B2 Neuro practice Q

Ibin Yankinoff is a Russian born athlete whose love of vodka has destroyed parts of his cerebellum. A newly developed drug selectively inhibits neurons located in the molecular layer of the cerebellum. Inhibition of these cells would have what effect on the deep nuclei of the cerebellum? a. None b. Inhibit c. Excite d. Receptor Sensitizatio

16. B

A 40 yr old man reports that ever since falling down a cliff, he has been experiencing shortness of breath, and an inability to perform rapid alternating movements. You would diagnose this patient as having: A. Dyspnea and dysdiadochokinesia B. Dysphonia and dysarthria C. Dyspnea and dysmetria D. Dysarthria and dysdiadochokinesia E. Dysmetria and intention tremor

A.

A patient presents with the following deficit; they are unable to track a moving finger to their right, but have no problem tracking it to their left (ie. lateral conjugate gaze to the left is ok, but not to the right). For this patient, the right eye is not __________ and the left eye is not ________ A. Abducting and adducting B. Adducting and abducting C. Abducting and abducting D. Adducting and adducting E. Abducting and converging

A. Yeah, this one was pretty easy. However, you still have to visualize your answer, which is good practice for eye movement stuff.

The structure indicated by '1' is the A. Medial vestibular nucleus B. Lateral vestibular nucleus C. Nucleus ambiguus D. Nucleus solitarius E. Spinal trigeminal nucleu

14. D.

The basal ganglia and cerebellum are key in movement. Disruption in either can cause severe motor impairments. To which nuclei do these two structures project to respectively? a. Anterior, Ventral Lateral b. Ventral Anterior, Mediodorsal c. Ventral Posterior, Ventral Anterior d. Ventral Anterior, Ventral Lateral e. VPM, VP

21. D

One of the functions of the midbrain is to influence the levels and consciousness and arousal. It does so by the Ascending Reticular Activating System (ARAS). One of the ARAS projections is to the Thalamus. Which of the following nuclei receive the ARAS? a. Cetromedian, Intralaminar b. VPM, VPL c. VA, VL d. Lateral Dorsal, Lateral Posterior e. Anterior, Mediodorsal

22. A

A women presents with loss of sensation of pain/temp, vibration, and touch on the right side of her body and face. She also has right sided hemiparesis and a fixed extension of the right arm. Assuming one lesion, the lady described is also most likely to show what other sign? a. Right sided partial ptosis b. Left sided partial ptosis c. Right sided complete ptosis d. Blown left pupil e. Jaw atrophy on right

23. B

A women presents with loss of sensation of pain/temp, vibration, and touch on the right side of her body and face. She also has right sided hemiparesis and a fixed extension of the right arm. Assuming one lesion, the lady described is also most likely to show what other sign?The artery most likely being described in the previous case? a. ACA b. MCA c. PCA d. AICA e. PICA

24. C

An 82 year widow is taken to the emergency by her son after suffering from a fall in the kitchen. When asked to stick out her tongue it deviates towards the right side. She cannot move her left leg and her left arm is noticeably weak relative to her right arm. Such a set of symptoms could be due to occlusion of which artery? a) anterior spinal artery b) posterior communicating artery c) anterior communicating artery d) anterior inferior cerebellar artery e) superior cerebellar artery

answer: a symptoms are consistent with a medial medullary syndrome in which CN XII , medial lemniscuses and CST in cerebral peduncle are involved. Typically occlusion of the anterior spinal artery gives rise to this syndrome the vertebral artery occlusion could as well. In the medial medullary syndrome the fibers of CN XII are affected resulted in ipsilateral deviation of tongue on protrusion; CST is affected resulting in contralateral weakness/hemiparesis; and medial lemniscuses is affected resulting in contralateral loss of discriminative touch, vibration sense and proprioceptive sense. b) posterior communicating artery connects the posterior circulation of the brain with the anterior circulation of the brain - it forms part of the Circle of Willis. c) the anterior communicating artery is part of the Circle of Willis and connects the two anterior cerebral arteries. It is the most common site of cerebral aneurysms. d) the anterior inferior cerebellar artery comes off the basilar artery and supplies the lateral margin of the pons as well anterior/inferior aspect of cerebellar (including flocculonodular lobe) e) superior cerebellar artery comes off the basilar artery and supplies a bit of the roof of the midbrain as well as the superior aspect of the cerebellum.

