Brainstem Clincal Application

Question 1

The somatic motor column (SE) includes the following nuclei:
Midbrain: ______, ______
Pons: ______, _______, ________
Medulla: ________, _________

Answer 1

oculomotor, trochlear nuclei, trigeminal nuclei, facial nuclei, abducens nuclei, nucleus ambiguous, hypoglossal nucleus

Question 2

A patient presents with contralateral spastic hemiplegia, contralateral loss of vibratory sense and proprioception (Romberg sign), and ipsilateral deviation of the tongue that is soft to the touch. What is the diagnosis?

Answer 2

Dejerine syndrome; inferior alternating hemiplegia

Question 3

The CST, medial lemniscus, and hypoglossal nucleus/nerve are lesioned, what artery is occluded?

Answer 3

Anterior spinal artery

Question 4

A patient presents with contralateral hemianalgesia, ipsilateral facial hemianalgesia, contralateral deviation of the uvula and hoarseness, contralateral beating nystagmus, vertigo, nausea, ipsilateral ataxia, and ipsilateral Horner syndrome. What is the diagnosis?

Answer 4

lateral medullary syndrome; Wallenberg syndrome

Question 5

Another name for lateral medullary syndrome is:

Answer 5

Wallenberg syndrome

Question 6

In the Medulla, if you have lesion to the ALS, you will also normally have lesion to the _________

Answer 6

hypothalamospinal tract (sympathetics —> Horner Syndrome)

Question 7

Lateral medullary syndrome/Wallenberg syndrome is most commonly due to occlusion of _______ artery

Answer 7

vertebral

Question 8

The 6 structures involved in lateral medullary syndrome/Wallenberg syndrome are:

Answer 8

ALS, spinal trigeminal tract/nucleus, nucleus ambiguus, vestibular nuclei, inferior cerebellar peduncle, hypothalamospinal tract

Question 9

A patient presents with contralateral hemiplegia, dysarthria, and dysphagia. What 2 possible diagnoses could this be, and which part of the brainstem is involved?

Answer 9

pure motor hemiparesis, dysarthria-hemiparesis or dysarthria clumsy hand syndrome (if leg spared)

medial anterior pons

Question 10

Which 2 structures are damaged in pure motor hemiparesis or dysarthria-hemiparesis?

Answer 10

contralateral corticospinal tract and corticonuclear tract

Question 11

A patient presents with contralateral spastic hemiplegia, dysarthria, dysphagia, contralateral ataxia, dysmetria, and dysrhythmia.
What is the diagnosis?

Answer 11

ataxic hemiparesis (because pontine nuclei are involved)

Question 12

pontine nuclei project to the ______ and lesion results in this clinical sign:

Answer 12

cerebellum, contralateral ataxia

Question 13

The pontocerebellar fibers project to the _______ and lesion results in these clinical signs:

Answer 13

cerebellum, dysmetria & dysrhythmia (difficulty with finger-to-nose and heel-to-shin tests)

Question 14

A patient presents with contralateral spastic hemiplegia, dysarthria, dysphagia, contralateral ataxia, dysmetria, dysrhythmia, as well as contralateral loss of discriminative touch and ipsilateral gaze palsy. What is the diagnosis and what area of the CNS is involved?

Answer 14

Foville syndrome/middle alternating hemiplegia; medial anterior and middle pons

Question 15

A patient presents with contralateral spastic hemiplegia, dysarthria, dysphagia (UMN to tongue and palate), contralateral ataxia, dysmetria, dysrhythmia, contralateral loss of discriminative touch, and ipsilateral gaze palsy.
What is the key clinical sign for this syndrome and what area in the CNS is affected?

Answer 15

Wrong way eyes, anterior and middle pons with PPRF included

Question 16

If the PPRF is lesioned on the right pons, what side will the gaze palsy be on?

Answer 16

right side

Question 17

If the medial lemniscus is lesioned on the right pons, what clinical sign results?

Answer 17

left-sided loss of discriminative touch

Question 18

A patient presents with left spastic hemiplegia, dysarthria, dysphagia, left-sided ataxia, dysmetria, dysrhythmia, left-sided loss of discriminative touch, and inability to look to the right in both eyes and nystagmus in left eye when looking to the left.
What is the key clinical sign in this syndrome and what areas of the CNS are affected?

