Case 190

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #190
Date of Admission: 2-16-2012

HISTORY OF PRESENT ILLNESS:

This 73-year-old right-handed retired African-American female was admitted to the hospital for the acute onset of right upper limb weakness. She is known to have hypertension and a 40 pack-year history of smoking, but she was taking no medications at the time of admission. On the morning of admission, the patient awoke with the inability to move her right upper limb and her right hand. This weakness seemed to gradually improve, but her son brought her to the emergency room because he was concerned about a stroke. Upon admission to the emergency room, her blood pressure was 200/117. This was treated and came under better control, and her right upper limb weakness continued to improve. However, she was admitted to the Neurology Service for further evaluation and management. She denied any prior neurologic problems or similar episodes.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Cranial nerve examination was entirely normal.

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 left side and in the right lower limb. In the right upper limb, muscle power was mildly weak throughout and was rated as 4+/5.

Reflexes: Deep tendon reflexes were equal and symmetric, and the plantar reflexes were flexor bilaterally.

Sensory System: The patient perceived all sensory modalities, including cortical sensations, normally in all four limbs.

Cerebellar Function: Cerebellar tests were performed normally in the left upper and lower limbs and in the right lower limb. In the right upper limb, finger-to-nose testing revealed dysmetria and dyssynergia, and rapid alternating movements were performed dysrhythmically.

Gait and Stance: Regular and tandem gait were performed normally, and the Romberg test was negative. The patient was able to walk on her heels and toes without difficulty.

Questions

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

2. Indicate the structures involved by the pathologic process to produce this patient’s right upper limb weakness. If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

3. Indicate the structures involved by the pathologic process to produce this patient’s right upper limb findings on cerebellar examination. If precise localization is not possible, list as many levels or structures as you can that might produce the same clinical picture.

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

5. The findings in this case represent a partial example of 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