Chapter 22. Brainstem Syndromes

Question 1

Question 22-1: 
A patient presents with blurred vision. Examination shows difficulty with upgaze to command but is able to look upward with pursuit. Lids appear retracted. Pupils are nonreactive. Which of the following are possible causes of  this presentation? 
A.  Multiple sclerosis 
B.  Hydrocephalus 
C.  Pineal tumor 
D.  Stroke 
E.  Any of the above

Answer 1

Answer 22-1: E.
Any of these can be potential causes for this
presentation. The patient has essential features
of the dorsal midbrain syndrome. The tetrad is
(I) supranuclear upgaze palsy, (2) pupils
which are areflexic or exhibit light-near
dissociation, (3) convergence-retraction
nystagmus, (4) lid retraction.

Question 2

Question 22-2:
Which of the following are clinical features of internuclear ophthalmoplegia (INO)?
A. Lateral gaze shows paresis of abduction of one eye and nystagmus of the other eye
B. Lateral gaze shows paresis of adduction of one eye and nystagmus of the other eye
C. Inability of adduct either eye
D. Inability to abduct either eye

Answer 2

Answer 22-2: B.
INO is associated with paresis of adduction of
one eye with nystagmus of the other eye on
attempted lateral gaze. This is due to a lesion
in the medial longitudinal fasciculus on the
side of the adduction paresis. Important causes
include stroke and mUltiple sclerosis, although
there are mUltiple other potential causes of the
same presentation

Question 3

Question 22-3: 
Which of the following conditions may produce total opthalmoplegia'? 
A.  Myasthenia gravis 
B.  Thyroid ophthalmopathy 
C.  Botulism 
D.  Wernicke's encephalopathy 
E.  All of  the above

Answer 3

Answer 22-3: E.
All of these can produce total
ophthalmoplegia, in addition to some other
important causes including PSP, GBS,
pituitary apoplexy, and tetanus

Question 4

Question 22-4:
A patient presents with complaint of diplopia and is found on examination to have inability to look left with either eye. When looking to the right, the left eye fails to adduct while the right eye abducts and has superimposed nystagmus. Which of the following statements is true?
A. The patient has an INO when looking to the left
B. Myasthenia is the most likely diagnosis
C. This finding is usually congenital
D. The patient has one-and-a-half syndrome

Answer 4

Answer 22-4: D.
The patient has a classic appearance of one and-
a-half syndrome, which is a gaze palsy to
one side and an INO to the other side. In this
patient, the INO is seen with right gaze.
Myasthenia may produce a similar
presentation, but this is not the most likely
diagnosis. In younger patients, demyelinating
disease predominates where in older patients
vascular disease is more likely. The lesion is
in the PPRF and the medial longitudinal
fasciculus on the side of the gaze palsy.

Question 5

Question 22-5:
A patient presents with hemisensory loss with pain on the same side of the body. There is no weakness. Which of the following statements are true regarding this condition?
1. Proprioception is preserved
2. The most likely diagnosis is mUltiple sclerosis
3. The pain is always stimulus-independent
4. The lesion is most likely in the entroposterolateral nucleus of the thalamus
Select: A = 1.2.3. B = 1. 3. C = 2,4 . D = 4 only. E = All

Answer 5

Answer 22-5: D.
The patient has thalamic syndrome, a
condition usually due to stroke or tumor.
Damage is usually in the VPL nucleus of the
thalamus, although parietal or brain stem
lesions can produce a similar clinical
presentation. The pain can be spontaneous,
although it can also be stimulus-evoked.
SenSory examination shows hemianesthesia
which can be dissociated, but proprioception
is. typically involved

Question 6

Question 22-6:
Which of the following are features of the Foramen magnum syndrome?
1. Hemiparesis can be present
2. Quadriparesis can be present
3. Lhennitte’s sign may be present
4. Third nerve palsy may be present
Select: A = 1,2,3. B = 1, 3. C = 2, 4. D =4 only. E= All

Answer 6

Answer 22-6: A.
Foramen magnum syndrome has a wide range
of causes, including benign tumors at the
craniocervical junction, Chiari malformation,
multiple sclerosis, atlantoaxial subluxation,
among other causes. Hemiparesis or
quadriparesis is common along with sensory
loss beginning in a C2 distribution

Question 7

Question 22-7: 
Patient has right hemiparesis, left hemiataxia, conjugate gaze paresis to the left. 
Select the most likely localization of the lesion from the following list. 
A.  Medial midbrain syndrome 
B. Lateral midbrain syndrome 
c. Lateral pontine syndrome 
D. Medial pontine syndrome 
E.  Medial medullary syndrome 
F.  Lateral medullary syndrome

Answer 7

Answer 22-7: D.
The medial pontine syndrome is characterized
by ipsilateral hemiataxia and contralateral
hemiparesis. Gaze palsy to the side of the
lesion is an important feature to localize the
lesion to the pons

Question 8

Question 22-8: 
Patient has right hemiparesis and hemiataxia, left third nerve palsy. 
Select the most likely localization of the lesion from the following list. 
A.  Medial midbrain syndrome 
B. Lateral midbrain syndrome 
c. Lateral pontine syndrome 
D. Medial pontine syndrome 
E.  Medial medullary syndrome 
F.  Lateral medullary syndrome

Answer 8

Answer 22-8: A.
Medial midbrain syndrome can produce
contralateral hemiparesis and hemiataxia
along with a third nerve palsyl The lesion is
on the left in this patient. The patient may also
have supranuclear horizontal gaze paresis
and/or an internuclear ophthalmoplegia

Question 9

Question 22-9: 
Patient has vertigo with nausea and vomiting and coordination difficulty. Examination shows right hemiataxia, right facial numbness, and right ptosis and meiosis. 
Select the most likely localization of the lesion from the following list. 
A.  Medial midbrain syndrome 
B. Lateral midbrain syndrome 
c. Lateral pontine syndrome 
D. Medial pontine syndrome 
E.  Medial medullary syndrome 
F.  Lateral medullary syndrome

Answer 9

Answer 22-9: F.
The lateral medullary syndrome is
characterized by ipsilateral facial numbness,
vertigo, ipsilateral ataxia. and diplopia. There
is contralateral loss of sensation on the body
and sometimes the face as well. Ipsilateral
Homer’s syndrome is a helpful localizing
sign. Hemiparesis is not expected with lateral
medullary syndrome

Question 10

Question 22-10: 
Patient has right hemiparesis, right hemisensory loss, and dysarthria. She has an upbeat nystagmus with eyes in the primary position.
Select the most likely localization of the lesion from the following list. 
A.  Medial midbrain syndrome 
B. Lateral midbrain syndrome 
c. Lateral pontine syndrome 
D. Medial pontine syndrome 
E.  Medial medullary syndrome 
F.  Lateral medullary syndrome

Answer 10

Answer 22-10: EThe
medial medullary syndrome is
characterized by contralateral weakness
sparing the face, ipsilateral tongue weakness,
upbeat nystagmus with eyes in the primary
position, and contralateral loss of sensation
again sparing the face. The lesion in this
patient is on the left.