1) A 46 year old female patient is referred to your office for vision testing because of blurred vision. You notice that the right eye, when asked to look straight ahead, points down and away from the nose. Upon further testing you notice mild weakness on the patients left arm. There is no ataxia or other noticeable sensory impairments. You suspect the following brainstem syndrome: a) right-sided Weber's syndrome b) left-sided Benedikt's syndrome c) right-sided Medial medullary syndrome d) left-sided Lateral medullary syndrome e) right-sided AICA syndrome

answer: a these are classic signs of Weber's syndrome which typically presents with ipsilateral cranial nerve III symptoms as well as contralateral weakness. b) Benedikt's syndrome is another midbrain syndrome which can be differentiated from Weber's syndrome because of the involvement of the red nucleus. The red nucleus receives input from the cerebellum and projects to the inferior olives, which in turn project to the cerebellum. The red nucleus is therefore part of the larger cerebellar motor control circuitry and therefore, lesions, to red nucleus could produce symptoms such as tremor, ataxia. c) medial medullary syndrome involves ipsilateral CN 12 symptoms (tongue deviation), contralateral medial lemniscus symptoms and contralateral corticospinal tract symptoms. It typically results from occlusion of the anterior spinal artery. d) lateral medullary syndrome results from occlusion of the posterior inferior cerebellar artery and produces a range of symptoms from dysphagia (nucleus ambiguous), to nystagmus (vestibular nuclei) to loss of pain/temp contralateral body (spinothalamic tract) to ipsi horner's (ptosis, miosis and anhydrosis) because of damage to the descending sympathetic fibers that course near the spinothalamic tract in the lateral medulla. e) AICA syndrome involves the lateral pons but would not present with CN III signs.

14) Following a viral infection a patient is seen by a neurologist because she was beginning to be disturbed by sounds that would normally not bother her. When asked to smile she couldn't raise the right side of her mouth. Only her left eyebrow elevated when she was asked to raise both eyebrows. Such a constellation of symptoms is most likely due to irritation of a cranial nerve whose nuclei are present in which region of the brainstem/spinal cord? a) medulla b) pons c) midbrain d) upper cervical e) none of the above

answer: b symptoms appear related to Bell's Palsy, which results from irritation of the facial nerve. The motor nucleus of the facial nerve is located in the pons. a) CN IX, X and XII have nuclei in the medulla. c) CN III and IV have nuclei in the midbrain d) CN XI has nuclei in upper cervical

A vestibular schwannoma has grown so large that it is compressing CN 7. As a result all parasympathetic secretions on that side are diminished. What is the only gland on the corresponding side still functional? a. Parotid b. Lacrimal c. Submandibular d. Sublingual

10

A victim of a car accident is brought to the emergency room. The patient is alert, oriented to person, place, and time, and complains only of his superficial wounds. Just to be safe, the physician shines a light into the patients left eye and observes constriction of the right pupil, and only the right when shining into the right eye. a. Right III b. Left III c. Right II d. Left II e. Left pretectal nucleus

11. B

Mrs. Elbie is a 24 yr old ex blond medical student who presents with the following after suffering an occlusive stroke: she stands with her feet wide apart and when she walks she tends to veer towards the right. She performs poorly on the heel to shin test on her right leg, but is normal on the left leg. Upper extremities are normal. Mrs. Elbie has no other symptoms. Damage to which one of the following could result in Mrs. Elbie's condition? A. Right inferior cerebellar peduncle. B. Right posterior spinocerebellar tract. C. Right juxtarestiform body of the inferior cerebellar peduncle. D. Left posterior spinocerebellar tract. E. Left anterior spinocerebellar tract.

11. B. Actually, 2 answers here (A, B) could explain her cerebellar symptoms on the right side, but A would have additional symptoms such as vertigo, nausea, from damage to vestibular connections to cerebellum. C is wrong because that would just result in vestibular symptoms with no cerebellar ones.

A 25 yr old patient presents with decreased (hypo) reflexes in the left arm and leg. Sensation is normal at all levels, and strength is also normal. What might be damaged to result in decreased reflexes with affecting sensation or muscle strength? A. Left corticospinal tract in the spinal cord. B. Right internal capsule. C. Left cerebellum. D. Left anterior horns from L2 to S2. E. Right precentral gyrus.

12. C. Cerebellar damage can result in hypotonia, would which decrease deep tendon reflexes. The muscle does not respond 'briskly'. Answers A, B and E would all result in hyperreflexia of the left arm and leg, but with muscle weakness as well. D would result in no patellar or Achilles reflex on the left side.

Which one of the following symptoms will result from the above lesion? A. Contralateral ataxia B. Nystagmus C. Ipsilateral Babinski sign D. Contralateral loss of pain and temperature sensation from the face E. Deviation of the tongue away from the lesion upon protrusion.

13. B. We can rule out C and E, since the corticospinal tract is not affected, nor is the hypoglossal nucleus/nerve. Damage in this region would affect trigeminal nucleus, so there would be pain and temperature loss, but from the ipsilateral face. Finally, answer A is wrong, because although the inferior cerebellar peduncle is damaged, those deficits would be ipsilateral. .

