Case 169

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #169

Date of Admission: 12-15-1988

HISTORY OF PRESENT ILLNESS:

This 82-year-old right-handed retired white male was admitted to the hospital for the acute onset of left hemiparesis. His general health was quite good except for longstanding hypertension. On the morning of admission, the patient awoke, feeling well without any problems. While shaving, he noticed the sudden onset of weakness in the left upper limb, as well as tingling of the left hand and left face. Within several minutes, he could no longer stand because of left lower limb weakness, and he had to sit down. He was transported to the emergency room, and, within the next hour, his symptoms seemed to improve and stabilize. Approximately 5 hours after the onset of symptoms, he stated that his left side was only minimally weak and the numbness was completely gone. He denied any other prior neurologic problems or similar symptoms.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Cranial nerve examination was entirely normal, except for very mild weakness of the left lower facial muscles and very mild decreased appreciation of pinprick and light touch in the left lower face.

Motor System: There were no areas of focal or generalized muscular atrophy. There were no fasciculations. Muscle tone was normal in all four limbs. Muscle power was normal (5/5) on the right side and mildly weak (4+/5) in the left upper and lower limbs.

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

Sensory System: The patient perceived all sensory modalities, including cortical sensations, normally on the right. On the left side, there was a very mild decreased appreciation to pinprick, light touch, and joint position sense, with the left lower limb being more involved than the left upper limb.

Cerebellar Function: Cerebellar tests were performed normally on the right. On the left side, finger-to-nose and heel-to-shin testing revealed an intention tremor and dysmetria. Rapid alternating movements were also performed dysrhythmically.

Gait and Stance: Not tested.

Questions

1. Considering the patient’s history and physical examination, how precisely can the neurologic lesion be localized in this case?

2. Does this patient’s left facial weakness indicate a lower motor neuron or upper motor neuron process?

3. Indicate the structures involved by the pathologic process to produce this patient’s mild left-sided hemiparesis, hyperreflexia, extensor plantar reflex, and left UMN facial weakness. If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

4. Indicate the structures involved by the pathologic process to produce this patient’s mild left-sided numbness and tingling of the face, arm, and leg. If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

5. Indicate the structures involved by the pathologic process to produce this patient’s left-sided findings on cerebellar examination (i.e., impaired finger-to-nose, heel-to-shin, dysdiadochokinesia). If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

6. Discuss the “localization of the lesion” in this case.

7. The findings in this case represent a classic neurologic syndrome. What is the name of that syndrome, and what is its usual cause?

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

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

Answers