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 +4  (nbme23#41)

She has many cardiovascular risk factors and likely suffered a stroke of the basilar artery causing locked in syndrome. According to FA this can cause a lesion at the pons, medullar, or lower midbrain -- however anatomically the basilar artery runs right on top of the pons so proximity most likely makes it the right answer.

mousie  The Boards and Beyond video of SC strokes was really helpful at explaining this if you are a video kind of person!
yotsubato  What pushed me away from pons was "dysarthric speech" which implied she still could speak to some degree.... which made me pick medulla.
mimi21  I think FA may be misleading. Primarily it will effect the Pons because that is where the majority of the Basilar Artery is located. and I guess it could effect the other locations? but everywhere I have looked Locked-in syndrome is an issue with the Pons. But someone please continue to clarify, cause I was a bit tripped up at first with this question
cbrodo  Although FA says it can be pons, medulla, or lower midbrain, "locked-in" syndrome generally arises from BL pons lesions. Another way you can rule out medulla and midbrain in this question is the ocular movement findings. Since the patient has impaired horizontal gaze BL, you can conclude that the Abducens nuclei are involved on both sides. The abducens nuclei are located in the pons.
gh889  USMLE secrets also states that it is most commonly in the pons Bates states that locked-in syndrome preserves consciousness but these patients have limited speaking ability

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