A researcher is studying the baroreflex. He isolates and cuts the glossopharyngeal nerve to observe its effects on blood pressure. Information conveyed by this nerve enters the same nucleus shared by which other cranial nerves? a. 7 b. 5 c. 7,5 d. 7,5,10 e. 7,10

13. E

Match the following lobes of the cerebellum with their corresponding functional and phylogenetic names, as well as the deep output nucleus used by each lobe. i. Flocculonodular Lobe Paleocerebellum Dentate ii. Anterior Lobe Neocerebellum Emboliform iii. Posterior Lobe Cerebralcerebellum Globose Vestibulocerebellum Fastigial Spinocerebellum Archicerebellum

14. i. Floculonodular: Archicerebellum, Vestibulocerebellum → Fastigial Nuclei (projects to ii. Anterior Lobe: Paleocerebellum, Spinocerebellum → Globose & Emboliform (projects to red vestibular nuclei and reticular formation i.e. vestibulospinal and reticulospinal tracts) iii. Posterior Lobe: Cerebralcerebellum, Neocerebellum → Ventral Lateral Nucleus of Thalamus nucleus)

A knife wound severs the juxtarestiform body of the inferior cerebellar peduncle. A likely symptom could manifest as? a. Intention Tremor b. Truncal Ataxia c. Vertigo d. Dysdiadochokinesia e. Resting Tremor

15. C

Johnnie Walker is concerned about his friend Captain Morgan, because the Captain just had an occlusive stroke of his right internal capsule. Johnnie brings you a list of symptoms and asks you if the Captain will have any of them. Help Johnnie out by selecting the correct answer below: A. The Captain will have a Babinski sign, right leg. B. The Captain will show paralysis of the ipsilateral lower face. C. The Captain's tongue will deviate to the right upon protrusion. D. The Captain will have loss of lacrimation, left side. E. The Captain will hypertonicity, left leg.

15. E. Right internal capsule stroke would cause left side CST (and CBT) problems. So answers A and B and C are wrong cause the symptoms are on the wrong side. D is incorrect because lacrimation is upper face, and not affected by CBT lesion.

16. Which of the following symptoms will this patient have? A. The patient will be unable to voluntarily look left or right. B. The patient will have ataxia, left leg. C. The patient left eye will be medially deviated at rest. D. When asked to smile, only the left side of the mouth will move. E. Babinski sign, left leg.

16. D. Answer A is incorrect because horizontal eye movement is directed by the frontal eye field. Yes, CN III is damaged in this patient, but that would affect only one eye. Answer B is wrong because damage to the left red nucleus could result in ataxia, but remember the rubrospinal tract crosses right away, so the ataxia would be contralateral. C is wrong, the eye would be deviated down and out. E is wrong, Babinski would be contralateral. That leaves D. Damage to cerebral peduncle = damage to CBT, so the contralateral lower face would be affected. Thus, left side of mouth moves, right side doesn't.

Due to his alcoholism, Ibin's cerebellar damage is most likely to affect what part of the cerebellum? a. Paleocerebellum b. Posterior Lobe c. Archicerebellum d. Neocerebellum e. Vestibulocerebellum

17. A

Which area is NOT damaged? A. Red nucleus B. CN III C. MLF D. Substantia nigra E. Crus cerebri

17. C.

After years of chronic hypertension a man notices subtle changes in his ability to move. He comes to the physician noting that a least a few times a day he experiences sudden involuntary uncontrolled movements that quickly disappear. Due to his hypertension the physician suspects a series of charcot-bouchard lesion ruptures. A common site for these ruptures occurs in which location? a. Outer Grey b. Deep Grey c. White matter d. Cerebellum e. Spinal Cord

18. B

Celine Dion is visiting St. Kitts. She speaks to the UMHS community "You all are so lucky to have me, Celine Dion, here. I am the greatest singer of all time". Unfortunately, Celine is not able to finish her speech after Dr D accidentally shoots her in the neck with his spear gun. When the students stop throwing garbage on her and laughing, Celine is taken to the hospital where the following is observed: Celine has double vision when looking to the left, but not to the right. Her left eyelid is drooping, and her left eye is medially deviated at rest. The right pupil appears larger than the left pupil. 18. Damage to which cranial nerve accounts for at least some of Celine's symptoms? A. Left CN III B. Right CN III C. Right CN IV D. Right CN VI E. Left CN VI

18. E. She only has diplopia when looking horizontally to the left, that means left CN VI. Damage to III or IV would result in vertical diplopia as well, Celine only has horizontal diplopia.

