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The brainstem (or brain stem) is the posterior stalk-like part of the
brain A brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as Visual perception, vision. I ...
that connects the
cerebrum The cerebrum, telencephalon or endbrain is the largest part of the brain containing the cerebral cortex (of the two cerebral hemispheres), as well as several subcortical structures, including the hippocampus, basal ganglia, and olfactory bulb. ...
with the spinal cord. In the
human brain The human brain is the central organ of the human nervous system, and with the spinal cord makes up the central nervous system. The brain consists of the cerebrum, the brainstem and the cerebellum. It controls most of the activities of ...
the brainstem is composed of the
midbrain The midbrain or mesencephalon is the forward-most portion of the brainstem and is associated with vision, hearing, motor control, sleep and wakefulness, arousal ( alertness), and temperature regulation. The name comes from the Greek ''mesos'', ...
, the pons, and the medulla oblongata. The midbrain is continuous with the thalamus of the diencephalon through the
tentorial notch The tentorial notch (also known as the tentorial incisure or incisura tentorii) refers to the anterior opening between the free edge of the cerebellar tentorium and the clivus for the passage of the brainstem. The midbrain continues with the t ...
, and sometimes the diencephalon is included in the brainstem. The brainstem is very small, making up around only 2.6 percent of the brain's total weight. It has the critical roles of regulating cardiac, and respiratory function, helping to control heart rate and
breathing rate The respiratory rate is the rate at which breathing occurs; it is set and controlled by the respiratory center of the brain. A person's respiratory rate is usually measured in breaths per minute. Measurement The respiratory rate in humans is mea ...
. It also provides the main motor and sensory nerve supply to the face and neck via the cranial nerves. Ten pairs of cranial nerves come from the brainstem. Other roles include the regulation of the central nervous system and the body's sleep cycle. It is also of prime importance in the conveyance of motor and sensory pathways from the rest of the brain to the body, and from the body back to the brain. These pathways include the
corticospinal tract The corticospinal tract is a white matter motor pathway starting at the cerebral cortex that terminates on lower motor neurons and interneurons in the spinal cord, controlling movements of the limbs and trunk. There are more than one million ne ...
(motor function), the
dorsal column-medial lemniscus pathway Dorsal (from Latin ''dorsum'' ‘back’) may refer to: * Dorsal (anatomy), an anatomical term of location referring to the back or upper side of an organism or parts of an organism * Dorsal, positioned on top of an aircraft's fuselage * Dorsa ...
(
fine touch In physiology, the somatosensory system is the network of neural structures in the brain and body that produce the perception of touch (haptic perception), as well as temperature (thermoception), body position ( proprioception), and pain. It ...
, vibration sensation, and proprioception), and the spinothalamic tract ( pain, temperature, itch, and crude touch).


Structure

The parts of the brainstem are the midbrain, the pons, and the medulla oblongata, and sometimes the diencephalon.


