A 63-year-old man complains of trouble swallowing and hoarseness

Discussion in 'Plab 1 and 2 forum' started by Neha Gupta, Jun 5, 2013.

  1. Neha Gupta

    Neha Gupta Active Member

    A 63-year-old man complains of trouble swallowing and hoarseness. On physical exam, he is noted to have ptosis and a constricted pupil on the left, and a diminished gag reflex. Neurological examination shows decreased pain and temperature sensation on the left side of his face and on the right side of his body. Which of the following vessels is most likely occluded?

    a) Anterior inferior cerebellar artery (AICA)

    b) Anterior spinal artery

    c) Middle cerebral artery (MCA)

    d) Posterior cerebral artery (PCA)

    e) Posterior inferior cerebellar artery (PICA
  2. Neha Gupta

    Neha Gupta Active Member

    E is the answer
    The signs and symptoms in this patient are consistent with occlusion of the posterior inferior cerebellar artery (PICA). PICA is a branch of the vertebral artery (which is itself a branch of the subclavian artery). Occlusion of PICA causes a lateral medullary syndrome characterized by deficits in pain and temperature sensation over the contralateral body (spinothalamic tract dysfunction); ipsilateral dysphagia, hoarseness, and diminished gag reflex (interruption of the vagal and glossopharyngeal pathways); vertigo, diplopia, nystagmus, and vomiting (vestibular dysfunction); ipsilateral Horner\'s syndrome (disruption of descending sympathetic fibers); and ipsilateral loss of pain and temperature sensation of the face (lesion of the spinal tract and nucleus of the trigeminal nerve). AICA (choice A) is a branch of the basilar artery. Occlusion of this artery produces a lateral inferior pontine syndrome, which is characterized by ipsilateral facial paralysis due to a lesion of the facial nucleus, ipsilateral cochlear nucleus damage leading to sensorineural deafness, vestibular involvement leading to nystagmus, and spinal trigeminal involvement leading to ipsilateral pain and temperature loss of the face. Also, there is ipsilateral dystaxia due to damage to the middle and inferior cerebellar peduncles. The anterior spinal artery (choice B) is a branch of the vertebral artery. Occlusion produces the medial medullary syndrome, characterized by contralateral hemiparesis of the lower extremities and trunk due to corticospinal tract involvement. Medial lemniscus involvement leads to diminished proprioception on the contralateral side, and ipsilateral paralysis of the tongue ensues from damage to the hypoglossal nucleus. The MCA (choice C) is a terminal branch of the internal carotid artery. Occlusion results in contralateral face and arm paralysis and sensory loss. Aphasia is produced if the dominant hemisphere is affected, left-sided neglect ensues if the right parietal lobe is affected, and quadrantanopsia or homonymous hemianopsia occur

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