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NBME 21 Answers

nbme21/Block 4/Question#37 (41.8 difficulty score)
A 66-year-old right-handed woman develops the ...
Area labeled 'B' (Internal capsule)🔍
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 +10  upvote downvote
submitted by hungrybox(770),
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lFngoilow a so,krte tsih eittnpa dha skesewan fo erh lfte acef adn yod,b os het okerts tusm heva cffaeedt eht hgirt dies of reh a.rnib B swa eth lnoy iehocc no the ihtgr edis of her ain.rb

ltSli nsfeu?cod eaRd n..o.

hTe yvrnulaot toomr isrfbe ponlaotiiccrs( atcrt) enecdds form teh rmryapi omtor ecrtx,o srcos dsuacse)et( ta eth ydmaulerl mpyrsda,i dan tenh syanpse ta het tarinreo mtoor hron fo the nasipl v.eell

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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 +7  
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 +15  



 +3  upvote downvote
submitted by divya(48),

simply internal capsule has corticospinal and corticobulbar tracts pass thru it, hence the c/l hemiparesis of body and face.

If at all they want to know what specifically passes thru ic (which is practically NEVER), then anterior limb - thalamocortical tracts, genu - corticobulbar, posterior limb - corticospinal, all sensory




 +1  upvote downvote
submitted by zevvyt(16),

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




 +1  upvote downvote
submitted by burak(41),
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tantePi ahd treacnl aficla vrena gedaam 4 letf miaphseesir; and lla teh ismgae ear mfro hte inarb. hreiEt eh sha aemgad ot ocaenrratltal ticaorlc sraea chihw snpreteer eehts uusrrcttse ro n-pnicrcicilalocoarpsttsooi vnree deaamg.

ntnlIear lsauepc roeoristp :libm pctioailConrs ootmr adn oryness s Gnue:neevr iClrtborcboau bAoirtrfne eirs :mlib ciloltmcraaoahT siferb

sderSmony dasecu by CI mdega:a erPu trmoo erss,aiephim ePur ssneory rtes,ok ge-tm,eixhiapAali Dythmaliys-sarCru dnha

burak  corticospinal-corticobulbar* +  



 +0  upvote downvote
submitted by sahusema(117),
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itteansP hwti na tneirnla plaesuc eortsk ylmcnmoo evha preu otmro ksewnase cfeitanfg eht alrcrnatlotae a,mr eg,l dna ewlro ce.af Cranaatotlrle scyatsipti or sdeeranci toen with eeflairpyrxhe rea asol .nsteper