Brainstem Case Patient 1 Flashcards
Patient #1
Overall Dx
Lateral Medullary Syndrome
Damage to the left dorsal lateral mid-medulla
ALS, Spinal Trigeminal Tract and Nucleus, Vestibular Complex and the Lateral Funiculus, Sympathetic Chain, CN V1, Nucleus Ambiguus.
No damage to the DC-ML, Internal Arcuate Fibers, CN XII, CN VII
Left neck pain after whiplash
Result from muscle overextension
Vertigo
VESTIBULAR COMPLEX is in the LATERAL FUNICULUS (blue circle)
Loss of pain and temperature sense on left face and right body
SPINAL TRIGEMINAL SYSTEM -> injury to the spinal trigeminal tract and/or nucleus on the ipsilateral side (left) INFERIOR to decussation
ALS SYSTEM SUPERIOR to the decussation (injury on left ALS tract, pain on right side of body)
Left corneal reflex absent, right corneal reflex intact
SPINAL TRIGEMINAL SYSTEM INFERIOR to the decussation, hence the brainstem injury is the same as loss of temp and pain on the left side.
Touch goes through V1 (ophthalmic branch) and blink goes through VII (zygomatic branch).
Since the right coneal reflex is OK, CN VII is unaffected, therefore is the Left V1 injury.
OK: Strength and reflexes normal
Both the DC-ML system and trigeminal mechnosensory PRINCIPLE NUCLEUS system are intact
The principle nucleus is SUPERIOR to the spinal nucleus, hence is unaffected by the mid-medullary injury that effects the spinal nucleus.
Voice is hoarse and uvula deviated to the right with “ahhh”
Vula deviates AWAY from normal side, so the LEFT side NUCLEUS AMBIGUOUS likely is damaged, which affects the left CN X.
Side note: Ambiguus is located just dorsal (posterior) to the inferior olivary nucleus in the lateral portion of the upper (rostral) medulla. It receives upper motor neuron innervation directly via the corticobulbar tract. Efferent to CN X Vagus Nerve (to pharynx and larynx) and to CN IX glossopharyngeal nerve (stylopharyngeus).
Left pupil was slightly small and eyelid drooped slightly
Left side SYMPATHETIC CHAIN damaged
slight ptosis is sympathetic. large ptosis is CN III
Left arm movements are uncoordinated
These movements are processed through the intermediate zone of the cerebellum.
The LATERAL CORTICOSPINAL TRACT travels through the LATERAL FUNICULUS.
The cerebellum double crosses, so damage to the LEFT lateral funiculus will impair coordination on the left limbs.
OK: There was no double vision
No damaged on extraocular nerves
OK: Tongue was strong and all muscles in face were normal
Corticalbulbar tract of facial nucleus intact, hypoglossal is fine
OK: Touch, vibration, pressure over body and face
DC-ML and the Trigeminal mechanosensory system is OK
OK: Right corneal reflex
CN VII is intact
OK: normal tongue
CN XII is intact
Normal facial muscle strength OK
CN VII is intact