Midbrain

The
midbrain The midbrain or mesencephalon is the forward-most portion of the brainstem and is associated with vision, hearing, motor control, sleep and wakefulness, arousal ( alertness), and temperature regulation. The name comes from the Greek ''mesos'', ...
is further subdivided into three parts: tectum,
tegmentum The tegmentum (from Latin for "covering") is a general area within the brainstem. The tegmentum is the ventral part of the midbrain and the tectum is the dorsal part of the midbrain. It is located between the ventricular system and distinctive ba ...
, and the
ventral tegmental area The ventral tegmental area (VTA) (tegmentum is Latin for ''covering''), also known as the ventral tegmental area of Tsai, or simply ventral tegmentum, is a group of neurons located close to the midline on the floor of the midbrain. The VTA is the ...
. The tectum forms the ceiling. The tectum comprises the paired structure of the
superior Superior may refer to: *Superior (hierarchy), something which is higher in a hierarchical structure of any kind Places *Superior (proposed U.S. state), an unsuccessful proposal for the Upper Peninsula of Michigan to form a separate state *Lake ...
and
inferior colliculi The inferior colliculus (IC) ( Latin for ''lower hill'') is the principal midbrain nucleus of the auditory pathway and receives input from several peripheral brainstem nuclei in the auditory pathway, as well as inputs from the auditory cortex. Th ...
and is the dorsal covering of the cerebral aqueduct. The
inferior colliculus The inferior colliculus (IC) ( Latin for ''lower hill'') is the principal midbrain nucleus of the auditory pathway and receives input from several peripheral brainstem nuclei in the auditory pathway, as well as inputs from the auditory cortex. Th ...
is the principal midbrain nucleus of the auditory pathway and receives input from several peripheral brainstem nuclei, as well as inputs from the auditory cortex. Its inferior brachium (arm-like process) reaches to the medial geniculate nucleus of the diencephalon. The superior colliculus is positioned above the inferior colliculus, and marks the rostral midbrain. It is involved in the special sense of vision and sends its superior brachium to the
lateral geniculate body In neuroanatomy, the lateral geniculate nucleus (LGN; also called the lateral geniculate body or lateral geniculate complex) is a structure in the thalamus and a key component of the mammalian visual pathway. It is a small, ovoid, ventral projec ...
of the diencephalon. The
tegmentum The tegmentum (from Latin for "covering") is a general area within the brainstem. The tegmentum is the ventral part of the midbrain and the tectum is the dorsal part of the midbrain. It is located between the ventricular system and distinctive ba ...
which forms the floor of the midbrain, is ventral to the cerebral aqueduct. Several nuclei, tracts, and the reticular formation are contained here. The
ventral tegmental area The ventral tegmental area (VTA) (tegmentum is Latin for ''covering''), also known as the ventral tegmental area of Tsai, or simply ventral tegmentum, is a group of neurons located close to the midline on the floor of the midbrain. The VTA is the ...
(VTA) is composed of paired
cerebral peduncle The cerebral peduncles are the two stalks that attach the cerebrum to the brainstem. They are structures at the front of the midbrain which arise from the ventral pons and contain the large ascending (sensory) and descending (motor) nerve tract ...
s. These transmit axons of upper motor neurons.


Midbrain nuclei

The midbrain consists of: * Periaqueductal gray: The area of gray matter around the cerebral aqueduct, which contains various neurons involved in the pain desensitization pathway. Neurons synapse here and, when stimulated, cause activation of neurons in the nucleus raphe magnus, which then project down into the
posterior grey column The posterior grey column (posterior cornu, dorsal horn, spinal dorsal horn, posterior horn, sensory horn) of the spinal cord is one of the three grey columns of the spinal cord. It receives several types of sensory information from the body, inc ...
of the spinal cord and prevent pain sensation transmission. * Oculomotor nerve nucleus: This is the third cranial nerve nucleus. * Trochlear nerve nucleus: This is the fourth cranial nerve. *
Red nucleus The red nucleus or nucleus ruber is a structure in the rostral midbrain involved in motor coordination. The red nucleus is pale pink, which is believed to be due to the presence of iron in at least two different forms: hemoglobin and ferritin. ...
: This is a motor nucleus that sends a descending tract to the lower motor neurons. *
Substantia nigra pars compacta The pars compacta (SNpc) is a portion of the ''substantia nigra'', located in the midbrain. It is formed by dopaminergic neurons and located medial to the pars reticulata. Parkinson's disease is characterized by the death of dopaminergic neurons ...
: This is a concentration of neurons in the ventral portion of the midbrain that uses dopamine as its neurotransmitter and is involved in both motor function and emotion. Its dysfunction is implicated in
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms beco ...
. * Reticular formation: This is a large area in the
midbrain The midbrain or mesencephalon is the forward-most portion of the brainstem and is associated with vision, hearing, motor control, sleep and wakefulness, arousal ( alertness), and temperature regulation. The name comes from the Greek ''mesos'', ...
that is involved in various important functions of the midbrain. In particular, it contains lower motor neurons, is involved in the pain desensitization pathway, is involved in the arousal and consciousness systems, and contains the locus coeruleus, which is involved in intensive alertness modulation and in autonomic reflexes. * Central tegmental tract: Directly anterior to the floor of the fourth ventricle, this is a pathway by which many tracts project up to the cortex and down to the spinal cord. *
Ventral tegmental area The ventral tegmental area (VTA) (tegmentum is Latin for ''covering''), also known as the ventral tegmental area of Tsai, or simply ventral tegmentum, is a group of neurons located close to the midline on the floor of the midbrain. The VTA is the ...
: A dopaminergic
nucleus Nucleus ( : nuclei) is a Latin word for the seed inside a fruit. It most often refers to: * Atomic nucleus, the very dense central region of an atom *Cell nucleus, a central organelle of a eukaryotic cell, containing most of the cell's DNA Nucl ...
, known as group A10 cells is located close to the midline on the floor of the midbrain. *
Rostromedial tegmental nucleus The rostromedial tegmental nucleus (RMTg), also known as the tail of the ventral tegmental area (tVTA), is a GABAergic nucleus which functions as a "master brake" for the midbrain dopamine system. It is poorly differentiated from the rest of the ve ...
: A GABAergic nucleus located adjacent to the ventral tegmental area. Midbrain - superior colliculus.svg, Cross-section of the midbrain at the level of the superior colliculus Midbrain - inferior colliculus.svg, Cross-section of the midbrain at the level of the inferior colliculus


