Brainstem dysfunction in critically ill patients

Abstract

The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting.

Keywords: Auditory and somatosensory evoked potentials and electroencephalogram; Autonomic nervous system; Brain injured patients; Brainstem dysfunction; Brainstem reflexes; Disorders of consciousness; Immune reflex; Intensive care unit; Neurological respiratory failure; Sedation.

Fig. 1

General anatomy of the brainstem and oculocephalic circuit. A Anatomical sagittal sections. B Representation of the sagittal section plans and of the oculocephalic circuit (ventral part)

Fig. 2

Anatomical axial sections of the brainstem. a Representation of the brainstem (dorsal part) and of the axial sections plans. b, c Midbrain axial sections. d Pons axial sections. e Medulla oblongata axial sections