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nbme 1 q4
4. 14. A 67-year-old woman is brought to the emergency department because of the inability to move the right side of her body since awakening this morning. She has type 2 diabetes mellitus. Her blood pressure is 170/95 mm Hg. Examination shows dysarthric speech, but language function is normal. Cranial nerves are intact except for moderate weakness of the right lower face. She is unable to move the right upper or lower extremities. Sensation is intact. There is hyperreflexia of the right upper and lower extremities, and Babinski's sign is present on the right. Which of the following is the most likely location of the lesion?
A) Basal ganglia
B) Brain stem
C) Cerebellum
D) Cervical nerve root
E) Frontoparietal cortex
F) Internal capsule
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B?
I am educated guessing...
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A) Basal ganglia - My other guess?
B) Brain stem - My guess//
C) Cerebellum - Ataxia, N/V, gait disturbances are key..
D) Cervical nerve root - Will produce specific Nerve root symptoms rather than hemiplegia
E) Frontoparietal cortex - this would produce Brocas/Wernickes Presentation
F) Internal capsule - Cant be this - this produces pure motor ymptoms
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Internal capsule - Cant be this - this produces pure motor ymptoms
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A. Basal ganglia lesions can produce (depending on where the lesion is) resting tremor (which improves with purposeful movement), chorea, athetosis, and dystonia.
B. Brain Stem Stroke Syndromes
The sine qua non of VA-BA ( PICA-AICA ) stroke syndromes is sensory or motor abnormalities that are bilateral or crossed coupled with unilateral or bilateral cranial nerve deficits scattered from cranial nerves (CNs) CNIII-CNXII. Other common findings include abrupt onset of headache, dizziness, impaired awareness, diplopia, nystagmus, strabismus, nausea, emesis, incoordination, vertigo, dysarthria, dysphagia, other bulbar or pseudobulbar signs, homonymous hemianopsia, blindness, visual agnosia, or pyramidal
tract signs.
C. The cerebellum helps coordinate movement, thus people with cerebella damage have signs such as ataxia, broadbased gait, dysmetria, intention tremor, difficulty with rapid alternating movements, and nystagumus
D. Cervical root
Klumpke paralysis: this results from excessive traction on the arm during delivery. It
results from injury to the 7th and 8th cervical nerve and 1st thoracic nerve. And there is
also an ipsilateral horner syndrome (miosis and ptosis).
Vs. erb-Duchene palsy: it involves the 5th and 6th cervical nerves. Clinically it presents
with absent moro reflex and intact grasp relex of the affected arm. Patients present with
a characteristic position, which consists of adduction and internal rotation of the arm with
pronation of the forearm.
Vs. facial nerve palsy: results from pressure over the facial nerve in utero, from efforts
during labor or from forceps delivery. Classic features of facial paralysis are present,
most apparent when the infant cries.
Vs. phrenic nerve injury: involves the 3rd, 4th, and 5th cervical nerves. It presents as
diaphragmatic paralysis and upper brachial palsy.
E. Denial of illness and typically is seen in patients :with right frontoparietal lesions, resulting in left hemiplegia that the patient denies.
Lacunar strokes:
The MC site for a lacunar infarct is the posterior internal capsule, producing a pure motor
stroke (the posterior internal capsule carries corticospinal and corticobulbar motor fibers). HTN and DM are 2 major risk factors
Pure motor hemi paresis: due to lacunar infarction in the posterior limb of the internal
capsule. You see unilateral motor deficit (face,arm, and to a lesser extent, leg); mild dysarthric speech ; no sensory, visual or higher cortical dysfunction.
The Babinski™s sign can indicate upper motor neuron lesion constituting damage to the corticospinal tract
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FFFFFF IS CORRECT AND GOOD LEARNING
A. Basal ganglia lesions can produce (depending on where the lesion is) resting tremor (which improves with purposeful movement), chorea, athetosis, and dystonia.