Pair the following statements/conditions with the appropriate nuclei. a. Releases DA to block prolactin secretion Preoptic b. Will decrease secretion during pregnancy Suprachiamastic c. Lesion will cause hyperthermia Supraoptic d. Lesion will cause poikilothermia Anterior e. Increased secretion will decrease plasma osmolarity Paraventricular f. Circadian Rhythms Dorsomedial g. Controls sex steroids Ventral Medial

19. a. Arcuate b. Arcuate c. Anterior d. Posterior e. Supraoptic f. Suprachiasmatic g. Preoptic h. Lateral i. Ventral medial j. dorsomedial

Celine Dion is visiting St. Kitts. She speaks to the UMHS community "You all are so lucky to have me, Celine Dion, here. I am the greatest singer of all time". Unfortunately, Celine is not able to finish her speech after Dr D accidentally shoots her in the neck with his spear gun. When the students stop throwing garbage on her and laughing, Celine is taken to the hospital where the following is observed: Celine has double vision when looking to the left, but not to the right. Her left eyelid is drooping, and her left eye is medially deviated at rest. The right pupil appears larger than the left pupil. What other symptom might you expect Celine to have?

19. B. Damage is to lateral white matter of pons, so she has Horner's as well.

A man take a harsh blow to the head, when he unknowingly asks Chuck Norris's wife to dance at a local fund raiser. When he comes to, he can no longer voluntarily look to his left, and at rest, his eyes deviate slightly to the right. When his head is jerked in either direction his eyes stay on his attempted target (normal doll's eye). Which of the following has been damaged? a. Right Frontal Eye Field b. Left Frontal Eye Field c. Right PPRF d. Left MLF e. Right MLF

2. B

A patient presents with paralysis on the left side of the face, and hearing loss on the same side ear. Further tests reveal loss of lacrimation on the left side, and decreased taste perception. There are no other deficits. The affected artery is most likely the A. Labyrinthine B. Superior cerebellar C. PICA D. AICA E. Basilar

20. A

Little Sally Walker was walking down the street, she did not know what to do so she stopped in front of.... Chuck Norris. After seeing what she thought to be an "anaconda", her amygdala relayed the sensation of fear to her hypothalamus for the appropriate physiological response. Which pathway is active between the amygdala and hypothalamus? a. Mammillothalamic Tract b. Mammillotegmental Tract c. Fornix d. Stria Terminalis e. Hypothalamospinal Tract

20. D

After waking up in the morning, an elderly man continues to fall due to extreme ataxia. He is found to have dysmetria, intention tremor in the right extremities, as well as a larger pupil on the right eye compared to the left, with a slight ptosis on the left. The man has no feeling of pain on the right side of his body but only from the waist down is his sense of vibration and touch lost. The affected artery is? a. Right AICA b. Left AICA c. Right Superior Cerebellar d. Left Superior Cerebellar e. Right PICA f. Left PICA

25. D

A well known exercise instructor comes into the clinic complaining of gagging after difficulties eating his morning wurst. He tells the physician that it is really hard to swallow and speak. He also has some mild ataxia with dizziness and a constricted left pupil. The artery most likely involved? a. AICA b. PICA c. ICA d. MCA e. ACA f. PCA g. SCA

26. B

Which of the following lesions/conditions would most likely account for the above patient's symptoms? A. Damage to right frontal eye field B. Bilateral damage to the MLF C. Damage to left frontal eye field D. Damage to right CN VI and right CN III E. Damage to right CN III and left CN II

3. C. Left frontal eye field controls lateral conjugate gaze to the right.

A man take a harsh blow to the head, when he unknowingly asks Chuck Norris's wife to dance at a local fund raiser. When he comes to, he can no longer voluntarily look to his left, and at rest, his eyes deviate slightly to the right. When his head is jerked in either direction his eyes stay on his attempted target (normal doll's eye). Which of the following has been damaged? a. Right Frontal Eye Field b. Left Frontal Eye Field c. Right PPRF d. Left MLF e. Right MLF

4. A

Mr. Bullhorn is a 24 yr old SGA representative who gets hit on the head during and SGA meeting. When he awakes, Mr. Bullhorn has the following symptoms: he has a direct but no consensual response when a light is shone in his left eye, and a consensual but not a direct response when the light is shone in his right eye. Mr. Bullhorn has damaged his: A. Left CN II B. Right CN II C. Left CN III D. Right CN III E. Right frontal eye field F. Left frontal eye field

4. D. Shine the light in the left eye, left pupil constricts. That shows that left CN II and left CN III are intact. Shine the light in the right eye, only the left pupil constricts. This tells us right CN II is working, so the problem must be right CN III.

