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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{SSK}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 45 year old woman with past medical history significant for resected breast cancer presents to the emergency department after suffering a tonic-clonic seizure lasting 3 minutes. She explains that she was walking her dog and then found herself on the ground with several people surrounding her, not knowing what had happened. The patient explains that she had been recovering well after her last chemotherapy cycle, and had no complaints except an annoying area of visual field disturbance she noticed recently. On physical exam, you notice the pattern of visual loss shown below. You order a brain MRI that shows a intracranial lesion with high suspicion for metastasis. Where is the most likely location of the lesion given the patient's symptoms?
|Prompt=A 45-year-old woman with past medical history significant for resected breast cancer presents to the emergency department after suffering a tonic-clonic seizure lasting 3 minutes. She explains that she was walking her dog and then found herself on the ground with several people surrounding her, not knowing what had happened. The patient reports that she had been recovering well since her last chemotherapy cycle, and has had no complaints except some minor visual disturbances. On physical exam, you notice the pattern of visual loss shown below. You order a brain MRI that shows an intracranial lesion with high suspicion for metastasis. Where is the most likely location of the lesion given the patient's findgins?




[[Image:Visual2.gif]]
[[Image:Visual2.gif]]
|Explanation=[[Image:Optic_tracts_with_explanation.jpg|900px]]
|Explanation=[[Image:Optic_tract_with_explanation.jpg|1000px]]
 
 
Internal carotid artery aneurysms, specifically those arising at the origin of the ophthalmic artery and closest to the lateral border of the optic chiasm can cause ipsilateral nasal hemianopia. This is cause by the compression of the lateral part of the optic nerve as it becomes the optic tract.
 
 
Educational objective: internal carotid artery aneurysms can compress the lateral part of the optic nerve causing ipsilateral nasal hemianopia.
 


References:
Cox TA, Corbett JJ, Thompson HS, Kassell NF. Unilateral nasal hemianopia as a sign of intracranial optic nerve compression. Am J Ophthalmol. 1981;92(2):230-2.


Jay WM. Visual field defects. Am Fam Physician. 1981;24(2):138-42.
Superior homonymous [[quadrantanopia]] is characterized by loss of vision in the upper quadrant of the visual field. It usually occurs with contralateral temporal lesions due to the interruption of the left [[Meyer's loop]]. Although classically associated with the [[temporal lobe]], it can also occur with certain lesions to the contralateral [[lateral geniculate nucleus]] (LGN) and certain localized lesions to the contralateral [[visual cortex]]. Superior quadrantanopia is commonly seen in patients with direct temporal lobe trauma, temporal lobe tumors commonly metastatic, or [[MCA]] infarcts.
|AnswerA=[[Image:Visual1.gif]]
|AnswerA=Parietal lobe
|AnswerAExp=Homonymous hemianopia involves loss of vision on one side. It usually occurs due to a lesion to the optic tracts or a PCA stroke although the latter usually has associated macular sparing. This lesion is not seen in patients with carotid artery aneurysms.
|AnswerAExp=Parietal lobe lesions are usually associated with inferior homonymous quadrananopia due to the interruption of the dorsal optic radiations (Baum's loop). Parietal lobe lesions do not usually cause superior quadrantanopia except if large enough to cause a mass effect.
|AnswerB=[[Image:Visual2.gif]]
|AnswerB=Frontal lobe
|AnswerBExp=Right upper quadrantopia is characterized by loss of vision in the right upper quadrant of the visual field. It usually occurs with left temporal lesions due to the interruption of the left Meyer's loop. This pattern is unusual with carotid artery aneurysms.
|AnswerBExp=Frontal lobe lesions usually cause visual field defects by compression the optic tracts or the optic nerve causing unilateral anopia. Frontal lesions can also affect the frontal eye fields involved in eye movements, such as voluntary saccades and pursuit. Frontal lobe lesions do not usually cause quadrantanopia.
|AnswerC=[[Image:Visual3.gif]]
|AnswerC=Temporal lobe
|AnswerCExp=Left nasal hemianopia usually occurs with lesions of the internal carotid artery (internal carotid thrombosis or anyrysms) at the origin of the ophthalmic artery. The lesion is usually located laterally to the optic chiasm interrupting part of the optic nerve as it becomes the optic tract. Our patient would best fit this pattern of visual field loss.
|AnswerCExp=Temporal lobe lesions usually present with visual field disturbances similar to our patient. Superior quadrantanopia is seen in temporal lesions due to the interruption of the Meyer's loop
|AnswerD=[[Image:Visual4.gif]]
|AnswerD=Occipital lobe
|AnswerDExp=This lesion portrays bitemporal hemianopia usually seen in large prolactinomas that compress the optic chiasm. It is unusual in cases with internal carotid artery lesions.
|AnswerDExp=Occipital lobe lesions usually cause homonymous hemianopia, although cases of quadrantanopia are also encountered. However, superior quadrantanopia is classically seen in temporal lobe lesions.
|AnswerE=[[Image:Visual5.gif]]
|AnswerE=Cerebellum
|AnswerEExp=Right lower quadrantopia is characterized by loss of vision in the right lower quadrant of the visual field. It usually occurs with left parietal lesions due to the interruption of the left dorsal optic radiations.
|AnswerEExp=The cerebellar lesions are usually not associated with visual field defects.
|EducationalObjectives=Superior quadrantanopia is characteristic of temporal lesions due to the interruption of the Meyer's loop.
|References=Jacobson DM. The localizing value of a quadrantanopia. Arch Neurol. 1997;54(4):401-4.
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Upper quadrantopia, Temporal lesions, Visual field defects,  
|WBRKeyword=Upper quadrantopia, Temporal lesions, Visual field defects, Quadrantanopia, Scotoma,
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 01:03, 28 October 2020
Author [[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Head and Neck, SubCategory::Neurology
Prompt [[Prompt::A 45-year-old woman with past medical history significant for resected breast cancer presents to the emergency department after suffering a tonic-clonic seizure lasting 3 minutes. She explains that she was walking her dog and then found herself on the ground with several people surrounding her, not knowing what had happened. The patient reports that she had been recovering well since her last chemotherapy cycle, and has had no complaints except some minor visual disturbances. On physical exam, you notice the pattern of visual loss shown below. You order a brain MRI that shows an intracranial lesion with high suspicion for metastasis. Where is the most likely location of the lesion given the patient's findgins?


