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WHERE IS THE LESION ?

1A. What cranial nerve is dysfunctional in this patient?

A.
B.
C.
D.

Right abducens nerve


Right oculomotor nerve
Right facial nerve
Right trochlear nerve

Correct. The oculomotor nerve (CN III) innervates the levator palpebrae muscle of
the eyelid to keep the eyelid open, all of the extraocular muscles except the lateral
rectus (abducens nerve) and superior oblique (trochlear nerve), and supplies
parasympathetic innervation to constrict the pupil. Thus a lesion of the right
oculomotor nerve will lead to ptosis, dilated pupil, and "down and out" position of the
eye, all on the right side, as seen in this patient.
1B. A patients facial appearance is shown below when he closes his eyes tight (left)
and wrinkles his forehead (right). When extraocular eye movements were tested, he
could not move his right eye laterally. What is the most likely location of the lesion?

A.
B.
C.
D.

Right midbrain
Right pons
Right medulla
Left frontal lobe

Correct. This is an example of a lesion at the facial colliculus in the right dorsal pons.

A lesion of the right facial nerve (fibers looping around the abducens nucleus) results
in paralysis of the entire right side of the face: the right lower face droops, the patient
cannot tightly close the right eye and cannot wrinkle the forehead on the right.
Lesion of the right abducens nerve and/or nucleus results in inability to abduct the
right eye.
1C. A patient has the appearance shown in the diagram below on an attempted gaze
to the left (A) or right (B). Convergence is normal. Where is the lesion ?

A.
B.
C.
D.

Bilateral medial longitudinal fissure


Right oculomotor nerve
Right abducens nerve
Left abducens nerve

Correct. The patient can abduct both eyes (lateral gaze is normal), but cannot adduct
both eyes (medial gaze is impaired on voluntary eye movements). However, both
oculomotor nuclei and nerves are intact since convergence is normal. Thus the
lesion is in the medial longitudinal fasciculus (MLF), and information from the
abducens nucleus is not reaching the oculomotor nucleus to mediate the medial
component of voluntary conjugate gaze.
1D. You are testing the blink reflex on your patient. When you touch a piece of
cotton to the right eye, both eyelids close in a blink. When you touch the left eye,
neither eye closes. Which of the following cranial nerves is involved in a lesion?
A.
B.
C.
D.

Left CN 5
Right CN 5
Left CN 7
Right CN 7

Correct. The trigeminal nerve (CN 5) is the afferent arm of the blink reflex (corneal
reflex) and the facial nerve (CN 7) is the efferent arm. If there is a lesion of left CN 5,
sensation of touching the cornea will not be conveyed centrally, and neither eye will
blink.

1E. A patient has the appearance shown in the diagram below on attempted gaze to
the right. All other ocular movements are normal. Where is the lesion?
A.
B.
C.
D.

Bilateral medial longitudinal fissure


Right oculomotor nerve
Right abducens nerve
Left abducens nerve

Correct. The abducens nerve innervates the lateral rectus muscle and mediates
lateral gaze. The inability to abduct the right eye suggests a lesion in the right
abducens nerve.

1F. A patient has the appearance shown in the diagram below looking straight
ahead. Extraocular eye movements are normal. Pupillary light reflexes are intact.

Where is the lesion?


A.
B.
C.
D.

Left oculomotor nerve


Right oculomotor nerve
Left Edinger-Westphal nucleus
Left superior cervical ganglion

Correct. The lesion is in the left sympathetic nervous system fibers to the eye, and
the only location involving sympathetic fibers listed is the left superior cervical
ganglion. This pathway (hypothalamospinal tract) begins in the hypothalamus,
descends through the brainstem and spinal cord, exits at about the T1- T2 level,
synapses in the superior cervical ganglion, and proceeds to the eye to mediate pupil
dilation and to innervate smooth muscle fibers in the levator muscle of the upper
eyelid. Damage in this pathway results in ipsilateral pupillary constriction and mild
ptosis (Horner's syndrome).

1G. After a stroke, a patient could not voluntarily move her eyes to the right when
asked. Both eyes moved normally when she was asked to look to the left. Where is
the lesion?

1I. Neurological examination revealed:


---paralysis and increased DTRs of left leg
---loss of vibration and proprioception of left leg
---loss of pain and temperature sensation in the right leg
Where is the lesion?
A.
B.
C.
D.

