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
Left posterior spinocerebellar tract and left fasciculus cuneatus
b. Numbness and impaired joint position sense (conscious proprioception) in the left upper limb more than the left lower limb
Left fasciculus cuneatus>>fasciculus gracilis
c. Weakness and hyperreflexia on the left side, with the upper limb more involved than the lower limb
Left lateral corticospinal tract
d. Diminished pain perception in the right upper limb
Left spinothalamic tract
e. Diminished pain perception on the left side of the face
Left spinal tract of V
2. Where is the lesion producing the above findings located?
Left C1-3 spinal cord white matter, involving the posterior and lateral funiculi
3. These findings constitute a partial example of a classic neurological syndrome. What is the name of this syndrome?
Brown-Sequard Syndrome (Hemisection of the spinal cord)
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?
Multiple areas
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).
See question #1 for her acute illness.
Right optic nerve (II) in 1976.
Left optic nerve (II) in 1979.
Right upper limb sensory symptoms (1979, 1980) are difficult to localize with certainty.
6. In general, what type of pathologic process do you think is involved in this case?
Demyelinating disease.
Probably Neuromyelitis optica (NMO, Devic disease) (vs Multiple sclerosis).
7. What diagnostic procedure(s) would you undertake at this point?
This patient was seen before the MRI era and before the ability to measure aquaporin-4 antibodies. CSF studies for oligoclonal bands and CNS synthesis of IgG would be obtained.
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