Pons

The pons lies between the midbrain and the medulla oblongata. It is separated from the midbrain by the superior pontine sulcus, and from the medulla by the inferior pontine sulcus. It contains tracts that carry signals from the
cerebrum The cerebrum, telencephalon or endbrain is the largest part of the brain containing the cerebral cortex (of the two cerebral hemispheres), as well as several subcortical structures, including the hippocampus, basal ganglia, and olfactory bulb. ...
to the medulla and to the cerebellum and also tracts that carry sensory signals to the thalamus. The pons is connected to the cerebellum by the cerebellar peduncles. The pons houses the respiratory pneumotaxic center and
apneustic center The respiratory center is located in the medulla oblongata and pons, in the brainstem. The respiratory center is made up of three major respiratory groups of neurons, two in the medulla and one in the pons. In the medulla they are the dorsal res ...
that make up the pontine respiratory group in the
respiratory center The respiratory center is located in the medulla oblongata and pons, in the brainstem. The respiratory center is made up of three major respiratory groups of neurons, two in the medulla and one in the pons. In the medulla they are the dorsal ...
. The pons co-ordinates activities of the cerebellar hemispheres. The pons and medulla oblongata are parts of the hindbrain that form much of the brainstem. Pons - Middle.svg, Cross-section of the middle pons (at the level of cranial nerve V) Pons - Inferior.svg, Cross-section of the inferior pons (at the level of the facial genu)


Medulla oblongata

The medulla oblongata, often just referred to as the medulla, is the lower half of the brainstem continuous with the spinal cord. Its upper part is continuous with the pons. The medulla contains the cardiac, dorsal and ventral respiratory groups, and vasomotor centres, dealing with heart rate, breathing and blood pressure. Another important medullary structure is the area postrema whose functions include the control of vomiting. Medulla - Rostral level cross section.svg, Cross-section of the rostral (superior) medulla Medulla - Middle level cross section.svg, Cross-section of the middle medulla Medulla - Inferior level cross section.svg, Cross-section of the inferior medulla