Left spinal cord


Right spinal cord
Left medulla
Right medulla

Correct. This is an example of the Brown-Sequard syndrome (hemisection of


the spinal cord). Tracts involved in a lesion of the left spinal cord involve (1) the
left corticospinal tract, which will synapse with lower motor neurons in the left
limbs; (2) the left dorsal column containing primary sensory neurons for vibration
and proprioception from the left limbs; and (3) the left spinothalamic tract
containing secondary sensory neurons for pain and temperature sensation
coming from the right limbs (the pain/temperature neurons cross at the level of
entry in the anterior commissure after synapsing in the dorsal horn).

1J. A patient had loss of pain and temperature on the right face and left body;
nausea; right-sided dysmetria; loss of gag reflex; dysarthria; ptosis and miosis in the
right eye. Where is the lesion?

A. Right dorsolateral midbrain

B. Left medial midbrain


C. Right dorsolateral medulla
D. Left lateral medulla
Case 1
A 60-year-old man collapsed while at work. After he regained consciousness in the
emergency room, neurological exam was performed with the following abnormalities
noted:

paralysis in the right arm and leg


dysarthria
deviation of the tongue to the left when protruded
loss of vibration, proprioception and discriminative touch sensation on the right
side of the body (the face has normal sensation).

Question : Where is the lesion ?


The lesion is in the left medial medulla (probably due to a cerebrovascular accident
(stroke) in the territory of the anterior spinal artery). The specific region of damage
and resulting clinical effects are:
.left pyramid - right hemiplegia
.left medial lemniscus - loss of proprioception and vibration sensation on the right
side of the body
.left hypoglossal nerve (CN12) - dysarthria (difficulty speaking because the tongue is
weak); deviation of the tongue to the left when protruded. The left side of the tongue
is weak, and cannot oppose the right tongue muscles when the tongue is protruded.
The hypoglossal nerve fibers are adjacent to the pyramid when exiting the medulla.

Case 2:

A 42-year-old woman fell off a ladder and fractured her spine in the lower back region.
Neurological examination one week later revealed the following abnormalities:

paralysis and increased deep tendon reflexes of the left leg


Babinski sign on the left
loss of proprioception, vibration and discriminative touch sensation of the
entire left leg
complete anesthesia of a strip across the hip and along the upper front thigh on
the left side
loss of pain and temperature sensation in the right leg and buttock

Question 3: Where is the lesion?


The lesion is a left hemisection of the spinal cord (Brown-Sequard syndrome). This
lesion interrupts all pathways of the left side of the cord at spinal cord segment L1.
The specific pathways involved and resulting clinical effects are:
----lateral corticospinal tract (left) --> left leg paralysis and hyperreflexia below the
lesion; Babinski sign on left (IPSILATERAL)
----fasciculus gracilus (dorsal column, left) --> loss of proprioception and vibration in
dermatomes below the lesion (IPSILATERAL)
----lateral spinothalamic tract (left) --> loss of pain and temperature sensation in the
right lower extremity, in dermatomes L3-S4 below the lesion (CONTRALATERAL)
----spinothalamic fibers of L1-L3 crossing from left to right within the L1 spinal cord
segment -> complete loss of pain and temperature sensation in the L2 dermatome on
the left side.
Case 3: Question

A 46-year-old man complained of radiating pains in his legs and back. He said both legs
were very sensitive to touch. Examination revealed only the following (there was no
weakness; pain sensation was not tested):

bilateral loss of vibratory sense and proprioception in both lower extremities


bilateral loss of knee and ankle reflexes
wide-based gait with slapping of the feet to the ground
urine retention

Question 1 : Which tracts are involved ?


The spinothalamic tract involvement is indicated by pain (irritation of the spinothalamic tract
neurons). Involvement of the dorsal column/medial lemniscus system is indicated by loss of
vibration and position sense and loss of 2-point discrimination. Decreased reflexes can be
caused by deficits in either the sensory or the motor component of the reflex. In this patient
there was no indication of weakness.
Question 2: Where is the lesion?
The lesion involves the dorsal roots and dorsal columns bilaterally in the lumbosacral region.
This is a case of tabes dorsalis (neurosyphilis). The pain and hypersensitivity to touch result
from irritation of small neurons which convey pain sensation. The loss of vibratory sense and
proprioception results from damage to dorsal root neurons in the dorsal roots, with
degeneration of dorsal column axons degeneration above the damaged cell bodies. The
bilateral loss of knee and ankle reflexes results from loss of the sensory component of the
reflexes.

