Case 6 Answers

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case 6 Answers

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

Not very precisely. Long tract signs do not localize well.
Left corticonuclear and corticospinal tracts above the lower third of the pons (see slide #1).

2. Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process. If precise localization is not possible, list as many levels and/or structures as you can that might produce the same clinical picture, if involved by the pathologic process.

Left precentral gyrus, posterior limb of internal capsule, crus cerebri, basilar (anterior) part of pons.

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

Pure motor hemiplegia.
Lacunar infarct in the posterior limb of the internal capsule (3rd quarter) or basilar (anterior) part of the pons.

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

Vascular. In this case, the infarct was in the left basilar part of the pons.
This small deep infarct (SDI) may have been due to a cardiac embolus to a paramedian branch of the basilar artery, in view of his history of atrial fibrillation, rather than small vessel disease (i.e., lipohyalinosis). The patient did not have a history of hypertension or diabetes, which are often associated with lacunar infarcts due to small vessel disease.

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

References:
1. Fisher CM, Curry HB. Arch Neurol 1965;13:30-44.
2. Fisher CM. Neurology 1982;32:871-876.
3. Jickling GC, Stamova B, Ander BP, et al. Ann Neurol 2011;70:477-485.
4. Bezerra DC, Sharrett AR, Matsushita K, et al. Neurology 2012;78:102-108.

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