Road Maps: Brainstem Flashcards
- A patient has hoarseness and difficulty swallowing, loss of pain and temperature sen- sations from the body contralateral to the lesion and from the face ipsilateral to the lesion, and Horner’s syndrome. A single lesion that accounts for all of the signs or symptoms is in:
A. The medial medulla
B. The lateral medulla
C. The caudal pons
D. The rostral pons
E. The midbrain
F. A cranial nerve or cranial nerves outside of the brainstem
B. The lateral medulla
The patient has lateral medullary syndrome. The long tracts affected in this syndrome are the spinothalmic tract and the descending hypothalmic fibers. The cranial nerves that may be affected by the lesion and localize the lesion to the lateral medulla are the vestibular or the cochlear nuclei, the glossopharyngeal nerve, and the vagus nerve. The spinal tract and spinal nucleus of the trigeminal nerve may be lesioned in lateral medullary syndrome.
- A patient cannot wrinkle his forehead or shut his eye on the side of the lesion. The affected eye is also dry and red, and the patient complains of being sensitive to loud sounds. An internal strabismus is present on the side of the facial weakness. The pa- tient also has weak upper and lower limbs and elevated muscle stretch reflexes con- tralateral to the facial weakness. A single lesion that accounts for all of the signs or symptoms is in:
A. The medial medulla
B. The lateral medulla
C. The caudal pons
D. The rostral pons
E. The midbrain
F. A cranial nerve or cranial nerves outside of the brainstem
C. The caudal pons
The patient has a form of medial pontine syndrome that has affected the corticospinal tract, the exiting fibers of the abducens nerve, and the facial nerve.
- A patient has a dilated pupil, a laterally deviated eye, loss of the near response on the side of the lesion, and weak upper and lower limbs contralateral to the side of the le- sion. A single lesion that accounts for all of the signs or symptoms is in:
A. The medial medulla
B. The lateral medulla
C. The caudal pons
D. The rostral pons
E. The midbrain
F. A cranial nerve or cranial nerves outside of the brainstem
The answer is E. The patent has medial midbrain syndrome. Medial midbrain syndrome results in a lesion of the corticospinal and corticobulbar tracts and the oculomotor nerve.
- A patient cannot wrinkle her forehead or smile on the right and has sensorineural hearing loss and weak jaw muscles on the right. The patient notes that the hearing loss has been progressive over the years, but the facial weakness and jaw weakness were evident only recently. A single lesion that accounts for all the signs or symptoms is in:
A. The medial medulla
B. The lateral medulla
C. The caudal pons
D. The rostral pons
E. The midbrain
F. A cranial nerve or cranial nerves outside of the brainstem
F. A cranial nerve or cranial nerves outside of the brainstem
- A patient has a loss of vibratory sense from the left side of the body and a spastic hemiparesis on the left, and the tongue deviates toward the right on protrusion. What blood vessel may have been involved in a stroke?
A. Posterior inferior cerebellar artery
B. Basilar artery
C. Anterior spinal artery
D. Paramedian branches of the basilar artery
E. Deep branches of a posterior cerebral artery
The answer is C. The patient has medial medullar syndrome, with 2 long tract signs (the medial lemniscus and the corticospinal tract), combined with a lesion of the hypoglossal nerve that localizes the lesion to the media medulla.
- A patient has nasal regurgitation of liquids during swallowing and nasal speech, mio- sis and ptosis of the right pupil and eyelid, respectively, and a loss of pain and tem- perature sensations from the body opposite the ocular signs. The patient notes that food tastes funny and that the right side of the face is dry. What blood vessel may have been involved in a stroke?
A. Posterior inferior cerebellar artery
B. Basilar artery
C. Anterior spinal artery
D. Paramedian branches of the basilar artery
E. Deep branches of a posterior cerebral artery
A. Posterior inferior cerebellar artery
The patient has lateral medullary syndrome. A lesion of descending hypothalmic fibers results in Horner’s syndrome with mitosis, ptosis, and anhidrosis ipsilateral to the lesion. Spinothalmic tract lesions result in a loss of pain and temperature sensations in the limbs and body contralateral to the lesion. The cranial nerves that may be affected by the lesion and localize the lesion to the lateral medulla are the vestibular or the cochlear nuclei, the glossopharyngeal nerve, and the vagus nerve.