Appearance

;From the front In the medial part of the medulla is the anterior median fissure. Moving laterally on each side are the
medullary pyramids In neuroanatomy, the medullary pyramids are paired white matter structures of the brainstem's medulla oblongata that contain motor fibers of the corticospinal and corticobulbar tracts – known together as the pyramidal tracts. The lower limi ...
. The pyramids contain the fibers of the corticospinal tract (also called the pyramidal tract), or the upper motor neuronal axons as they head inferiorly to synapse on lower motor neuronal cell bodies within the anterior grey column of the spinal cord. The anterolateral sulcus is lateral to the pyramids. Emerging from the anterolateral sulci are the CN XII ( hypoglossal nerve) rootlets. Lateral to these rootlets and the anterolateral sulci are the olives. The olives are swellings in the medulla containing underlying inferior nucleary nuclei (containing various nuclei and afferent fibers). Lateral (and dorsal) to the olives are the rootlets for CN IX (
glossopharyngeal The glossopharyngeal nerve (), also known as the ninth cranial nerve, cranial nerve IX, or simply CN IX, is a cranial nerve that exits the brainstem from the sides of the upper medulla, just anterior (closer to the nose) to the vagus nerve. B ...
), CN X ( vagus) and CN XI (
accessory nerve The accessory nerve, also known as the eleventh cranial nerve, cranial nerve XI, or simply CN XI, is a cranial nerve that supplies the sternocleidomastoid and trapezius muscles. It is classified as the eleventh of twelve pairs of cranial nerv ...
). The pyramids end at the pontine medulla junction, noted most obviously by the large basal pons. From this junction, CN VI ( abducens nerve), CN VII ( facial nerve) and CN VIII ( vestibulocochlear nerve) emerge. At the level of the midpons, CN V (the trigeminal nerve) emerges. Cranial nerve III (the oculomotor nerve) emerges ventrally from the midbrain, while the CN IV (the trochlear nerve) emerges out from the dorsal aspect of the midbrain. Between the two pyramids can be seen a decussation of fibers which marks the transition from the medulla to the spinal cord. The medulla is above the decussation and the spinal cord below. ;From behind The most medial part of the medulla is the posterior median sulcus. Moving laterally on each side is the gracile fasciculus, and lateral to that is the
cuneate fasciculus Cuneate means "wedge-shaped", and can apply to: * Cuneate leaf The following is a list of terms which are used to describe leaf morphology in the description and taxonomy of plants. Leaves may be simple (a single leaf blade or lamina) or compou ...
. Superior to each of these, and directly inferior to the obex, are the gracile and cuneate tubercles, respectively. Underlying these are their respective nuclei. The obex marks the end of the fourth ventricle and the beginning of the
central canal The central canal (also known as spinal foramen or ependymal canal) is the cerebrospinal fluid-filled space that runs through the spinal cord. The central canal lies below and is connected to the ventricular system of the brain, from which it ...
. The posterior intermediate sulcus separates the gracile fasciculus from the cuneate fasciculus. Lateral to the cuneate fasciculus is the lateral funiculus. Superior to the obex is the floor of the fourth ventricle. In the floor of the fourth ventricle, various nuclei can be visualized by the small bumps that they make in the overlying tissue. In the midline and directly superior to the obex is the vagal trigone and superior to that it the hypoglossal trigone. Underlying each of these are motor nuclei for the respective cranial nerves. Superior to these trigones are fibers running laterally in both directions. These fibers are known collectively as the striae medullares. Continuing in a rostral direction, the large bumps are called the facial colliculi. Each facial colliculus, contrary to their names, do not contain the facial nerve nuclei. Instead, they have facial nerve axons traversing superficial to underlying abducens (CN VI) nuclei. Lateral to all these bumps previously discussed is an indented line, or sulcus that runs rostrally, and is known as the sulcus limitans. This separates the medial motor neurons from the lateral sensory neurons. Lateral to the sulcus limitans is the area of the vestibular system, which is involved in special sensation. Moving rostrally, the inferior, middle, and superior cerebellar peduncles are found connecting the midbrain to the cerebellum. Directly rostral to the superior cerebellar peduncle, there is the superior medullary velum and then the two trochlear nerves. This marks the end of the pons as the
inferior colliculus The inferior colliculus (IC) ( Latin for ''lower hill'') is the principal midbrain nucleus of the auditory pathway and receives input from several peripheral brainstem nuclei in the auditory pathway, as well as inputs from the auditory cortex. Th ...
is directly rostral and marks the caudal midbrain. Middle cerebellar peduncle is located inferior and lateral to the superior cerebellar peduncle, connecting pons to the cerebellum. Likewise, inferior cerebellar peduncle is found connecting the medulla oblongata to the cerebellum.


Blood supply

The main supply of blood to the brainstem is provided by the basilar arteries and the vertebral arteries.


Development

The human brainstem emerges from two of the three primary brain vesicles formed of the neural tube. The mesencephalon is the second of the three primary vesicles, and does not further differentiate into a secondary brain vesicle. This will become the midbrain. The third primary vesicle, the rhombencephalon (hindbrain) will further differentiate into two secondary vesicles, the metencephalon and the myelencephalon. The metencephalon will become the cerebellum and the pons. The more caudal myelencephalon will become the medulla.