Answer 18

1 1/2 syndrome; medial anterior and middle pons with MLF and PPRF included

Question 19

The 6 structures of the medial mid pons to be concerned about if there is a lesion are:

Answer 19

corticospinal tract, corticonuclear tract, pontine nuclei & pontocerebellar fibers, medial lemniscus, MLF, PPRF

Question 20

Are UE or LE more affected with a medial lesion of the mid pons?

Answer 20

UE (especially hand)

Question 21

A localizing sign for the pons is _______.

While the localizing sign for the medulla is _________.

Answer 21

facial hemiplegia (facial nuc. and nerve), dysphagia (nucleus ambiguus)

Question 22

A patient presents with contralateral hemianalgesia, ipsilateral facial hemianalgesia, ipsilateral facial hemiplegia, and ipsilateral horner syndrome.
What is the diagnosis and what area of the CNS is this in?

Answer 22

Gubler syndrome, caudal pons

Question 23

In __________ syndrome, the following clinical signs are noted:
left UE and LE loss of pain sensation, right-sided loss of pain to the face, right-sided facial droop that affects the lower face, vertigo, left-beating nystagmus, right-sided ataxia, dysmetria and dysrhythmia, as well as right-sided ptosis and myosis.

Answer 23

AICA syndrome

Question 24

The key clinical signs of ________ are vertigo, left-beating nystagmus, ipsilateral ataxia, and ipsilateral horner syndrome

Answer 24

AICA syndrome

Question 25

The cause of ataxia, dysmetria, and dysrhythmia in AICA syndrome is damage to the _____ in the _________.

Answer 25

MPC (middle cerebellar peduncle), caudal pons

Question 26

A patient presents with loss of pin prick sensation to the left side body, right facial hemianesthesia, deviation of jaw to the right, right ataxia with dysmetria and dysrhythmia, right-sided ptosis and myosis, and some loss of discriminative touch to the LE.
What portion of the CNS is lesioned?

Answer 26

lateral posterior quadrant of mid pons

Question 27

damage to the ________ in the mid pons results in:

Answer 27

possible loss of discriminative touch sensation of mostly LE and some UE

Question 28

Lesion to the hypothalamospinal tract results in:

Answer 28

Horner syndrome

Question 29

bilateral lesion to pontine basis results in this diagnosis:

Answer 29

Locked-in syndrome

Question 30

a patient presents with tetraplegia, inability to speak and swallow, and impaired horizontal eye movement. What is the diagnosis?

Answer 30

Locked-in syndrome

Question 31

The _______ (structure) is unaffected in Locked-in Syndrome, which means the patient is awake and alert

Answer 31

reticular formation

Question 32

Only vertical eye movements and blinking are possible in _________, while the patient is tetraplegic and unable to speak

Answer 32

Locked-in syndrome

Question 33

________ is typically caused by a basilar artery infarct or thrombosis

Answer 33

Locked-in syndrome

Question 34

The _______ part of the reticular formation is spared in Locked-in syndrome

Answer 34

midbrain

Question 35

Bauby blinking to dictate The Diving Bell and the Butterfly book. He was only blinking because he had:

Answer 35

Locked-in syndrome

Question 36

If vertical gaze is unaffected, the lesion cannot be in the ______

Answer 36

midbrain reticular formation

Question 37

The _______ is the most posterior/dorsal portion of the midbrain

Answer 37

Tectum

Question 38

The substantia nigra is found in the ________

Answer 38

midbrain

Question 39

The distinguishing feature of __________ (diagnosis) is right oculomotor palsy with ipsilateral loss of accommodation and pupillary light reflex

Answer 39

Weber syndrome

Question 40

A patient presents with dryness in the right eye, hypersensitivity to noise in right ear, and loss of taste to anterior tongue. The right eyelid also droops.
There is no myosis.

Answer 40

Bell’s palsy

Question 41

A __________ describes weakness of only lower facial muscles without ptosis or dryness of the eye, and potentially loss of taste sensation to anterior 2/3 of tongue.

Answer 41

central seven

Question 42

A patient presents with right oculomotor palsy, right-sided loss of accommodation and pupillary light reflex, cerebellar outflow tremor, left-sided ataxia and dysmetria.
What is the diagnosis and what area in the CNS is the lesion in?

Answer 42

Claude syndrome, middle midbrain

Question 43

Cerebellar outflow tremor results from damage to the _________ in the _______

Answer 43

red nucleus, medial midbrain

Question 44

________ is associated with ipsilateral deafness

Answer 44

AICA syndrome

Question 45

ipsilateral deafness is also a clinical sign of ________ because the labyrinthine artery supplies the cochlear nuclei in the pons

Answer 45

AICA syndrome