- A patient has a laterally deviated left eye, a ptosis of the left eyelid, and a dilated left pupil. The patient can shut the affected eye but cannot prevent saliva from dripping from the corner of the mouth on the right. There are elevated muscle stretch reflexes and weakness in the right upper and lower limbs. What blood vessel may have been involved in a stroke?
A. Posterior inferior cerebellar artery
B. Basilar artery
C. Anterior inferior cerebellar artery
D. Paramedian branches of the basilar artery
E. Deep (thalamoperforating) branches of a posterior cerebral artery
E. Deep (thalmoperforating branches of a posterior cerebral artery)
The patient has medial midbrain syndrome. Medial midbrain syndrome result in a lesion of the corticospinal and corticobulbar tracts and the oculomotor nerve. A lesion of the corticobulbar fibers results in a contralateral lower face weakness.
8. A patient has numbness of the face and scalp on the right, burns the anterior part of the tongue but cannot feel the stimulus, and has weakness in chewing on the right. When the left cornea is stimulated both eyes blink, but when the right cornea is stim- ulated neither eye blinks. Localize the probable lesion site. A. Trigeminal nerve B. Spinal nucleus of V C. Principal sensory nucleus of V D. Ventral trigeminal tract E. Mesencephalic nucleus of V
A. Trigeminal nerve
- A 49-year-old secretary with a history of high blood pressure experienced a sudden onset of dizziness, nausea, and vomiting. She was brought to the emergency room, where a neurological exam revealed:
• A horizontal nystagmus
• Dysphagia and hoarseness
• Absent gag reflex on the left
• Alteration of taste from the tongue
• Analgesia and thermal anesthesia on the left side of the face
• Analgesia and thermal anesthesia on the right side of the body
• Horner’s syndrome
• Significant hearing loss on the left compared with the right
The dysphagia and hoarseness in this patient may be due to a lesion in the:
A. Dorsal motor nucleus of X
B. Nucleus solitarius
C. Nucleus ambiguus
D. Inferior salivatory nucleus
E. Superior salivatory nucleus
C. Nucleus ambiguus
- A 49-year-old secretary with a history of high blood pressure experienced a sudden onset of dizziness, nausea, and vomiting. She was brought to the emergency room, where a neurological exam revealed:
• A horizontal nystagmus
• Dysphagia and hoarseness
• Absent gag reflex on the left
• Alteration of taste from the tongue
• Analgesia and thermal anesthesia on the left side of the face
• Analgesia and thermal anesthesia on the right side of the body
• Horner’s syndrome
• Significant hearing loss on the left compared with the right. The analgesia and thermal anesthesia on the left side of the face in this case most likely resulted from a lesion of:
A. The trigeminal nerve
B. The mesencephalic nucleus of V
C. The principal nucleus of V
D. The spinal tract of V
E. The trigeminal ganglion
The answer is D. The analgesia and thermal anesthesia most likely resulted from a lesion of the spinal tract of V because the patient’s loss is limited to pain and temperature on the side of the lesion.
- A 49-year-old secretary with a history of high blood pressure experienced a sudden onset of dizziness, nausea, and vomiting. She was brought to the emergency room, where a neurological exam revealed:
• A horizontal nystagmus
• Dysphagia and hoarseness
• Absent gag reflex on the left
• Alteration of taste from the tongue
• Analgesia and thermal anesthesia on the left side of the face
• Analgesia and thermal anesthesia on the right side of the body
• Horner’s syndrome
• Significant hearing loss on the left compared with the right. What else might be observed in the patient other than the signs and symptoms noted previously?
