

Coordination; Balance; Modulation of sound
impulses from inner ear.

(1) (2)

(1) aka, preolivary sulcus (2) aka, postolivary sulcus

Medulla Oblongata
tegmentum
White matter tracts
Medial longitudinal
fasciculus: Oculomotor-vestibular;

Spinothalamic tract:
Somatosensory;

Central tegmental tract:

Motor;

Medial lemniscus:
Auditory;

Spinocerebellar tract:
Somatosensory.

Medulla Oblongata
tegmentum
Glossopharyngeal CN9
CN9 nuclei is in upper and
mid medulla: Nucleus ambiguus; Solitary tract nucleus; Inferior salivatory nucleus;

Vagus CN10
CN10 nuclei in upper and
mid medulla: Nucleus ambiguus; Solitary tract nucleus; Dorsal vagal nucleus;

Sensory fibers terminate in

spinal nucleus CN5;

Sensory fibers terminate in

spinal nucleus CN5

CN9 exits medulla in

postolivary sulcus above CN10.

CN10 exits medulla in

postolivary sulcus between CN9 and 11.

Medulla Oblongata
tegmentum
Accessory CN11
Bulbar nuclei in lower
nucleus ambiguus in upper and mid medulla;

Hypoglossal CN12
CN12 nuclei in mid medulla,
dorsally results in hypoglossal eminence or trigone (bulge in fourth ventricle);

CN11 exits medulla in

postolivary sulcus below CN10.

CN12 exits anterior medulla

in pre-olivary sulcus.

Cranial nerves - Medulla

Medulla Oblongata
Blood supply
Distal vertebral arteries; Posterior inferior cerebellar
arteries;

Anterior spinal artery.

What is seen in imaging?

Medullary olives and pyramids well seen; CN9-12 seen as they exit medulla:
CN9-11 postolivary sulcus; CN12 pre-olivary sulcus;

CN nuclei and white matter tracts can be identified by typical location,

but are not resolved on imaging.

Medulla Oblongata
Axial T1-weighted MRI:

1, Nasal concha; 2, Left maxillary sinus; 3, Clivus; 4, Medulla; 5, Cerebellar tonsil; 6, Cerebellar peduncle.

Medulloblastoma

ROUND, DENSE, ARISES FROM THE ROOF OF THE 4TH VENTRICLE!!!

Cerebellum

Cerebellum
Posterior fossa; Posterior to the brainstem
and 4th ventricle;

Uses brainstem to connect

with the cerebrum to: Muscle tone; Posture; Balance; Coordination.

cerebellum

Cerebellum
2 Cerebellar hemispheres; Midline vermis:
Connects hemispheres.

Three surfaces:
Superior, inferior and
anterior;

3 paired peduncles:
Connects to brainstem;

Cortical gray matter; Central white matter; 4 paired deep gray nuclei.

Cerebellum
Divided into lobes and
lobules by transverse fissures.

Cerebellum
Lobules of Superior Vermis Lingula (anterior) Central lobule Culmen Declive Folium (posterior) Lobules of Inferior Vermis Tuber Pyramid Uvula Nodule Associated Hemispheric lobules pair Wing of lingula Wing of central lobule Quadrangular lobule Simple lobule Superior semilunar lobule Associated Hemispheric lobules pair Inferior semilunar lobule Biventricular lobule Tonsils Flocculus

Cerebellum
Cerebellar tonsils:
2 Rounded prominences; Inferomedial part of the
inferior surface.
cerebellum

Cerebellar tonsils

Arnold-Chiari malformation

Cerebellum
Cerebellar peduncles
3 pairs of nerve fiber tracts; Superior cerebellar
peduncles: Midbrain;

Middle cerebellum peduncles:

Pons;

Inferior cerebellum peduncles:

Medulla oblongata.

Cerebellum
4 paired deep gray nuclei
Dentate nuclei:
Largest; Most lateral; Project to thalamus via
superior cerebellar peduncles;

From thalamus to precentral

gyrus (motor cortex).

Cerebellum
Middle cerebellar peduncle

cerebellum

Cerebellum
Coronal T2-weighted cut.
Brain MRI: 1, Lateral ventricle; 2, Fornix; 3, Colliculus; 4, Cerebellar hemisphere; 5, Middle cerebellar
peduncle;

6, 4th ventricle; 7, Tentorium cerebelli.

Cerebellum
Adjacent CSF cisterns
CPA cistern:
Lateral;

Quadrigeminal plate
cistern: Posterior to midbrain,
above cerebellum

Superior cerebellar cistern:

Above cerebellum, below
tentorium.

Cisterna magna:
Inferior;

Cerebellum
Blood supply
Superior cerebellar artery; Anterior inferior cerebellar
artery;

Posterior inferior cerebellar

artery.

Cerebellum blood supply

Cerebellar Infarct

CNS lymphoma
involving Cerebellum

Quick Review!!!

Questions!
Which part of the midbrain is unique (no correspondent
in other segments of brainstem)?

Where is the cerebral aqueduct?

Where is the 4th ventricle?

Vessels

Cranial nerves

Cases

Case 1
Thin-walled, well-delineated, ring-enhancing cystic-appearing mass

Cerebellar abscess

Case 2
Rapid correction of hyponatremia!!!

Central Pontine Myelinolysis

Case 3
CSF peritoneal shunt catheter previously!!!

Endometrial tissue
CSF peritoneal shunt catheter previously;

Case 4 (1/2)
Multiple plaques involving corpus callosum and pons!!!

Case 4 (2/2)
CSF positive for oligoclonal bands!!!

Multiple Sclerosis

Case 5
Avidly enhancing cylindrical (IAC) or "ice cream on cone" (CPA-IAC) mass!!! Location: within CPA cistern!!!

Acoustic Neuroma

Case 6
Soft or "plastic" tumor!!! Heterogenous signal. 2/3 infratentorial usually from floor of the 4th ventricle, sometimes only in CPA cistern.

Ependymoma

Case 7
CSF-like mass insinuates cisterns, encases nerves/vessels!!! Lobulated, irregular, "cauliflower-like" mass with "fronds!!!

Epidermoid

Intracranial hypotension

References
Sectional anatomy for imaging professionals; Clinically oriented anatomy; StatDx; http://radiopaedia.org/; http://www.inforadiologie.ch/mri_sagittal_brain_t1.php#lsm1_1

THANK YOU FOR YOUR ATTENTION!!!

Imaging thanks:

Dr. Eugene Yu Dr. Kieran Murphy