After awaking at his normal time an older man falls to the floor after getting out of bed. He tells his wife to take him to the hospital because he cannot move his left leg very well. Upon examination, upper limb strength is normal with normal reflexes. The man's left leg is hypereflexic and show a positive babinski. The man's right leg is normal. Which artery was mostly likely involved? a. Right Internal Carotid b. Left MCA c. Right MCA d. Right ACA e. Left ACA

5. D

6' in the above diagram refers to the: A. Cingulate gyrus B. Parieto-occipital sulcus C. Pineal gland D. Splenium of the corpus callosum E. None of the above are correct

5. D.

A chronically hypertensive patient comes into the neurology clinic complaining of trouble eating, and numbness in the face. It is noted that the man has jaw deviation to the right upon opening, and a complete loss of sensation on the right side of his face. A T2 weighted MRI shows no bleeds but does show an enlarged, calcified artery compressing the trigeminal nerve root. Which artery is most likely calcified and enlarged? a. Superior Cerebellar b. AICA c. PICA d. PCA e. Calcarine

6. A

A cotton ball is rolled into a whisk and is used to test a child who just had a pilocytic astrocytoma surgically removed. When the whisk of cotton is touched to the left cornea, only the left eye blinks shut. When touching the right eye only the left blinks shut. Surgery on this child more than likely caused damage to which area of the brainstem? a. Right mid pons b. Left mid pons c. Right Caudal Pons d. Left Caudal Pons e. Right Rostral Medulla f. Left Rostral Medull

7. C

Which one of the following structures is NOT visible in the above diagram?

7. E. Not an exam type question exactly because answer E is an all of the above answer, but a good question to work through.

While running a race during a tract meet an athlete steps on a tack that pierces his shoe and sole of foot. Although he feels the pain immediately, he continues the race and forgets about the pain until the race is finished. Pain modulation occurred by the periaqueductal grey synapsing on the raphe nucleus magnus in the medulla. The substance that activated the raphe was? a. Ach b. NE c. 5HT d. Enkephalin e. Endorphin

D

'1' in the above diagram refers to the: A. Pineal gland B. Anterior commissure C. Posterior commissure D. Mammilary bodies E. Interthalamic adhesion

D.

A patient suffers a stroke which damages the right lateral geniculate nucleus. This patient will most likely have a(n): A. Bitemporal hemianopia B. Upper left quadrantinopia C. Lower right quadrantinopia D. Left homonymous hemianopia E. Right homonymous hemianopia

D. Remember information from the left halves of your visual fields goes to the right half of your brain (in this case, the temporal side of the left visual field, and nasal side of right visual field).

A 45-year-old woman was brought to the emergency room complaining of a loss of motor control and sensation in her left lower limb. She had no vertigo or other cranial nerve signs. Angiographic procedures revealed that an artery supplying the brain was 90% occluded. Which of the following arteries was occluded in this patient? a) Left Anterior Cerebral Artery b) Right Anterior Cerebral Artery c) Right Middle Cerebral Artery d) Left Middle Cerebral Artery e) Left Posterior Cerebral Artery f) Right posterior cerebral artery

answer: b the right anterior cerebral artery supplies the medial surface of the hemisphere running up along the corpus callosum. a) an occlusion of the left anterior cerebral artery would produce right sided loss of sensation and/or weakness from lower limb. c) right middle cerebral artery supplies the lateral aspect of the right hemisphere - given the somatotopic organization of the pre and post central gyrus, occlusion of the right middle cerebral artery could give rise to loss of somatosenation on the left side of the upper body/face and/or weakness in same structures. Right MCA occlusions would not typically result in language deficits/aphasias as language is lateralized in about 95% of individuals to the left hemisphere. d) left MCA occlusion would give rise to right sided weakness of face/upper body and/or loss of somatosensory input from these regions of body with also the potential for aphasias and language disorders. e and f ) the posterior cerebral arteries supply the visual cortex (occipital lobe) as well as medial temporal lobe structures such as the hippocampus. The posterior cerebral arteries are the terminal branches of the basilar and as they course back towards the medial temporal lobes they innervate much of the midbrain. Therefore occlusion of the PCA can give rise to various midbrain syndromes which could include weakness/paralysis in different parts of the body. However, PCA occlusions confined to midbrain also present with cranial nerve signs (CN III palsies in particular) which you would not see with PCA occlusions involving the hemispheres.

A 52 year old man examined at a neurological clinic presents with multiple symptoms including right sided miosis, ptosis and anhydrosis; slight ataxia, loss of pain and temperature sensation on the right side of the face, mild loss of pain and temperature on the left side of the body, as well as vertigo. Such a constellation of symptoms could be caused by damage to the a) Anterior cerebral artery b) Posterior inferior cerebellar artery (PICA) c) Posterior communicating artery d) Middle cerebral artery e) Anterior communicating artery

answer: b this constellation of symptoms is associated with lateral medullary syndrome: also called Wallenberg's syndrome. This syndrome results from occlusion of the posterior inferior cerebellar artery which supplies blood to the lateral aspect of the medulla and associated nuclei. In lateral medullary syndrome, hypoxia of descending sympathetic fibers (coursing next to spinothalamic tract) causes an ipsilateral horner's syndrome (accounting for the miosis, ptosis and anhydrosis observed in this patient); damage to inferior cerebellar peduncle causes ataxia; damage to descending tract of V causes loss of pain/temp on ipsi face; damage to STT causes loss of pain and temp on contralateral side of body; and damage to vestibular nuclei causes vertigo. a) anterior cerebral artery does not supply brainstem so you would not expect major cranial nerve signs. c) posterior communicating artery is part of the circle of willis and connects the posterior circulation of the brain (vertebral artery/basilar artery system) with the anterior circulation of the brain (internal carotid system) - occlusion would not affect the medulla. d) middle cerebral artery comes of the internal carotid and is part of the anterior circulation of the brain. It does not provide any blood supply to the brainstem or associated cranial nerve nuclei. e) anterior communicating artery links the two anterior cerebral arteries but does not supply any blood to the brainstem.

