Case History #87
Date of Consultation: 12-12-1980
HISTORY
OF PRESENT ILLNESS:
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.
NEUROLOGICAL
EXAMINATION:
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.
Questions:
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?
Answers