]]

Answer A AnswerA::Parietal lobe
Answer A Explanation [[AnswerAExp::Parietal lobe lesions are usually associated with inferior homonymous quadrananopia due to the interruption of the dorsal optic radiations (Baum's loop). Parietal lobe lesions do not usually cause superior quadrantanopia except if large enough to cause a mass effect.]]
Answer B AnswerB::Frontal lobe
Answer B Explanation [[AnswerBExp::Frontal lobe lesions usually cause visual field defects by compression the optic tracts or the optic nerve causing unilateral anopia. Frontal lesions can also affect the frontal eye fields involved in eye movements, such as voluntary saccades and pursuit. Frontal lobe lesions do not usually cause quadrantanopia.]]
Answer C AnswerC::Temporal lobe
Answer C Explanation AnswerCExp::Temporal lobe lesions usually present with visual field disturbances similar to our patient. Superior quadrantanopia is seen in temporal lesions due to the interruption of the Meyer's loop
Answer D AnswerD::Occipital lobe
Answer D Explanation AnswerDExp::Occipital lobe lesions usually cause homonymous hemianopia, although cases of quadrantanopia are also encountered. However, superior quadrantanopia is classically seen in temporal lobe lesions.
Answer E AnswerE::Cerebellum
Answer E Explanation AnswerEExp::The cerebellar lesions are usually not associated with visual field defects.
Right Answer RightAnswer::C
Explanation [[Explanation::


Superior homonymous quadrantanopia is characterized by loss of vision in the upper quadrant of the visual field. It usually occurs with contralateral temporal lesions due to the interruption of the left Meyer's loop. Although classically associated with the temporal lobe, it can also occur with certain lesions to the contralateral lateral geniculate nucleus (LGN) and certain localized lesions to the contralateral visual cortex. Superior quadrantanopia is commonly seen in patients with direct temporal lobe trauma, temporal lobe tumors commonly metastatic, or MCA infarcts.
Educational Objective: Superior quadrantanopia is characteristic of temporal lesions due to the interruption of the Meyer's loop.
References: Jacobson DM. The localizing value of a quadrantanopia. Arch Neurol. 1997;54(4):401-4.]]

Approved Approved::Yes
Keyword WBRKeyword::Upper quadrantopia, WBRKeyword::Temporal lesions, WBRKeyword::Visual field defects, WBRKeyword::Quadrantanopia, WBRKeyword::Scotoma
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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