Case 44

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #44

Date of Consultation: 9-21-1979

HISTORY OF PRESENT ILLNESS:

This 70-year-old right-handed black female was referred for neurologic consultation concerning her left-sided signs and symptoms. In April of 1979, the patient had the acute onset of obtundation, dysarthria, and left-sided weakness. These symptoms partially resolved while in the emergency room of another hospital, but she was admitted to the hospital for further evaluation. Since being discharged from the hospital, her neurologic symptoms had been stable. The patient was aware only of a mild left-sided weakness, and she did not feel the need to see another physician. However, her family and her referring internist convinced her to keep her appointment in neurology clinic.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: The patient was oriented to person, place, and time. Her fund of general information was quite adequate. There were no deficits of long term or short term memory. Calculations were performed appropriately. Reading, writing, and speech functions were all intact. There were no difficulties in repeating test phrases, comprehending spoken language, following commands, or naming objects. The patient exhibited difficulty persisting with certain motor activities requiring sustained effort, such as holding her arms in the extended position with her eyes closed. Attempts at copying a complex figure, such as a rectangle intersected by a triangle, were very poorly performed. When presented with bilateral simultaneous sensory stimuli, the patient failed to recognize the stimulus on the left side of the body or the left side of space. The patient’s mood was normal.

Cranial Nerves: Cranial nerve examination was normal except for the following. Visual field examination revealed an inability to perceive objects in the left inferior quadrant of the visual field of each eye. There was also a very slight flattening of the left nasolabial fold.

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

Reflexes: Deep tendon reflexes were 3/4 bilaterally. The plantar reflexes were flexor on the right and equivocal on the left.

Sensory System: Light touch, pinprick, and vibration were somewhat less well perceived on the left side of the body than on the right. In addition, there was a profound loss of joint position sense, two-point discrimination, and stereognosis on the left side. These sensory modalities were entirely normal on the right side.

Cerebellar Function: Intact.

Gait and Stance: Regular gait was performed on a slightly widened base, and there was a mild degree of spasticity and circumduction of the left lower extremity. Tandem gait was not attempted. The Romberg test was negative.

Questions:

1. What is the term describing the patient’s indifference to, and to some extent denial of, her clinical signs and symptoms?

2. What is the term describing the patient’s inability to persist with activities requiring sustained effort?

3. What is the term describing the patient’s inability to copy complex geometric figures?

4. What is the term describing the patient’s failure to recognize the stimulus on the left side of the body or the left side of space, when presented with bilateral simultaneous sensory (visual or tactile) stimuli?

5. How would you describe this patient's visual field deficit?

6. What specific structures are involved by the pathologic process in this case to produce the mental status, visual, and sensory findings noted on the examination?

Signs or Symptoms Site of Lesion

Mild Anosognosia

Motor impersistence

Constructional apraxia

Sensory extinction

Left homonymous inferior
quadrantanopsia

Left UMN facial weakness (mild)

Left hemiparesis (mild)

Decreased touch, pinprick,
vibration on the left

Decreased joint position sense,
two-point discrimination,
stereognosis on the left

7. Considering her entire neurological picture, in what region of the brain would you place the epicenter of her neurologic lesion?

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

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

Answers