Case 20

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #20

Date of Consultation: 11-16-1987

HISTORY OF PRESENT ILLNESS:

This 73-year-old right-handed white female was admitted to the hospital because of sudden onset of right-sided numbness and weakness. The patient was sitting and sewing, when she suddenly noticed that she could not use the right upper limb well. She got up and walked to the garage and informed her husband that she was having this difficulty. She then walked back to the telephone and called one of her children to inform her of the symptoms. By the time she finished with the telephone conversation, she had developed some weakness of the right lower limb and was having some difficulty walking and supporting her weight. She noted no other neurologic signs or symptoms at that time and was admitted to the hospital for further evaluation and observation. In the first 3 days of hospitalization, her right-sided weakness resolved completely. Neurological consultation was obtained at this point. The patient had a longstanding history of hypertension and diabetes.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Cranial nerve examination was normal except for the following. Sensory testing of the face revealed a marked loss of sensation on the right side, including light touch, pinprick, and temperature. Sensory testing on the left side of the face was normal. There was no facial weakness present.

Motor System: There were no areas of focal muscular atrophy. There were no fasciculations. Muscle tone was normal. Muscle power was normal bilaterally. There were no involuntary movements, although the patient tended to hold the right upper limb in very peculiar positions. These positions appeared to be very uncomfortable, and, when she would look down and notice them, she would promptly correct the position of the limb. With the arms outstretched and the eyes closed, the patient exhibited a continuous, irregular movement of the fingers of the right hand.

Reflexes: Deep tendon reflexes were equal and symmetric. Plantar reflexes were flexor bilaterally.

Sensory System: Sensory examination was entirely normal on the left side. On the right side, there was an absence of appreciation of pinprick, light touch, vibration, and joint position sense in both the upper and the lower limbs.

Cerebellar Function: Intact.

Gait and Stance: Not tested.

Questions

1. What is the localizing significance of the fact that essentially all sensory modalities are involved in this case, as opposed to the sparing of one or more of the modalities?

2. What is the meaning or significance of this patient holding her right upper limb in very unusual, somewhat uncomfortable positions, and the irregular, constant movement of the right fingers when the eyes are closed?

3. Indicate the possible anatomical locations of the pathologic process in this case.

4. Indicate the specific structures possibly involved by the pathologic process.

5. This patient’s signs and symptoms constitute a classic neurologic syndrome. What is the name of that syndrome, and what is its usual cause?

6. In general, what type of pathologic process do you think is involved in this case?

7. What diagnostic procedure(s) would you undertake at this point?

Answers