Question 25.2

Examine the photograph shown below

This image is not from the college paper, but is reproduced without any permission whatsoever from this blog post by A. Lewis. Hang in there.

a) List three likely anatomical sites of lesions that can result in these eye signs

b) Give two associated  clinical  features  that would  help determine  the site of the lesion?

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College Answer

a) List three likely anatomical sites of lesions that can result in these eye signs

Any three anatomical sites of the lesion:
•    Hemispheric lesion (hemispherectomy, massive hemispheric CVA, thalamic CVA)
•    Brainstem   lesion   (brainstem   infarct,   multiple   sclerosis,   brainstem   tumour   or encephalitis)
•    Central cord lesion (syringomyelia, glioma, ependymoma, traumatic)
•    T1 root  lesion  (Pancoast  tumour,  cervical  rib, brachial  plexus  avulsion,  aortic  or subclavian aneurysm
•    Sympathetic  chain  (laryngeal,  pharyngeal,  thyroid  or  parathyroid  surgery,  carotid artery lesion, malignancy at base of skull)

b) Give two associated  clinical  features  that would  help determine  the site of the lesion?

Any two of:
•    distribution of loss of sweating
•    distribution of loss of pain and temperature sensation
•    motor deficit
•    signs of central cord syndrome

•    wasting of small muscles of hand and clubbing
•    cervical LNs
•    Signs of head / neck surgery/trauma
•    Subclavian artery bruit


This question is well revised from Table 10-12 of the most recent edition of Talley and O'Connor, which I have fancifully reinterpreted below:

Causes of Horner's Syndrome
  • Malignancy in the apex of the lung
  • Thyroid cancer
  • Neck trauma or surgery
  • Lower trunk brachial plexus injuries
  • Carotid aneurysm or dissection
  • Cluster headache
  • Brainstem stroke (lateral medullary syndrome)
  • Syringobulbia
  • Syringomyelia

In brief, one could answer the question in the following manner:

a) three likely anatomical sites of lesions:

  • Cortical hemisphere (eg. stroke or tumour)
  • Brainstem (eg. stroke or tumour)
  • Brachial plexus (eg. pancoast tumour)

b) two associated  clinical  features  that would  help determine the site:

  • Contralateral hemiparesis (cortical hemisphere or brainstem infarct)
  • Brainstem nuclei signs (diplopia, vertigo, ataxia)
  • Brachial plexus signs (eg. arm pain or weakness, small muscle wasting)

This could be really over-done. For example, in the cranial nerves section, there is a much longer list:

Localisation of Lesions in Horner's Syndrome

Causes of Horner's

Associated clinical findings:

Cluster headache
  • Transient Horners; comes and goes
  • Severe headache, with rhinorrhoea and excessive tear production
Cortical stroke (hemispheric)
  • weakness, sensory deficit, homonymous hemianopia, diplopia, or ataxia
  • No sensory or motor level (instead, hemiplegia)
Brainstem stroke (lateral medullary syndrome)
  • Contralateral pain and temperature sensory loss
  • Ipsilateral facial sensory loss
  • Ipsilateral nystagmus
  • Dysphagia
  • Ipsilateral V, IX and X cranial nerve lesions
Cavernous sinus pathology
  • An associated sixth nerve palsy
  • Everything in the cavernous sinus may have been taken out (that being upper facial branches of the 5th nerve, the 4th nerve and the 3rd nerve)
  • Dysphagia
  • Nystagmus
  • Pharyngeal and palatal weakness
  • Asymmetric weakness and atrophy of the tongue
  • Sensory loss involving primarily pain and temperature senses in the distribution of the trigeminal nerve
  • Bilateral signs!
  • Dissociated sensory loss: lost pain and temperature sensation, but preserved light touch, vibration and proprioception
  • Cape-like distribution of pain
  • Hand weakness
  • Bowel and bladder incontinence, sexual dysfunction
Spinal injury or infarction
  • Weakness, sensory deficit; with a distinct sensory or motor level
  • No diplopia or hemianopia
Malignancy in the apex of the lung
  • Wasting of small muscles of hand and clubbing
  • Cervical and axillary lymph nodes
Thyroid cancer
  • Suprasternal mass, goitre
  • Thyroid bruit
  • Cervical and supra/infraclavicular lymph nodes
  • Signs of retrosternal goitre, eg. stridor
Neck trauma or surgery
  • Various scars, signs of head / neck surgery/trauma (it wouldn't be subtle)
Lower trunk brachial plexus injuries
  • Motor deficit isolated to the affected arm
  • Weakness in all median and ulnar innervated hand muscles
  • Weakness in radial innervated distal forearm and wrist muscles.
  • Sensory loss in the medial aspect of the arm, forearm and hand
Carotid aneurysm or dissection
  • Sudden onset of the syndrome
  • Pain of the neck or face
  • A carotid bruit which is unilateral


Clinical Examination of the Critically Ill Patient, 3rd edition by L.I.G. Worthley - which can be ordered from our college here.

Clinical Examination: whatever edition, by Talley and O'Connor. Can be acquired any damn where.