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NBME 21 Answers

nbme21/Block 4/Question#37 (50.6 difficulty score)
A 66-year-old right-handed woman develops the ...
Area labeled 'B' (Internal capsule)🔍,📺

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submitted by hungrybox(1110),
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Fognloliw a oske,tr shit tetpani hda nekwesas fo erh lfte ecaf nda ,doyb so eht stkero muts ehav tcaefdef the gtrhi dsie fo hre ar.inb B asw the nyol hcceoi no het rghti dies fo reh ban.ri

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hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +8  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +22  

submitted by divya(63),
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iyplms alrntine caeuspl hsa ictcrposlnioa dan roicarbcultbo tstrca ssap hrut ,ti eenhc eth /cl emsrisehiap fo obyd and a.fce

If at all tehy atwn to wonk what ilyaeflcpsic psasse urth ci hih(cw si aipcltrcayl E,RNEV) retninoterha lbmi - maltcailrachoot anutgcer,st - oorsia,rbu piortltrcecob imbl - osirant,copcli all noyessr

submitted by zevvyt(33),

A= Caudate ( flanks Lateral Ventricle) B= Internal Capsule, between Thalamus and Lentiform Nucleus( Putamen, GP) C= Thalamus( Flanks 3rd Ventricle D= Temporal Lobe E= Occipital Lobe

submitted by burak(58),
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burak  corticospinal-corticobulbar* +  

submitted by sahusema(153),
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natitsPe ithw an tenilran uclepas okrste mocnmloy veah prue motor sneksewa igfatnecf teh telalaratronc mra, e,gl and eolwr ecf.a ealtrtarColna spytiiasct ro scireedan onet with lepryfxeheair aer aosl teenpr.s