Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #17

Date of Consultation: 5-30-1980


This 37-year-old white female school teacher was referred for neurological consultation to evaluate multiple neurologic symptoms.  Approximately 2 to 3 weeks prior to consultation, the patient noted difficulty in typing with the left hand and also noted that when she reached for things with the left hand she would miss them.  Soon thereafter, she noticed that fine coordinated movements involving the left hand, such as buttoning her clothes, also were deteriorating.  These symptoms of incoordination continued to progress up to the time of consultation.  Approximately 2 weeks prior to consultation, she also noted numbness, tingling, and a cold, heavy feeling involving the left hand and much of the left upper limb.  Within a few days, the sensation of coldness and heaviness began to spread onto the left side of the trunk, both anteriorly and posteriorly, and by the time of consultation extended from about the 3rd rib down to the groin but not really into the left lower limb.  During this period of time, the left upper limb also felt somewhat weak to the patient.

The patient gave a history of prior neurologic problems.  In 1976, she noted the gradual onset of decreased vision in the right eye that stabilized for a short time and then completely resolved within 3 weeks.  The right eye had been asymptomatic since.  In March of 1979, the patient noticed the gradual onset of decreased vision in the left eye, which progressed to perception of hand motion only over a period of 10 days.  Associated with this decreased vision, she noticed pain in the eye with extraocular movements.  An ophthalmologist treated her with Prednisone, and her visual acuity improved to 20/300 within 2 weeks.  The medication was discontinued after a 10 day taper, and the vision in the left eye again deteriorated until she could see hand motion only.  Prednisone was started again, and her visual acuity improved back to 20/200.  By the first of June 1979, visual acuity was 20/40 in the left eye and remained stable since that time.  In August of 1979, the patient noted transient numbness and tingling of the right hand after being out in the sun and overheating.  She jumped into a swimming pool, and the symptoms completely resolved.  Since that time, she had experienced transient recurrences of right upper limb numbness and tingling, but these always spontaneously resolved after a few days to a few weeks. 


Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  Visual acuity was 20/20 in the right eye and 20/100 in the left eye.  Funduscopic examination revealed moderate pallor of the right optic disc and marked optic atrophy of the left optic disc.  Visual field testing revealed a dense central scotoma in the left eye but no abnormality in the right eye.  There was a 3+ afferent pupillary defect (APD, Marcus Gunn pupil) present in the left eye, and there was 80 per cent color desaturation in the left eye.  There was a mild decreased appreciation of pinprick on the left side of the face. 

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal on the right side.  On the left side, there was a mild to moderate weakness (4/5) with the upper limb being worse than the lower limb. 

Reflexes:  Deep tendon reflexes were brisk bilaterally in all 4 limbs but were somewhat brisker on the left side than the right.  Plantar reflexes were flexor bilaterally. 

Sensory System:  Sensory examination was normal except for the following.  In the upper limbs, pinprick was perceived much better on the left than the right.  Joint position sense was intact in the right upper limb and totally absent on the left.  In the lower limbs, pinprick, vibration, and light touch were equal bilaterally.  Joint position sense was mildly impaired in the left foot but was normal in the right. 

Cerebellar Function:  The patient performed all cerebellar tests normally on the right.  On the left, there was dysmetria, dyssynergia, and difficulty with rapid alternating movements, with the upper limb being much more involved than the lower limb. 

Gait and Stance:  Intact.


1.  Considering only the patient's acute neurologic problem in the 2 to 3 weeks prior to consultation, what specific structures are involved by the pathologic process to produce each of the findings listed below?  Indicate the side of the lesion.

a.  Ataxia (dysmetria, dyssynergia, dysdiadochokinesia) on the left side, with the upper limb more involved than the lower limb

b.  Numbness and impaired joint position sense (conscious proprioception) in the left upper limb more than the left lower limb

c.  Weakness and hyperreflexia on the left side, with the upper limb more involved than the lower limb

d.  Diminished pain perception in the right upper limb

e.  Diminished pain perception on the left side of the face

2.  Where is the lesion producing the above findings located?

3.  These findings constitute a partial example of a classic neurological syndrome.  What is the name of this syndrome?

4.  Considering her entire neurologic history, have multiple areas of the central nervous system been involved, or is a single localized site involved throughout the entire course of her illness?  

5.  If multiple areas have been involved, list them and indicate which structures are involved by the pathologic process.  Indicate the side of the lesion(s).  

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?

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