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brainstem

Brainstem

(or brain stem) is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. It is usually described as including the medulla oblongata (myelencephalon), pons (part of metencephalon), and midbrain (mesencephalon).

Less frequently, parts of the diencephalon are included.

Function

The brainstem provides the main motor and sensory innervation to the face and neck via the cranial nerves.

Of the twelve pairs of cranial nerves, ten pairs come from the brainstem. Though small, this is an extremely important part of the brain as the nerve connections of the motor and sensory systems from the main part of the brain to the rest of the body pass through the brainstem. This includes the corticospinal tract (motor), the posterior column-medial lemniscus pathway (fine touch, vibration sensation, and proprioception), and the spinothalamic tract (pain, temperature, itch, and crude touch). The brainstem also plays an important role in the regulation of cardiac and respiratory function. It also regulates the central nervous system, and is pivotal in maintaining consciousness and regulating the sleep cycle. The brainstem has many basic functions including heart rate, breathing, sleeping, and eating.


Brainstem surgery remains a challenge for the neurosurgeon despite recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring. A detailed knowledge of the microsurgical anatomy of the brainstem surface and its internal architecture is mandatory to plan appropriate approaches to the brainstem, to choose the safest point of entry, and to avoid potential surgical complications.

An extensive review of the literature was performed regarding the brainstem surgical approaches, and their correlations with the pertinent anatomy were studied and illustrated through dissection of human brainstems properly fixed with 10% formalin. The specimens were dissected using the fiber dissection technique, under ×6 to ×40 magnification. 3D stereoscopic photographs were obtained (anaglyphic 3D) for better illustration of this study. RESULTS The main surgical landmarks and their relationship with the cerebellum and vascular structures were identified on the surface of the brainstem. The arrangements of the white matter (ascending and descending pathways as well as the cerebellar peduncles) were demonstrated on each part of the brainstem (midbrain, pons, and medulla oblongata), with emphasis on their relationships with the surface. The gray matter, constituted mainly by nuclei of the cranial nerves, was also studied and illustrated.

The objective of this article is to review the microsurgical anatomy and the surgical approaches pertinent to the brainstem, providing a framework of its external and internal architecture to guide the neurosurgeon during its related surgical procedures 1).

Dysfunction

(pupillary dilation, coma, and fatal systemic decompensation).

Baroreflex

The baroreflex or baroreceptor reflex is one of the body's homeostatic mechanisms that helps to maintain blood pressure at nearly constant levels. The baroreflex provides a rapid negative feedback loop in which an elevated blood pressure reflexively causes the heart rate to decrease and also causes blood pressure to decrease. Decreased blood pressure decreases baroreflex activation and causes heart rate to increase and to restore blood pressure levels. The baroreflex can begin to act in less than the duration of a cardiac cycle (fractions of a second) and thus baroreflex adjustments are key factors in dealing with postural hypotension, the tendency for blood pressure to decrease on standing due to gravity.

The system relies on specialized neurons, known as baroreceptors, in the aortic arch, carotid sinuses, and elsewhere to monitor changes in blood pressure and relay them to the brainstem. Baroreceptors are stretch receptors and respond to the pressure induced stretching of the blood vessel in which they are found. Baroreflex induced changes in blood pressure are mediated by both branches of the autonomic nervous system - that is the parasympathetic and sympathetic nerves. Baroreceptors are active even at normal blood pressures so that their activity informs the brain about both increases and decreases in blood pressure.

The body contains two other, slower acting systems to regulate blood pressure: the heart releases atrial natriuretic peptide when blood pressure is too high, and the kidneys sense and correct low blood pressure with the renin-angiotensin system.

Autonomic impairment, as measured by heart rate variability and baroreflex sensitivity, is significantly associated with increased mortality after traumatic brain injury. These effects, though partially interlinked, seem to be independent of age, trauma severity, intracranial pressure, or autoregulatory status, and thus represent a discrete phenomenon in the pathophysiology of traumatic brain injury. Continuous measurements of heart rate variability and baroreflex sensitivity in the neuromonitoring setting of severe traumatic brain injury may carry novel pathophysiological and predictive information 2).