A 64 year old male patient comes to the clinic his wife has noticed trouble with chewing food. Upon examination, right-sided weakness of the jaw is noted as well as right-sided loss of vibratory and pressure sense on the face and mild loss of pain and temperature on the right side of the face. The patient was alert to date, time and place, and there were no other significant cognitive abnormalities or disorders of consciousness. You suspect damage to which level of the nervous system? a) left cervical cord b) right midbrain c) right pons d) left medulla t ventro postero lateral (VPL) nucleus of the thalamus

answer: c All of the symptoms presented here are trigeminal related. Chewing problems and weakness with muscles of mastication suggest problems with cranial nerve V. The motor nucleus of V is located in the pons. Loss of vibration and pressure sense on right side of face suggest damage to right chief sensory nucleus of V. Loss of pain and temp on right side of face suggest damage to descending spinal tract of V fibers on the right that convey pain/temp from the face. a) left cervical cord does not contain tracts or nuclei that pertain to sensory or motor innervation of the face. b) the right midbrain does not contain cranial nerve V nuclei (though the mesencephalic nucleus of V does work its way up to caudal midbrain - this nucleus, however, is concerned with jaw proprioception). d) the trigeminal motor and chief sensory nucleus are not located in the medulla. Descending pain and temp fibers of the trigeminal system do, however, descend to the medulla. e) somatosenssory information from the body (spinothalamic pain and temp as well as dorsal column medial lemniscus touch, proprioception and vibration sense) ascend to the ventroposterolateral nucleus (VPL) of the thalamus. Trigeminal information, however, is routed by second order sensory neurons to the VPM (ventroposteromedial) nucleus of the thalamus.

A 72 year old male patient complained of a droopy smile, marked right-sided tinnitus and vertigo. Neurological examination revealed marked weakness on the right side of the face. Such symptoms could be explained by a pathological process involving which of the following foramen? a) superior orbital fissure b) hypoglossal canal c) internal acoustic meatus d) jugular foramen e) foramen magnum

answer: c both CN VII and CN VIII course thru the internal acoustic meatus and therefore damage to this structure can cause CN VII and CN VIII symptoms. CN VII symptoms could include a Bell's Palsy like episode of facial weakness (explaining the droopy smile). CN VIII symptoms could include loss of hearing on one side or tinnitus (ringing in the ear) as well as vestibular components such as vertigo. a) CN III, IV and VI as well as V1 of the trigeminal course thru the superior orbital fissure. b) CN XII courses thru the hypoglossal canal d) CN IX, X and XI course thru the jugular foramen e) the foramen is the largest foramen in the skull and at the caudal medulla/upper cervical region of the neural axis.

A 22 year old man is seen by an ophthalmologist because of diplopia (double-vision). When asked to look straight ahead his left eye appears normal and his right eye deviates towards his nose. Vertical eye movements are normal. You suspect damage to which brainstem region? a) rostral midbrain b) caudal midbrain c) mid-level pons d) medial medulla e) lateral medulla

answer: c deviation of eye towards the nose suggests that the lateral rectus muscle is not working properly or the cranial nerve that innervates it (cranial nerve VI). The abducens nucleus is located medially in the pons. a) rostral midbrain contains a bit of the oculomotor nucleus. Damage to this nucleus would cause down and out syndrome, as well as dilation and potentially eyelid closure. b) caudal midbrain contains the nucleus of cranial nerve IV - this would not cause medial deviation of the eyeball, but rather, slight elevation of the eyeball and a resulting vertical diplopia. d) No cranial nerve nuclei associated with vision are found in the medulla. The medial medulla contains, among other things, the cranial nerve XII nucleus. A lesion to this nucleus or associated fiber tract would cause ipsilateral deviation of the tongue. e) lateral medulla contains many important nuclei but none associated with vision.