Function

There are three main functions of the brainstem: # The brainstem plays a role in conduction. That is, all information relayed from the body to the cerebrum and cerebellum and vice versa must traverse the brainstem. The ascending pathways coming from the body to the brain are the sensory pathways and include the spinothalamic tract for pain and temperature sensation and the
dorsal column-medial lemniscus pathway Dorsal (from Latin ''dorsum'' ‘back’) may refer to: * Dorsal (anatomy), an anatomical term of location referring to the back or upper side of an organism or parts of an organism * Dorsal, positioned on top of an aircraft's fuselage * Dorsa ...
(DCML) including the gracile fasciculus and the
cuneate fasciculus Cuneate means "wedge-shaped", and can apply to: * Cuneate leaf The following is a list of terms which are used to describe leaf morphology in the description and taxonomy of plants. Leaves may be simple (a single leaf blade or lamina) or compou ...
for touch, proprioception, and pressure sensation. The facial sensations have similar pathways and will travel in the spinothalamic tract and the DCML. Descending tracts are the axons of upper motor neurons destined to synapse on lower motor neurons in the ventral horn and posterior horn. In addition, there are upper motor neurons that originate in the brainstem's vestibular, red, tectal, and reticular nuclei, which also descend and synapse in the spinal cord. # The cranial nerves III-XII emerge from the brainstem. These cranial nerves supply the face, head, and viscera. (The first two pairs of cranial nerves arise from the cerebrum). # The brainstem has integrative functions being involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, awareness, and consciousness. Thus, brainstem damage is a very serious and often life-threatening problem.


Cranial nerves

Ten of the twelve pairs of cranial nerves either target or are sourced from the brainstem nuclei. The nuclei of the oculomotor nerve (III) and trochlear nerve (IV) are located in the midbrain. The nuclei of the trigeminal nerve (V), abducens nerve (VI), facial nerve (VII) and vestibulocochlear nerve (VIII) are located in the pons. The nuclei of the glossopharyngeal nerve (IX), vagus nerve (X), accessory nerve (XI) and hypoglossal nerve (XII) are located in the medulla. The fibers of these cranial nerves exit the brainstem from these nuclei.


Clinical significance

Diseases of the brainstem can result in abnormalities in the function of cranial nerves that may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems. Localizing neurological lesions in the brainstem may be very precise, although it relies on a clear understanding on the functions of brainstem anatomical structures and how to test them.
Brainstem stroke syndrome A brainstem stroke syndrome falls under the broader category of stroke syndromes, or specific symptoms caused by vascular injury to an area of brain (for example, the lacunar syndromes). As the brainstem contains numerous cranial nuclei and white ...
can cause a range of impairments including locked-in syndrome. Duret haemorrhages are areas of bleeding in the midbrain and upper pons due to a downward traumatic displacement of the brainstem. Cysts known as syrinxes can affect the brainstem, in a condition, called
syringobulbia Syringobulbia is a medical condition in which syrinxes, or fluid-filled cavities, affect the brainstem (usually the lower brainstem). The exact cause is often unknown, but may be linked to a widening of the central canal of the spinal cord. Thi ...
. These fluid-filled cavities can be congenital, acquired or the result of a tumor. Criteria for claiming brainstem death in the UK have developed in order to make the decision of when to stop ventilation of somebody who could not otherwise sustain life. These determining factors are that the patient is irreversibly unconscious and incapable of breathing unaided. All other possible causes must be ruled out that might otherwise indicate a temporary condition. The state of irreversible brain damage has to be unequivocal. There are brainstem reflexes that are checked for by two senior doctors so that
imaging technology Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image). Imaging technology is the application of materials and methods to create, preserve, or duplicate images. ...
is unnecessary. The absence of the cough and gag reflexes, of the
corneal reflex The corneal reflex, also known as the blink reflex or eyelid reflex, is an involuntary blinking of the eyelids elicited by stimulation of the cornea (such as by touching or by a foreign body), though it could result from any peripheral stimulus. ...
and the vestibulo–ocular reflex need to be established; the pupils of the eyes must be fixed and dilated; there must be an absence of motor response to stimulation and an absence of breathing marked by concentrations of carbon dioxide in the arterial blood. All of these tests must be repeated after a certain time before death can be declared.Black's Medical Dictionary 39th edition 1999


Additional images

File:Human brain frontal (coronal) section description.JPG, The midbrain, pons, and medulla oblongata are labelled on this coronal section of the human brain. File:Human brainstem.gif, 3D visualization of the brainstem in an average human brain


See also

* Triune brain - reptilian brain


References


External links

* Comparative Neuroscience at
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