Pathology

Brainstem cavernous malformation

Brainstem compression

Brainstem hemorrhage

Brainstem lesion

Brainstem abscess


Penetration of the clivus is required for surgical access of the brainstem

Safe surgical entry zones

Ten formalin-fixed and frozen brainstem specimens (20 sides) were analyzed. The white fiber dissection technique was used to study the intrinsic microsurgical anatomy as related to safe entry zones on the brainstem surface. Three anatomic landmarks on the anterolateral brainstem surface were selected: lateral mesencephalic sulcus, peritrigeminal area, and olivary body. Ten other specimens were used to study the axial sections of the inferior olivary nucleus. The clinical application of these anatomic nuances is presented.

The lateral mesencephalic sulcus has a length of 7.4 to 13.3 mm (mean, 9.6 mm) and can be dissected safely in depths up to 4.9 to 11.7 mm (mean, 8.02 mm). In the peritrigeminal area, the distance of the fifth cranial nerve to the pyramidal tract is 3.1 to 5.7 mm (mean, 4.64 mm). The dissection may be performed 9.5 to 13.1 mm (mean, 11.2 mm) deeper, to the nucleus of the fifth cranial nerve. The inferior olivary nucleus provides safe access to lesions located up to 4.7 to 6.9 mm (mean, 5.52 mm) in the anterolateral aspect of the medulla. Clinical results confirm that these entry zones constitute surgical routes through which the brainstem may be safely approached.

The white fiber dissection technique is a valuable tool for understanding the three-dimensional disposition of the anatomic structures. The lateral mesencephalic sulcus, the peritrigeminal area, and the inferior olivary nucleus provide surgical spaces and delineate the relatively safe alleys where the brainstem can be approached without injuring important neural structures 3).


Fifteen formalin and alcohol-fixed human brainstems were dissected using fiber dissection techniques, X6-X40 magnification, and three-dimensional photography to define the anatomy and the safe entry zones. The entry zones evaluated were the perioculomotor, lateral mesencephalic sulcus, and supra and infracollicular areas in the midbrain; the peritrigeminal zone, supra and infrafacial approaches, acoustic area, and median sulcus above the facial colliculus in the pons; and the anterolateral, postolivary, and dorsal medullary sulci in the medulla. RESULTS:: The safest approach for lesions located below the surface is usually the shortest and most direct route. Previous studies have often focused on surface structures. In this study, the deeper structures that may be at risk in each of the proposed safe entry zones plus the borders of each entry zone were defined. This study includes an examination of the relationships of the cerebellar peduncles, long tracts, intraaxial segments of the cranial nerves, and important nuclei of the brainstem to the proposed safe entry zones.

Fiber dissection technique in combination with the 3-D photography is a useful addition to the goal of making entry into the brainstem more accurate and safe 4).


Thirteen safe entry zones have been reported and validated for approaching lesions in the brainstem, including the anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region, peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicularzone, infracollicularzone, median sulcus of the fourth ventricle, anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone. A discussion of the approaches, anatomy, and limitations of these entry zones is included.

A detailed understanding of the anatomy, area of exposure, and safe entry zones for each major approach allows for improved surgical planning and dissemination of the techniques required to successfully resect intrinsic brainstem lesions 5).

1)
Párraga RG, Possatti LL, Alves RV, Ribas GC, Türe U, de Oliveira E. Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations. J Neurosurg. 2015 Oct 30:1-19. [Epub ahead of print] PubMed PMID: 26517774.
2)
Sykora M, Czosnyka M, Liu X, Donnelly J, Nasr N, Diedler J, Okoroafor F, Hutchinson P, Menon D, Smielewski P. Autonomic Impairment in Severe Traumatic Brain Injury: A Multimodal Neuromonitoring Study. Crit Care Med. 2016 Mar 10. [Epub ahead of print] PubMed PMID: 26968025.
3)
Recalde RJ, Figueiredo EG, de Oliveira E. Microsurgical anatomy of the safe entry zones on the anterolateral brainstem related to surgical approaches to cavernous malformations. Neurosurgery. 2008 Mar;62(3 Suppl 1):9-15; discussion 15-7. doi: 10.1227/01.neu.0000317368.69523.40. PubMed PMID: 18424962.
4)
Yagmurlu K, Rhoton AL Jr, Tanriover N, Bennett J. Three-Dimensional Microsurgical Anatomy and the Safe Entry Zones of the Brainstem. Neurosurgery. 2014 Jun 30. [Epub ahead of print] PubMed PMID: 24983443.
5)
Cavalcanti DD, Preul MC, Kalani MY, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg. 2015 Oct 9:1-18. [Epub ahead of print] PubMed PMID: 26452114.
brainstem.txt · Last modified: 2017/01/28 10:10 (external edit)