Case 6
A 41-year-old man was referred to an ophthalmologist because he was having
trouble with his eyes. He could not see objects off to the side, but could see fine
when objects were directly in front of him. Examination revealed bitemporal
hemianopsia.
Question 1: What is the most likely location for a lesion?
The lesion is in the optic chiasm, with destruction of the fibers from the medial retina
crossing to project to the contralateral lateral geniculate nucleus. The medial retina
receives visual input from the lateral visual fields, so peripheral vision is impaired in
this patient. The most common cause of a lesion in the optic chiasm is a tumor of the
pituitary.
Case 7
A 66-year-old man woke up one morning and could not move his right arm or hand.
He had trouble trying to speak to his wife, but could understand her questions and
follow her directions. At the hospital, neurological exam revealed the following
abnormalities:

paralysis of right lower face muscles (but he could wrinkle his forehead on
both sides)
paralysis and hyperreflexia of right hand and arm
mild sensory loss (both modalities) in right hand, arm and face
Broca's aphasia

Question 1: What is the most likely location for a lesion?


The lesion is an infarct in the distribution of the left middle cerebral artery (MCA)
caused by thrombosis. The lesion includes the precentral gyrus (motor strip),
innervating hand, arm and face, and Broca's area. The postcentral gyrus (sensory
strip) is involved to a lesser extent.

Case 8
A 64-year-old man with a history of poorly controlled hypertension collapsed while
shoveling snow. He regained consciousness at the hospital. Examination revealed
the following:

paralysis of left arm, leg and lower face


complete sensory loss in left arm, leg and face

Question 2: What is the most likely location for a lesion that would cause all of these
findings?
The lesion probably involves the right internal capsule, due to intracerebral hemorrhage.
Both motor and sensory pathways go through the internal capsule and would be interrupted.
A lesion in the medulla that was large enough to interrupt both the medial lemniscus and the
spinothalamic tract (dorso-lateral) would cause many other symptoms. A lesion in the medial
frontal lobe cortex would cause leg paralysis. A lesion in the thalamus would interrupt only
sensory pathways; and not motor.

Case 9:

A 39-year-old woman went to see her family physician complaining of weakness in her legs.
She said her legs felt tired when she stood up too long. She first noticed the weakness three
months earlier. Examination revealed increased reflexes in both legs and bilateral Babinski
signs. There was marked weakness of foot,ankle and calf muscles, but thigh muscles did not
show definitive weakness. Sensory examination revealed mild deficits in all modalities in both
lower legs.
Question 1: Which of the major long tracts are involved?
All three major tracts are involved. Corticospinal tract involvement is indicated by increased
deep tendon reflexes and bilateral Babinski signs. Spinothalamic tract and dorsal
column/medial lemniscus system involvement are indicated by the sensory deficits in all
modalities.
Question 2: Where could a single CNS lesion be located to cause this clinical presentation?
A single lesion in the midline of the frontal and parietal lobes, compressing the medial (leg)
motor strip bilaterally and the medial sensory strip bilaterally would cause this presentation.
A tumor (meningioma) in the midline is a likely pathogenesis.

Case 10: Question 1


A 55-year-old man presented with loss of all sensation in the left thumb, adjacent hand and strip
along the lateral forearm. There were no other abnormal findings on neurological exam.
Question 1: Where is the lesion?
The presentation consists of sensory loss in all modalities in the C6 dermatome (no motor
deficits are described). Thus the lesion involves the left C6 dorsal root.
A lesion in the dorsal column would cause loss of proprioception and vibration below the lesion
ipsilaterally (not just in the dermatome). A lesion in the left lateral spinothalamic tract would
cause loss of pain and temperature below the lesion contralaterally. A lesion in the ventral root
would cause motor deficits.
Case 11 :
A 67-year-old man complained of double vision. Neurological examination revealed
inability to close his left eye, inability to wrinkle the left side of his forehead, and no
movement on the left side of his face when he tried to smile. An internal strabismus
of the left eye was noted and he was unable to abduct the left eye.
Question 1: The inability to close his left eye, and left-sided facial weakness as
described, indicate a lesion in which of the following locations?
A lesion in the motor fibers of the facial nerve will cause the presentation described.
Remember that in the pons, the fibers of the facial nerve (CN7) leave the facial nucleus,
and curve around the abducens nucleus before exiting.

