Info

(E)

Superior alternating hemiplegia

41. In axial MRI which of the following structures is an important landmark that separates the third ventricle (rostral to this point) from the quadrigeminal cistern (caudal to this point)?

o (A) Lamina terminalis o (B) Habenular nucleus o (C) Massa intermedia o (D) Pulvinar o (E) Superior colliculus

42. A 77-year-old woman presents with deficits that suggest a lesion involving long tracts and a cranial nerve. CT shows an infarct in the region served by the penetrating branches of the basilar bifurcation. Which of the following structures is most likely located in this vascular territory?

o (A) Abducens nerve o (B) Anterolateral system o (C) Corticospinal fibers in pyramid o (D) Medial lemniscus o (E) Red nucleus

Questions 43 through 46 are based on thefollowing patient.

A 69-year-old man is brought to the emergency department with the complaint of a sudden loss of sensation. The history reveals that the man is overweight, hypertensive, and does not regularly take medication. When the man speaks his voice is gravely and hoarse. The examination further reveals a loss of pain and thermal sensations on the right side of his body and on the left side of his face. CT shows an infarcted area in the medulla.

43. Damage to which of the following structures would most likely explain the man's hoarse, gravely voice?

o (A) Facial nucleus o (B) Gracile nucleus o (C) Hypoglossal nucleus o (D) Nucleus ambiguus o (E) Spinal trigeminal nucleus

44. Injury to which of the following structures in this man is most specifically related to the loss of pain and thermal sensations on the body below the neck?

o (A) Anterolateral system o (B) Cuneate fasciculus o (C) Gracile fasciculus o (D) Medial lemniscus o (E) Spinal trigeminal tract

45. Damage to which of the following structures would most specifically explain the loss of pain and thermal sensations on the man's face?

o (A) Anterolateral system o (B) Medial lemniscus o (C) Medial longitudinal fasciculus o (D) Solitary tract o (E) Spinal trigeminal tract

46. The CT shows an infarcted area in the medulla in this man. Based on the deficits described, and the corresponding structures involved, which of the following vessels is most likely occluded? o (A) Anterior spinal artery o (B) Posterior spinal artery o (C) Posterior inferior cerebellar artery o (D) Anterior inferior cerebellar artery o (E) Penetrating branches of the vertebral artery

47. A 77-year-old man presents with an ataxic gait. There are no other deficits. CT shows an infarcted area in the medulla in the territory served by the posterior inferior cerebellar artery. Damage to which of the following structures would most likely explain the symptoms experienced by this man?

o (A) Anterolateral system o (B) Corticospinal tract o (C) Nucleus ambiguus o (D) Restiform body o (E) Vestibular nuclei

48. Which of the following cranial nerve nuclei is located in the anterior (ventral or inferior) and medial portion of the periaqueductal grey at the cross-sectional level of the superior colliculus?

o (A) Abducens o (B) Mesencephalic o (C) Oculomotor o (D) Trigeminal motor o (E) Trochlear

49. A 53-year-old woman presents with motor deficits that the examining neurologist describes as a superior alternating hemiplegia. Which of the following cranial nerve roots is most likely involved in this lesion?

o (A) Abducens o (B) Hypoglossal o (C) Oculomotor o (D) Trigeminal o (E) Trochlear

50. An 82-year-old woman presents to the emergency department with difficulty swallowing (dysphagia). Which of the following nuclei of the medulla contain motor neurons that innervate muscles involved in swallowing?

o (A) Dorsal motor vagal o (B) Hypoglossal o (C) Inferior salivatory o (D) Medial vestibular o (E) Nucleus ambiguus

Questions 51 through 53 are based on the following patient.

A 73-year-old man is brought to the emergency department after losing consciousness at his home. CT shows a hemorrhage into the right hemisphere. The man regains consciousness, but is not fully alert. After 3—4 days the man begins to rapidly deteriorate: his pupils are large (dilated) and respond slowly to light, eye movement becomes restricted, there is weakness in the extremities on the left side, and the man becomes comatose. Repeat CT shows an uncal herniation.

