Giesler Lecture 46

Page 1 LESION PATHOPHYSIOLOGY II

CASE VI A. Findings/symptoms 1. 80 year old man found “unconscious” 2. Mental status examination a. eyes are open b. no speech; does not follow commands c. blinks rapidly at times when asked something 3. rest of neurologic examination a. can look up and down conjugately; can converge b. cannot look laterally c. cannot move face d. cannot move limbs 4. Ultimately, can answer yes/no questions by blinking once for “yes” and twice for “no”.

Giesler Lecture 46

Page 2 B Diagnosis: “Locked In Syndrome”. Likely due to infarction of the ventral pons bilaterally, basilar artery thrombosis (occluding the basilar artery between the level of the anterior inferior cerebellar arteries and the level of the superior cerebellar arteries.)

CST PN

IV Ventricle

ML

RF VIVII MCP

SCP

Modified from D.E.Haines, Neuroanatomy, An Atlas of Structures, Sections and Systems, Williams and Wilkins, 1995

CST, corticospinal tract; MCP, middle cerebellar peduncle; ML, medial lemniscus; MLF, medial longitudinal fasciculus; PN, pontine nucleus; RF, reticular formation; SCP, superior cerebellar peduncle; VI, abducens

Giesler Lecture 46

Page 3 CASE VII A. Findings/symptoms

1. 71 year old hypertensive man with the abrupt onset of left sided weakness:

2. Neurologic Examination:

“Elevate eyebrows”-

note: labial fold- “Smile”-

“Close eyelids”

a. problems with muscles of facial expression.

c. initally weakness of the left arm and leg d. left Babinski sign e. within a few weeks, posture illustrated

3. The following were not present: a. sensory findings b. visual field deficit c. spatial neglect or neglect of deficit

Giesler Lecture 46

Page 4

4. Peripheral (Bell’s) or central VII nerve damage?

Giesler Lecture 46

Page 5 B. Diagnosis: Occlusion of a lenticulostriate artery, with lacunar infarction of the genu and posterior limb of the internal capsule on the right.

Giesler Lecture 46

Page 6 CASE VIII A. Findings/symptoms: 1. 29 year old woman with left eye pain and diminished vision for three days. 2. Neurologic examination

At rest

Shine light in right eye.

Shine light in left eye. a. light in right eye- b. light in left eye- c. Condition of autonomic supply of eye? i. ii.

Giesler Lecture 46

Page 7 d. patient has decreased visual acuity in the left eye d. optic disc swelling on the left Diagnosis: a. Optic neuritis left, relative afferent pupillary defect (“Marcus-Gunn pupil”) B. Possible cause a. demyelinating attack b. ischemia; ophthalmic artery embolism

Giesler Lecture 46

Page 8 CASE IX A. Findings/symptoms: 1. 67 year old man awakens “confused”. Some speech does not make sense. Not able to answer his wife’s questions. No complaints; dresses himself; calm throughout. 2. Mental status examination a. fluent; some non-sense words (paraphasias) b. does not follow simple commands or answer yes/no questions c. cannot repeat d. cannot read for comprehension (e.g. “close your eyes” on a card) 3. Rest of neurologic examination a. right superior quadrantanopsia b. no facial or limb weakness

Giesler Lecture 46

Page 9 B. Diagnosis: Dominant temporal lobe infarct possibly due to occlusion of branch of the left middle cerebral artery producing Wernicke’s aphasia.

The optic radiations in the temporal lobe (Meyer’s loop) were also affected.

C. Note the patient’s lack of awareness of deficit (anosognosia).

Giesler Lecture 46

Page 10 CASE X

A. Findings/symptoms: 1. 65 year old man with chronic atrial fibrillation 2. Suddenly,

a. “confused” b. stumbling into furniture c. complains of a severe occipital headache.

3. In E.R.: a. sleepy but interactive b. vivid visual hallucinations c. completely blind d. poor short term memory e. impaired upward gaze f. diminished light touch sensation over face and limbs bilaterally.

4. Over the subsequent months,

a. blindness and memory disturbance persist b. sensory disturbance evolves into an unremitting pain within all

extremities. i. ii. III.

Giesler Lecture 46

Page 11 B. Diagnosis: Damage to the midbrain, thalamus, parietal and occipital lobes.

Occlusion of rostral basilar artery and both posterior cerebral arteries

Posterior Cerebral

Arteries

C. Damage to

1. Reticular formation within midbrain 2. Occipital cortex bilaterally. 3. Medial temporal lobes. 4, Midbrain tegmentum 5. Thalamus bilaterally

CM, centromedian nucleus; CC, corpus callosum; DMN, dorsal medial nucleus; GP, globus pallidus; MB, mammillary body; Put, putamen; VA-VL, ventral anterior-ventral lateral nuclei; VPL, ventral posterior lateral nucleus Modified from D.E> Haines, Neuroanatomy An atlas of structures, sections, and

systems, Williams & Wilkens, 1995.

Giesler Lecture 46

Page 12 CASE XI

A. Findings/Symptoms:

1. 40 year old woman has chronic right-sided headaches (migraine variant) 2. At 42, she has

a. episode of uncontrolled shaking in her left hand, followed by marked transient weakness in that hand. b. mild weakness of the lower half of the left face c. mild weakness in the left hand with slow finger movements d. spasticity, hyperreflexia and altered sensation in the left upper and lower extremities e. inability to see in the left visual field of each eye f. increasing difficulty navigating between places within her neighborhood and, increasingly, even within her house. g. she is unaware of her problems

Giesler Lecture 46

Page 13 B. Diagnosis: Tumor in right parietal lobe, internal capsule and thalamus