Question 2: An abnormality in which of the following would cause inability to abduct the
left eye?
A lesion in the left abducens nucleus or nerve (CN6) would cause internal strabismus of
the left eye and inability to abduct the left eye. There would be no innervation of the
lateral rectus muscle. In this patient, the facial nerve abnormalities help localize the
lesion to the abducens nucleus.

Question 3: Where is the lesion in this patient?


The lesion would be located in the dorsal pons (tegmentum). As indicated by the signs
and symptoms the lesion would include the abducens nucleus and the internal genu of
the facial nerve as it curves around the abducens nucleus. Note that the facial colliculus
is a landmark on the surface of the pons, and should not be listed as a location for this

lesions.

Case 12: Question 1

A 42-year-old woman had loss of pain and temperature sensation on the right side of her face
and left side of her body. She also had hoarseness, difficulty swallowing, and nystagmus.
Question 1: Loss of pain and temperature sensation (analgesia and thermanesthesia) on the
right side of the face indicates involvement of:
The spinal tract of nerve V carries pain and temperature sensory fibers from the face. These
fibers have cell bodies in the trigeminal ganglion, enter the brainstem at the level of the pons in
cranial nerve V, and then descend to the medulla before synapsing and crossing the midline.
Loss of only facial pain and temperature sensation, with normal discriminative touch and
vibration sensation, indicates a lesion in the descending fibers of the spinal tract of V.

Question 2: Where is the lesion?


This is an example of Wallenberg's syndrome (lateral medullary syndrome). Structures that may
be involved are anterolateral system/spinothalamic tract (causing contralateral loss of pain and
temperature in the body), spinal trigeminal tract (of V) and nucleus (ipsilateral loss of pain and
temperature sensation in the face), vestibular nucleus (nystagmus), nucleus ambiguus or roots
of cranial nerves IX and X (hoarseness and dysphagia), solitary tract and nucleus (loss of taste
from the ipsilateral half of the tongue - not identified in this patient). Patients may also have
Horner syndrome if the sympathetic fibers descending from the hypothalamus are impaired.
Question 3: Occlusion of which artery could cause this presentation?

Case 13
A 55-year-old man complained of weakness of the right arm and leg. Examination
revealed hyperreflexia and Babinski sign on the right, and weakness of the right
lower face. The left eye showed ptosis, dilated pupil, and inability to adduct.
Question 1: Hyperreflexia, Babinski sign and weakness of the lower face indicate an
abnormality of:
These are all indications of UMN abnormalities. In contrast, indications of lower motor
neuron involvement would include hyporeflexia and atrophy for the limbs. For the
face, a lower motor neuron lesion involving cranial nerve VII would cause weakness
of both the lower face and the forehead. In this patient the motor abnormalities
suggest a lesion in the corticospinal and corticobulbar fibers on the left side of the
brain, above the pons (where cranial nerve VII exits).

Question 2: The left eye ptosis, dilated pupil, and inability to adduct indicate a lesion in: The
are classic signs of a third nerve palsy.
Question 3: Where could a single lesion be located to cause the clinical presentation in this
patient?
The only place a single lesion could involve corticospinal and corticobulbar fibers, as well as the
third cranial nerve is the ventral midbrain.

Case 14: Queston 1

A 31-year-old woman previously diagnosed with multiple sclerosis complained of double vision.
With attempted gaze to the right, the right eye abducted and the left eye did not move. With
attempted gaze to the left, both eyes moved normally.
Question 1: Where is the lesion?
A lesion in the left MLF interrupts communication between the right abducens nucleus and the
left oculomotor nucleus.
Case 15: Question 1

A 76-year-old man complained of vision problems and bumping into things. Examination
showed loss of vision in both right visual fields.
Question 1: Where could a lesion be located to cause this presentation?
Loss of vision in both right visual fields, called right homonymous hemianopsia, is caused by
a lesion in the left visual pathways caudal to the optic chiasm. The lesion could be in the left
optic tract, left lateral geniculate nucleus, optic radiations in the left parietal lobe, or visual
cortex in the left occipital lobe. Other neurological exam findings may help to localize the
lesion; e.g. an additional finding of loss of sensation (all modalities) on the right side would
help localize the lesion to the left parietal lobe. If there are no motor or sensory deficits, i.e.
the patient's only deficit is right homonymous hemoanopsia, and if there is macular sparing,
then the most likely location of the lesion is the left occipital lobe.