Localization And Neurologic Examination

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USMLE Step 2 CK › Localization And Neurologic Examination

Questions 1 - 10
1

Which of the following is the most likely location of the lesion?

Right spinal cord at C5

Right pons

Left thalamus

Left medial medulla

Explanation

This patient's findings are classic for Brown-Séquard syndrome (spinal cord hemisection). The lesion is on the right side at the C5 level, causing ipsilateral (right-sided) motor weakness (corticospinal tract) and loss of proprioception/vibration (dorsal columns), and contralateral (left-sided) loss of pain and temperature (spinothalamic tract, which decussates at the level of the cord).

2

Which of the following is the most likely location of the lesion responsible for this patient's symptoms?

Right internal capsule

Left lateral medulla

Right medial pons

Left cerebral peduncle of the midbrain

Explanation

This patient presents with a left oculomotor nerve (CN III) palsy (ptosis, 'down and out' gaze, mydriasis) and contralateral (right-sided) hemiparesis. This constellation of findings is characteristic of Weber syndrome, which is caused by a lesion in the left cerebral peduncle of the midbrain, affecting the exiting CN III fascicles and the adjacent corticospinal tract.

3

Where is the lesion most likely located?

Left frontal lobe

Right parietal lobe

Left temporal lobe

Right occipital lobe

Explanation

This patient has fluent (Wernicke's) aphasia, characterized by impaired comprehension and fluent but meaningless speech. This localizes to Wernicke's area in the dominant (usually left) superior temporal gyrus. The associated right superior quadrantanopia ('pie in the sky') is caused by involvement of the lower optic radiation (Meyer's loop), which also passes through the temporal lobe.

4

Which of the following locations best explains this patient's presentation?

Left midbrain

Right lateral medulla

Left internal capsule

Right cerebellar hemisphere

Explanation

This is a classic presentation of Wallenberg syndrome, or lateral medullary syndrome, typically caused by an occlusion of the posterior inferior cerebellar artery (PICA). The lesion in the right lateral medulla affects the spinal trigeminal nucleus (ipsilateral face sensation), spinothalamic tract (contralateral body sensation), nucleus ambiguus (dysphagia, hoarseness), inferior cerebellar peduncle (ipsilateral ataxia), and descending sympathetic fibers (ipsilateral Horner syndrome).

5

A lesion in which of the following locations would best explain her symptoms?

Left trigeminal nerve

Right internal capsule

Left facial nerve nucleus or nerve

Right motor cortex

Explanation

This patient has a left-sided lower motor neuron (LMN) facial palsy, involving both the upper (forehead) and lower face. This localizes the lesion to the facial nerve nucleus in the pons or the peripheral facial nerve (CN VII) itself after it exits the brainstem. In contrast, an upper motor neuron (UMN) lesion, such as in the motor cortex or internal capsule, would spare the forehead due to bilateral cortical innervation of the upper face.

6

What is the most likely location of this patient's lesion?

Corpus callosum

Right parietal lobe

Left frontal lobe

Right temporal lobe

Explanation

This patient is demonstrating contralateral hemispatial neglect, a condition where she is unaware of or fails to attend to stimuli on the left side of her body and space. This is a classic sign of a lesion in the non-dominant (usually right) parietal lobe, which is responsible for spatial awareness and attention.

7

This patient's signs are best explained by a lesion in which of the following structures?

Left abducens nucleus (CN VI)

Right oculomotor nerve (CN III)

Right medial longitudinal fasciculus (MLF)

Optic chiasm

Explanation

This patient has internuclear ophthalmoplegia (INO) affecting the right eye's adduction. INO is caused by a lesion in the medial longitudinal fasciculus (MLF), a white matter tract that coordinates horizontal eye movements by connecting the contralateral abducens nucleus (CN VI) with the ipsilateral oculomotor nucleus (CN III). A lesion in the right MLF prevents the right medial rectus from firing when the left eye abducts, causing impaired adduction of the right eye on leftward gaze. The nystagmus in the abducting eye is also characteristic. Convergence is spared as it does not rely on the MLF.

8

Where is the infarct most likely located?

Left inferior frontal gyrus

Right medial temporal lobe

Right superior temporal gyrus

Left angular gyrus

Explanation

The patient's clinical presentation is consistent with Broca's aphasia, an expressive aphasia characterized by non-fluent, agrammatical speech with intact comprehension. This localizes the lesion to Broca's area, which is located in the inferior frontal gyrus of the dominant (usually left) hemisphere. The proximity of this area to the primary motor cortex explains the associated contralateral face and arm weakness.

9

Which of the following locations best explains this constellation of findings?

Left cavernous sinus

Left midbrain

Brainstem tegmentum

Left orbit

Explanation

This patient has multiple cranial neuropathies affecting the left eye. The ptosis and 'down and out' gaze indicate a CN III palsy. The numbness over the forehead and cheek corresponds to the V1 and V2 divisions of the trigeminal nerve. The cavernous sinus is a unique anatomical space through which CN III, IV, VI, V1, and V2 travel. A single lesion here, such as from pituitary apoplexy or thrombosis, can affect all these nerves simultaneously.

10

Where is the lesion most likely located?

Left parietal lobe

Left basal ganglia

Right cerebellar hemisphere

Cervical spinal cord

Explanation

The patient's signs of ipsilateral limb ataxia (dysmetria, intention tremor) and truncal ataxia (falling to the right) are classic for a lesion in the right cerebellar hemisphere. The cerebellum is responsible for coordinating voluntary movements, posture, balance, and motor learning. Cerebellar lesions cause deficits on the same side of the body.

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