Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #87

Date of Consultation: 12-12-1980


This 50-year-old right-handed white male railroad worker was referred for neurologic evaluation of recent onset of seizures.  The patient was admitted to the neurology service on 4-20-79 for the acute onset of right hemiparesis and a nonfluent or expressive aphasia.  Five days prior to admission, the patient noted the acute onset of weakness of the right lower limb.  Over the next two to three days, the weakness spread to involve the entire right side of his body and language dysfunction became apparent.  The patient was ultimately transferred to the physical medicine and rehabilitation service and received physical and speech therapy.  He was discharged from the hospital on 5-11-79 with improvement in his neurological state.  He did well until April of 1980, when he had his first seizure.  From April through November of 1980, the patient experienced 6 seizures, all of which were quite stereotyped and similar.  In discussing these seizures, the patient denied any aura or warning before the seizure.  The patient was aware of the onset of the seizure and described it as beginning with the right upper limb abducting at the shoulder and flexing at the elbow with a simultaneous turning of the head and eyes to the right.  The patient indicated that at that point he lost consciousness and therefore was unaware of further events during the seizure.  His fiancée noted that after the initial head, eye, and right upper limb movements he lost consciousness, fell to the ground, and assumed an opisthotonic posture with his eyes either deviated straight upward or to the right.  She described very little clonic jerking during the seizure and indicated that tonic posturing was the predominant movement.  This portion of the seizure usually lasted one to two minutes and was not usually accompanied by urinary incontinence or tongue biting.  However, he had hit his head while falling during a seizure.  After the seizure, the patient was typically drowsy and confused for approximately 15 to 30 minutes and often had a right postictal (Todd's) paralysis for another 30 minutes. 

Mental Status Exam:  The patient was oriented to person, place, and time.  His fund of general information was adequate.  Long term and short term memory testing was normal.  The patient exhibited a mild to moderate predominantly nonfluent aphasia characterized by difficulty with repeating simple test phrases, occasionally blocking on words, and generally being aware of what he wanted to say but having difficulty expressing it.  He was able to comprehend verbal and written instructions without difficulty. 

Cranial Nerves:  Cranial nerve examination was normal except for a mild weakness of the right lower facial muscles. 

Motor System:  Muscle bulk, tone, and posture were normal bilaterally.  Muscle power testing revealed a mild weakness of the right upper limb and a moderate to marked weakness of the right lower limb.

Reflexes:  Deep tendon reflexes were slightly brisker on the right side than the left.  Plantar reflexes were flexor on the left and extensor on the right.

Sensory System:  Intact.

Cerebellar Function:  Intact.

Gait and Stance:  Intact except for mild weakness and circumduction of the right lower limb.  Tandem gait was performed adequately.  The Romberg test was negative.


1.  How would you classify this patient's seizure disorder? 
2.  Is there anything in the description of the seizure that indicates a precise localization of the onset of the seizure?  If so, which aspects help localize the lesion and where is the lesion located?  Indicate the side of involvement.
3.  Is the localization obtained through the seizure history consistent with that indicated by his original neurological presentation?  Indicate the precise location of his original neurologic lesion, including the side of involvement.  Indicate the specific structure(s) involved by the original lesion.
4.  In general, what type of pathologic process is involved in this case?  If vascular, what vessel is involved?
5.  What diagnostic procedure(s) would you undertake at this point?


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