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CASE 2

Girl with Sudden Weakness


• At the age of 6 years, a 10 year old girl had the sudden
onset of a headache over the left frontal area followed by
the acute onset of right sided weakness and inability to
talk. She couldn’t move her right arm or leg. She could
recognize her family and could understand what was
said to her but she couldn’t talk.
• Over the next few months, her strength improved so that
she could walk but she still had problems using her right
hand. She started to talk in one word sentences, then
short phrases, and finally in full sentences. She would
still have problems at times finding the right word to say
or coming up with the correct name of an object.
Select the parts of the neurological
examination that you need to see for
localization of the patient's lesion.
• Mental Status Exam
• Cranial Nerve Exam
• Coordination Exam
• Sensory Exam
• Motor Exam
• Gait exam
Mental Status Exam

• The patient has occasional difficulty


finding the words she wants to use and
naming objects.
• The rest of the mental status examination
is normal.
Language
• At the age of 6 years, this 10 year old girl had the
sudden onset of a headache over the left frontal area
followed by the acute onset of right sided weakness and
inability to talk. She couldn’t move her right arm or leg.
She could recognize her family and could
understand what was said to her but she couldn’t
talk.
• Over the next few months, her strength improved so that
she could walk but she still had problems using her right
hand. She started to talk in one word sentences, then
short phrases, and finally in full sentences. She would
still have problems at times finding the right word to say
or coming up with the correct name of an object
Motor examination
• Right facial nerve
• Right upper extremity incoordination
• Right lower extremity incoordination
• Right side of body weakness and tone
change
• Right side of body hyperreflexia
• Right side Babinski
RIGHT CRANIAL NERVE 7
DEFICIT – Upper Motor Neuron
"Y" Neuroaxis
To localize the level of the lesion for this case, start with the
"Y" neuroaxis.
On the diagram, click the level(s) you think is involved.
Supratentorial
"X" Neuroaxis
Continue to localize the lesion for this case.
On the diagram, click the side you think is involved.
Identify the damaged structure
• SUPRATENTORIAL
• > CORTEX
• > LEFT SIDE:
Identify the damaged structure
• Now that you have localized the level and
the side of the lesion, identify the specific
structures that are damaged. Use the
VIEWING OPTIONS to review various
structures
1 Genu of the corpus callosum
2 Splenium of the corpus callosum
3 Caudate
4Internal capsule
5 Putamen
6 Globus pallidus
7 Thalamus
8 Optic Radiation
9 Frontal cortex
10 Temporal cortex
11 Parietal cortex
12 Occipital cortex
CASE DISCUSSION
• The patient had the acute onset of right sided weakness
and inability to speak. The temporal profile of her illness
is most consistent with a vascular event or a stroke.
• On examination she has right sided weakness with the
greatest deficit being in the hand.
• She has mild asymmetry of the nasal labial folds with the
right side being less distinct than the left.
• There is no asymmetry to the action of the orbicularis
oculi or frontalis muscles so this is most consistent with
an upper motor neuron lesion affecting the lower half of
the face (a “central” 7th nerve lesion).
• The distribution of the extremity weakness, hypertonia,
hyperreflexia, pathological reflexes, and gait are
consistent with a right hemiparesis caused by an upper
motor lesion.
• Because the face as well as the extremities is involved,
then the lesion has to be above the level of the 7th
cranial nerve and it is on the left side of the brain.
We now need to consider her other findings
to further help us localize the level of the
lesion.

• The patient had problems with expressive


language. She could understand what was said
to her but she couldn’t say anything. With time
she regained her ability to talk but still has mild
difficulty with finding the right word or naming
objects. Her findings are consistent with an
expressive aphasia which localizes to the
posterior inferior frontal gyrus (Broca’s area) of
the dominant hemisphere which for her is the left
hemisphere.
So taking into account her right hemiparesis plus
her expressive aphasia the lesion has to be at the
supratentorial level in the left cerebral hemisphere

• It has to involve the inferior frontal lobe as well as either


the precentral gyrus or the white matter tracts coming
from the motor cortex. The precentral gyrus or motor
strip runs all the way from the Sylvian fissure to the
central fissure and is supplied by both the middle
cerebral and the anterior cerebral arteries (the middle
cerebral artery for the face and upper extremity and the
anterior cerebral artery for the trunk and lower
extremity). So if we postulate that the motor deficit is
from a lesion of the precentral gyrus then the vascular
event that caused the stroke would have to be an
occlusion of the internal carotid artery prior to the
bifurcation into the anterior and middle cerebral arteries.
That would be a huge infarct.
Another possible explanation for
the hemiparesis
• Lesion at the level of the internal capsule
where the descending corticospinal and
corticobulbar tracts are anatomically in a
small area and supplied by branches of
the middle cerebral artery. The best fit for
a lesion would be the internal capsule and
part of the frontal lobe which includes
Broca’s area and part of the precentral
gyrus.
POSSIBLE DAMAGED STRUCTURES
How do we explain the patient’s incoordination on
the right side? The incoordination is not from a
cerebellar lesion but rather from her corticospinal
tract lesion

• CST lesion can cause incoordination


• The key distinguishing feature
here is UMN signs
MRI image of the patient
• The patient’s MRI scan showed an
infarction in this area. There was also
infarction of the caudate and the
putamen/gobus pallidus on the left as well.
She didn’t have basal ganglia symptoms
because with the hemiparesis the
extrapyramidal dysfunction was not
expressed.