A 68 year women is brought to the ER following a stroke. Her speech had become slurred and she had rapidly developed right-sided weakness of arm and face. The attending ER physician suspected a stroke involving which artery? a) Left posterior cerebral artery b) Left anterior cerebral artery c) Left middle cerebral artery d) Right anterior cerebral artery e) Right middle cerebral artery

answer: c left middle cerebral artery supplies blood to lateral surface of left hemisphere. This includes the part of the precentral gyrus associated with the upper limb and face. In addition the middle cerebral artery on the left supplies blood to regions of cortex devoted to language processing (in approximately 95% of people). Therefore a left sided stroke involving the MCA could give rise to right sided weakness of arm and face as well as language difficulty. Slurred speech could arise from other abnormaliites. a) left PCA supplies blood to left medial temporal lobe (hippocampus) as well as left occipital cortex. Full occlusion of this artery could result in a contralateral homonymous hemianopsia (visual field deficit) b) left ACA supplies medial surface of left hemisphere including left paracentral lobule - lower limb structures. d) right ACA supplies medial surface of right hemisphere - para central lobule to lower limb e) right middle cerebral artery occlusion would give rise to left sided weakness and typically not produce language deficits.

During a neurological exam a patient is brought into a dimly lighted room and a flashlight is shown into the left eye. You notice that the left eye does not constrict but the right eye does constrict. Which of the following lesions could explain this deficit? a) demyelination of left optic nerve b) demyelination of right optic nerve c) lesion to left CN III fibers d) lesion to right CN III fibers e) lesion to left ptergopalatine nucleus

answer: c the pupillary light reflex pathway involves sensory fibers of CN II and motor fibers of CN III (output of edinger westphal nucleus). Motor output to the right eye must be intact because of the preserved consensual reflex. Sensory input to the left most be intact because of the preserved consensual reflex. Therefore the lesion must involve the motor output on the left to the left pupillary sphincter muscle. a) A lesion to the sensory component of the reflex arc on the left would prevent both the direct and the consensual reflex from taking place. b) a lesion of the right CN II fibers would not affect reflexes generated by flashing light into the left eye. d) a lesion to fibers associated with the right CN III would cause loss of consensual but not loss of direct on the left. e) ptergopalatine nucleus is a parasympathetic nucleus innervated by preganglionic fibers associated with the facial nerve.

During a play-off game, a college hockey player is struck hard on the back of his neck with a hockey stick. A CT scan reveals a bone fragment lodged into the lateral aspect of his right dorsal columns in the cervical spinal cord. Which of the following functions will most likely be disrupted given this patient's presentation? a) Motor control of ipsilateral leg b) motor control of contralateral leg c) Proprioception of ipsilateral leg d) propriocetpion of ipsilateral arm e) Pain from ipsilateral face f) pain from contralateral face

answer: d dorsal columns contain the gracile fasiculus and cuneate fasiculcus tracts conveying discriminative touch, vibration and proprioceptive information to the gracile and cuneate nuclei of the medulla. A lesion to the lateral margin of the right dorsal columns would affect the cuneate fasiculus, a tract affecting the upper body. You would expect loss of discriminative touch, vibration sense and conscious proprioception (as opposed to unconscious proprioception which is conveyed by the spinocerebellar tracts) - a and b) motor control of the legs is not mediated by the dorsal columns but rather by the corticospinal tract as well as descending c) lateral margin of right dorsal column would affect cuneate fasiculus, not gracile fasiculus, and therefore knock out conscious proprioception from arm, not from the leg. e and f) pain/temp from face is conveyed by the trigeminal system and does not involve the dorsal columns of the spinal cord. Recall that pain/temp for the body travels in the spinothalamic tract to VPL nucleus of the thalamus. Pain and temp for the face travels in the trigeminal system to VPM nucleus of the thalamus.

A 61 year old man presents with slight vertigo, loss of taste sensation on the right side of the tongue, and loss of pain and temperature on the right side of the face. The taste symptoms could be explained by damage to which of the following nuclei? a) Nucleus Ambiguous b) Inferior Salivatory Nucleus c) Edinger-Westphal Nucleus d) Nucleus Solitarius e) Medial Vestibular nucleu

answer: d taste information from cranial nerves 7 (anterior 2/3 of tongue), 9 (posterior 1/3 of tongue) and 10 (epiglottis) is transmitted to the solitary nucleus via the solitary tract. From the solitary nucleus taste information is in part conveyed to the VPM nucleus of the thalamus via the central tegmental tract. a) the nucleus ambiguous contains components of cranial nerve 9 and 10 - its is referred to by some as the swallowing center as it coordinates the complex motor sequences necessary for swallowing food. Lesion of the nucleus ambiguous, however, would not cause deficits in the sensation of taste nor would it cause loss of pain/temp on the face. b) the inferior salivatory nucleus is a component of CN IX. It is the origin of preganglionic parasympathetic fibers that innervate the otic ganglion. Post ganglionic fibers in the otic ganglion project to the parotid gland to stimulate secretion. c) the edinger westphal nucleus is a component of the oculomotor complex. Pre ganglionic parasympathetic cell bodies associated with CN III are located in the Edinger Westphal nucleus. These preganglionic fibers project to the ciliary ganglion in the orbit of the eye. Post ganglionic fibers from the ciliary ganglion project to the pupillary sphincter muscle to cause constriction. A lesion of the this pathway would result in abnormal dilation of the pupil (mydriasis). This can be seen, for example, secondary to uncal herniation in which the midbrain and associated structures are compressed.

