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NBME 22 Answers

nbme22/Block 2/Question#38 (25.9 difficulty score)
Following a stroke, a patient is hoarse and ...
Lateral medulla๐Ÿ”

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 +4  upvote downvote
submitted by moloko270(60),
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this is Wagerlenbl rdenmsyo - oskret cadeus yb tstuionbrco of IACP - os ttash hyw we egt ptmymsso of adgpshia,y shaes,oresn naebst agg xlfere (p. 502 FA)

armymed88  dysphagia from hit of nucleus ambiguus (CN IX/X/XI) Sensation changes due to hit of lateral spinothalamic tract and spinal trigeminal Check out rule of 4s if you haven't already +2  
theecohummer  Yup, lateral meduallary syndrome or Wallenburg Syndrome. Whatever you want to call it. The hemifacial analgesia is from damage to the spinal trigeminal nucleus/tract, and you get the hoarseness from damage to the vagus and the body loss is from the spinal thalamic tract. You can also get Hornerโ€™s syndrome with this. +10  
dr.xx  Lateral medullary syndrome = Wallenberg's syndrome +  

I approached this using the Rule of 4's. Patient has hoarseness, which is a CN 10 problem. CN 10 is located in the medulla. Patient also has decreased pain/temp to her left face and right body, which suggests impairment of spinothalamic tract and sensory to CN 5. These lesions are lateral. Thus, the lesion is at the lateral medulla.

 +1  upvote downvote
submitted by lowyield(11),

just as an aside to what everyone saying, don't forget the 2 exceptions to the rule of 4s:

don't localize w/ CN5 (as seen here) b/c it is big and spans the pons and medulla

don't localize w/ the vestibular signs of CN8 b/c it is big. You CAN however localize with the sensoneural signs of CN8

usmleboy  This is the key to this Q! +1