51. Based on its location, which of the following parts of the brainstem is most likely to be directly affected by uncal herniation, especially in the early stages?

o (A) Diencephalon/thalamus o (B) Mesencephalon/midbrain o (C) Myelencephalon/medulla o (D) Pons and cerebellum o (E) Pons only

52. Damage to corticospinal fibers in which of the following locations would most likely explain the weakness in his extremities?

o (A) Left basilar pons o (B) Left crus cerebri o (C) Right basilar pons o (D) Right crus cerebri o (E) Right posterior limb of the internal capsule

53. The dilated, and slowly responsive, pupils in this man are most likely explained by damage to fibers in which of the following?

o (A) Abducens nerve o (B) Corticonuclear fibers in the crus o (C) Oculomotor nerve o (D) Optic nerve o (E) Sympathetic fibers on cerebral vessels

54. The sagittal MRI of a 26-year-old man shows a dark shadow in the midbrain tegmentum on the midline at the cross-sectional level of the inferior colliculus. Which of the following structures does this dark area represent?

o (A) Central portions of the red nucleus o (B) Compact and reticular parts of the substantia nigra o (C) Decussation of the superior cerebellar peduncle o (D) Decussation of trigeminothalamic fibers o (E) Motor (pyramidal) decussation

55. The CT of a 39-year-old man with untreated hypertension shows a small hemorrhage in the brainstem. This lesion encompasses the brachium of the inferior colliculus and the brain substance immediately internal to this structure. Which of the following structures is also most likely involved in this lesion?

o (A) Anterolateral system o (B) Central tegmental tract o (C) Corticospinal fibers o (D) Mesencephalic tract o (E) Oculomotor nerve

56. A 69-year-old man complains of difficulty walking. The examination reveals no weakness, but does reveal a loss of discriminative touch and vibratory sense on the left lower extremity. MRI shows a small infarcted area in the midbrain. Which of the following structures is most likely involved in the infarcted area?

o (A) Anterolateral system o (B) Corticospinal fibers o (C) Lateral part of the medial lemniscus o (D) Medial part of the medial lemniscus o (E) Rubrospinal fibers

57. Which of the following nuclei containing visceromotor (autonomic) cell bodies is located immediately inferior to the medial vestibular nucleus, medial to the solitary tract and nucleus, and has axons that exit the brainstem on the glossopharyngeal nerve?

o (A) Dorsal motor nucleus o (B) Edinger-Westphal nucleus o (C) Inferior salivatory nucleus o (D) Intermediolateral cell column o (E) Superior salivatory nucleus

58. An 81-year-old woman is brought to the emergency department by her adult grandson. He explains that during dinner she slumped off of her chair, did not lose consciousness, but had trouble speaking. The examination reveals weakness of the upper and lower extremities on the left and deviation of the tongue to the right on protrusion. Which of the following most specifically describes this deficit in this elderly patient?

o (A) Alternating hemianesthesia o (B) Hemihypesthesia o (C) Inferior alternating hemiplegia o (D) Middle alternating hemiplegia o (E) Superior alternating hemiplegia

Questions 59 and 60 are based on thefollowing patient.

A 79-year-old woman is brought to the emergency department after a fall in her home from which she was unable to get up. The examination reveals a deviation of the tongue to the left on protrusion, a pronounced weakness of the right upper and lower extremities, and a loss of position and vibratory sense and discriminative touch on the right side of the body below the neck. CT shows an infarcted area in the medulla.

59. Which of the following represents the best localizing sign in this patient?

o (A) Deviation of the tongue o (B) Motor loss on lower extremity o (C) Motor loss on upper extremity o (D) Sensory loss on lower extremity o (E) Sensory loss on upper extremity

Damage to which of the following tracts or fiber bundles would most likely give rise to the sensory deficits experienced by this pa-

tient?

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