B. Brain Stem Stroke Syndromes
The sine qua non of VA-BA ( PICA-AICA ) stroke syndromes is sensory or motor abnormalities that are bilateral or crossed coupled with unilateral or bilateral cranial nerve deficits scattered from cranial nerves (CNs) CNIII-CNXII. Other common findings include abrupt onset of headache, dizziness, impaired awareness, diplopia, nystagmus, strabismus, nausea, emesis, incoordination, vertigo, dysarthria, dysphagia, other bulbar or pseudobulbar signs, homonymous hemianopsia, blindness, visual agnosia, or pyramidal
tract signs.
C. The cerebellum helps coordinate movement, thus people with cerebella damage have signs such as ataxia, broadbased gait, dysmetria, intention tremor, difficulty with rapid alternating movements, and nystagumus
D. Cervical root
Klumpke paralysis: this results from excessive traction on the arm during delivery. It
results from injury to the 7th and 8th cervical nerve and 1st thoracic nerve. And there is
also an ipsilateral horner syndrome (miosis and ptosis).
Vs. erb-Duchene palsy: it involves the 5th and 6th cervical nerves. Clinically it presents
with absent moro reflex and intact grasp relex of the affected arm. Patients present with
a characteristic position, which consists of adduction and internal rotation of the arm with
pronation of the forearm.
Vs. facial nerve palsy: results from pressure over the facial nerve in utero, from efforts
during labor or from forceps delivery. Classic features of facial paralysis are present,
most apparent when the infant cries.
Vs. phrenic nerve injury: involves the 3rd, 4th, and 5th cervical nerves. It presents as
diaphragmatic paralysis and upper brachial palsy.
E. Denial of illness and typically is seen in patients :with right frontoparietal lesions, resulting in left hemiplegia that the patient denies.
Lacunar strokes:
The MC site for a lacunar infarct is the posterior internal capsule, producing a pure motor
stroke (the posterior internal capsule carries corticospinal and corticobulbar motor fibers). HTN and DM are 2 major risk factors
Pure motor hemi paresis: due to lacunar infarction in the posterior limb of the internal
capsule. You see unilateral motor deficit (face,arm, and to a lesser extent, leg); mild dysarthric speech ; no
lacunar stroke. HAS 5 CLASSIC SYNDROMES. 1.pure motor stroke 2.pure sensory
stroke 3.ataxia hemiparesis 4.Dysarthria clumsy hand syn and 5.Mixed
> sensorimortor stroke
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LACUNAR STROKE
¢Pure motor stroke/hemiparesis; usually in the posterior limb of the internal capsule, which carries the descending corticospinal and corticobulbar tracts, or the basis pontis
- Hemiparesis or hemiplegia is noted, with hyperreflexia and Babinski sign; no involvement of any other system is observed.
¢Ataxic hemiparesis - sites of infarction are the posterior limb of the internal capsule, basis pontis, and corona radiata
A combination of pyramidal signs (eg, hemiparesis, hyperreflexia, Babinski sign) and cerebellar ataxia on the same side of the body. Lower extremities are typically more involved than are upper extremities. Nystagmus may be present.
¢Dysarthria/clumsy hand The lesion is in the pons. -
Unilateral lower facial weakness with dysarthric speech is noted. On protrusion, the tongue may deviate to the side of facial weakness. A mild, ipsilateral hemiparesis usually is noted, but the arm is ataxic. Ipsilateral hyperreflexia and Babinski sign may be observed.
¢Pure sensory stroke - ¢Pure sensory stroke
â—¦This lacunar syndrome consists of persistent or transient numbness and/or tingling on one side of the body (eg, face, arm, leg, trunk).
â—¦Occasionally, patients complain of pain or burning, or of another unpleasant sensation. The infarct is usually in the thalamus Unilateral sensory loss is observed. Although the patient may complain of weakness, no weakness is found on examination.
Mixed sensory stroke ;infarct is usually in the thalamus and adjacent posterior internal capsule (seemingly,
A combination of pyramidal signs (eg, hemiparesis, hyperreflexia, Babinski sign) is noted, as is sensory loss in the absence of any cortical signs.
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