A young man is brought to the ER following an automobile accident in which he was thrown from a car. Neurological examination revealed left hemiparesis with loss of vibratory and joint position sense below C5 on the left side. Loss of pain and temperature sensation was observed on the right side below C5. An MRI was performed. What kind of spinal cord damage could cause such symptoms? a) complete transection of the spinal cord b) lesion of the right lateral funiculus of the spinal cord c) rupturing of the anterior spinal artery d) lesion of the dorsal columns on the right side of the spinal cord e) hemisection of the left spinal cord

answer: e Looks like a brown sequard hemi-section of cervical spinal cord with typical associated symptoms. Lesion of CST in spinal cord will give rise to ipsilateral weakness (as the tract has already crossed in the caudal medulla). Lesion of STT in spinal cord will give rise to loss of pain/temp on contralateral side of body BELOW level of lesion as tract has already crossed. Lesion of dorsal columns on one side will give rise to loss of discriminative touch, proprioception and vibration sense ipsilateral to lesion as this tract has not crossed neural axis (second order neurons in this tract cross in the medulla as internal arcuate fibers). a) complete transection of spinal cord would give bilateral weakness, bilateral loss of pain/temp, and bilateral loss of dorsal column function (disc. Touch, vibration, proprioception). Etc. b) lesion of right lateral funiculus could damage right CST and potential right spinocerebellar tracts giving rise to right sided weakness/paralysis (not the left hemiparesis observed in this case). Dorsal columns and spinothalamic tract would be preserved. c) anterior spinal artery occlusion would affect STT bilaterally as well as CST bilaterally leaving dorsal columns preserved. d) lesion of dorsal columns on right side of spinal cord would cause ipsi loss of discriminative touch, vibration sense and proprioception, leaving CST and STT function spared.

A 65-year-old woman complains of brief attacks of intense pain on the left side of her face that are precipitated by light touch and other normally innoxious stimuli. Her physician prescribes carbamazepine, which significantly reduces recurrence of the painful attacks. What was the most likely diagnosis? a) Thalamic pain b) Lesion of the periaqueductal gray c) Weber's syndrome d) Lateral medullary syndrome e) Trigeminal neuralgia

answer: e classic signs of trigeminal neuralgia - typically symptoms associated with irritation of one branch of the trigeminal nerve. a) thalamic pain syndrome results from damage or lesions to thalamus and can be quite severe. However the symptoms do not present in the dermatopic fashion as seen with trigeminal neuralgia b) lesion of periaqueductal gray might cause enhanced pain transmission as the periaqueductal grey is part of an endogenous pain reduction system in the nervous system. c) weber's syndrome is a midbrain syndrome characterized by ipsilateral CN III signs and contralateral CST symptoms (weakness, hemiparesis) d) lateral medullary syndrome results from occlusion of posterior inferior cerebellar artery and results in symptoms such as vertigo (vestibular nuclei), dysphagia (nucleus ambiguous), horner's syndrome (descending sympathetics from hypothalamus), loss of pain/temp in contra body (spinothalamic tract), etc. But it is not characterized typically by excruciating pain localized to the face.

15) Which of the following would not explain right-sided weakness/paralysis of the upper limb? a) An occlusion of the left posterior cerebral artery b) A tumor compressing the left cerebral peduncle c) An infarct involving the left medullary pyramid d) Right hemi-section of the spinal cord at T 4 e) An occlusion of the left anterior cerebral artery f) more than one above

answer: f (both e and f are correct responses) weakness/paralysis restricted to the upper limb could not evolve from a spinal cord lesion in the lower thoracic as this level of the spinal cord is caudal to the brachial plexus and neural outflow form cervical spinal cord. the anterior cerebral artery supplies the paracentral lobule on the medial surface of the left hemisphere of the brain. As such, it supplies blood to the part of the cortex that generates motor control for the lower limb on the right side of the body. It does not supply blood to the region of the motor homunculus associated with upper limbs/face (this is the territory of the middle cerebral artery) a) an occlusion of the left posterior cerebral artery could cause many symptoms depending on the location of the occlusion. If the occlusion were confined to the medial temporal lobes or occipital lobe visual symptoms would be expected. But if the occlusion occurred in some of the branches of the PCA that penetrate the midbrain then you could see weakness in the contralateral body, including the upper limb. b) the corticospinal tract courses thru the cerebral peduncle - therefore damage to the left cerebral peduncle ( also called the crus cerebri) could cause contralateral/right sided weakness in the lower and/or upper limbs. c) the corticospinal tract courses thru the medullary pyramids before decussating in the caudal medulla. A lesion of the left medullary pyramid, therefore, would cause contralateral/right sided weakness/paralysis