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A.
B.
C.
D.
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.
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.
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.
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?
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?
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:
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):
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
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:
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.
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.
lesions.
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.
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.
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.