A. The uvula may deviate to the left.
B. Sensations of touch might also be altered in the anterior two thirds of the tongue.
C. The pupil on the left will be dilated compared with the pupil on the right.
D. The horizontal nystagmus will have a quick component to the right.
E. Retrograde changes might be evident in neurons in the dorsal horn of the spinal cord on the left.
The answer is D. The horizontal nystagmus will have a quick component to the right; the fast phase of a vestibular evoked nystagmus is away from the side of the lesion (the left). In this patient, the uvula may deviate to the right. Sensation of touch will not be altered in the anterior two third of the tongue. the pupil on the left will be constricted (Horner’s syndrome) compared with the pupil on the right. Retrograde changes might be evident in neurons in the dorsal horns of the spinal cord on the right (left spinothalmic tract).
- Your elderly patient has presbycusis that is more evident on the right than the left. What might you correctly conclude?
A. The patient has hair cell degeneration at the base of the cochlea.
B. The patient has excessive wax buildup in the external auditory meatus.
C. The patient has hyperacusis.
D. The patient has otosclerosis.
E. Bone conduction will be better than air conduction on the left.
The answer is A. Hair cell degeneration at the base of the cochlea is the most common cause of presbycusis, a sensorineural hearing loss in the elderly. All other choices indicate a conductive hearing loss.
13. A complete destructive lesion of the facial nerve just as it emerges from the brainstem will result in retrograde chromatolysis in which of the following nuclei? A. Nucleus ambiguus B. Inferior salivatory nucleus C. Superior salivatory nucleus D. Ventral cochlear nucleus E. Solitary nucleus
The answer is C. The superior salivatory nucleus contains the cell bodies of preganglionic parasympathetic neurons with axons in the facial nerve. There would be an anterograde degeneration in the solitary nucleus; no other choices contributes fibers to the facial nerve.
- During a neurological evaluation, you note that when you stimulate your patient’s right cornea with a wisp of cotton, both eyes blink, but when you stimulate the left, there is no response. Your patient may also have which of the following signs
or symptoms?
A. A dry eye
B. Altered sensations of taste from the tongue
C. A dilated pupil on the left
D. Altered sensation in the skin of the forehead
E. A drooping of the corner of the mouth on the left
D. Altered sensation in the skin of the forehead
- By placing warm water in the patient’s left external auditory meatus, under normal circumstances you would expect:
A. A nystagmus with a quick component to the right
B. Both eyes to drift slowly to the left
C. The left eye to look to the left
D. A nystagmus with a quick component to the left
E. Both eyes to look superiorly
D. A nystagmus with a quick component to the left
- A transverse section through the brainstem contains the solitary nucleus. What other structure might you expect to see in the same section?
A. Principal (chief) sensory nucleus of V
B. Facial motor nucleus
C. Spinal nucleus of V
D. Abducens nucleus
E. Trochlear nucleus
The answer is C. All other structures are found in either the pons or midbrain.
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 17. Internal strabismus
F. Abducens nucleus
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 18. Tongue deviates upon protrusion
O. Hypoglossal nucleus
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 19. Uvula deviates during swallowing
L. Nucleus ambigus
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 20. Decreased output of parotid gland
C. Inferior salivatory nucleus
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 21. Ptosis and constricted pupil
Q. Descending hypothalmic fibers
MATCHING PROBLEMS Questions 17–42: Clinical features match Choose from A–U the one most closely associated with the clinical deficit. Choices (each choice may be used once, more than once, or not at all): A. Facial motor nucleus B. Solitary nucleus C. Inferior salivatory nucleus D. Motor nucleus of V E. Edinger-Westphal nucleus F. Abducens nucleus G. Trochlear nucleus H. Spinal nucleus of V I. Mesencephalic nucleus of V J. Dorsal motor nucleus of X K. Superior salivatory nucleus L. Nucleus ambiguus M. Principal sensory nucleus of V N. Oculomotor nucleus O. Hypoglossal nucleus P. Trigeminal ganglion Q. Descending hypothalamic fibers R. Corticospinal fibers S. Corticobulbar fibers T. Anterolateral system U. Medial lemniscus 22. Diplopia and ptosis
Oculomotor nucleus
