Cross-sections of the brainstem. A. Rostral midbrain, B. caudal midbrain, C. Pons, D. Rostral medulla, E. Caudal medulla. A= nucleus ambiguus, ML= medial lemniscus, S= nucleus solitarius, SC= Spinothalamic tract, numbers 3-12 refer to cranial nerves. (From Stephen Goldberg’s wondrous book ‘Clinical neuroanatomy made ridiculously simple’)
Signs seen in lateral brainstem syndromes (from Gates, 2005). Note trapezius weakness is rarely seen in lateral medullary lesions.
References
- Gates P. The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal 2005; 35: 263-266 [PMID 15836511]
- Goldberg S. Clinical Neuroanatomy Made Ridiculously Simple. MedMaster Series, 2000 Edition.
- Patten J. Neurological Differential Diagnosis. Springer-Verlag.
LITFL Links
- Brainstem Rules of 4 (original rules)
- Helpful Brainstem Figures (original figures)
- The rule of 4 of the brainstem (Rules re-imagined)
- A spider called Willis
- Using the Brainstem 1
- Using the Brainstem 2
- The Magic of the Neuro Exam
- Look Left, Look Right (Internuclear Ophthalmoplegia)
- More Befuddling Pupillary Asymmetry (Horner Syndrome)
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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