Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #141

Date of Consultation: 2-25-1998


This 91-year-old hypertensive white female awoke on 2-24-98 with right-sided weakness and slurred speech.  She came to the emergency room, where her extraocular movements were intact and a mild to moderate right hemiparesis was noted.  She was admitted to the hospital.

The next morning (2-25-98), the patient’s right hemiparesis was more severe, and she noticed horizontal (side-by-side) diplopia with right gaze.  Because of these symptoms neurological consultation was requested. 


Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  Visual acuity, visual field, and funduscopic examinations were normal.  External ocular movement testing revealed intact and normal vertical eye movements.  With right gaze, the right eye abducted fully, but the left eye did not move past midline toward the right.  With left horizontal gaze, neither eye moved past the midline toward the left.  Weakness of the right lower facial muscles was present with grimacing.  However, the patient was able to elevate her eyebrows and close her eyes tightly on both sides.  A moderate dysarthria was present.

Motor System:  No evidence of focal muscular atrophy or fasciculations was present.  Muscle tone was normal in all four limbs.  Muscle power was normal on the left side.  On the right side, there was a moderate to marked (2-3/5) weakness of all muscle groups. 

Reflexes:  Deep tendon reflexes were slightly brisker in the right upper and lower limbs than on the left.  Plantar reflexes were flexor on the left and extensor on the right. 

Sensory System:  Intact. 

Cerebellar Function:  Intact.

Gait and Stance:  Not tested.


1.  Is this patient’s facial weakness of the lower motor neuron or upper motor neuron type?

2.  Indicate the specific structures involved by the pathologic process for each of the signs or symptoms listed below.            

a.  Right UMN facial palsy and right hemiparesis:  
b.  Inability to move either eye past midline when attempting to look horizontally to the left:  
c.  Inability to move the left eye past midline when looking horizontally to the right: 

3.  Indicate the precise anatomical location of the lesion, including the side of involvement.      

4.  This patient’s eye movement findings represent a classic neuro-ophthalmologic syndrome.  What is the name of this syndrome?  Name the components of this syndrome.      

5.  In general, what type of pathologic process is involved in this case?    

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

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