Clinical Cases

Case 1 A 23 yr old women complained of pain in her right breast and progressive weakness of her right lower limb for a period of many months. The neurologic examination revealed weakness in the right lower limb. This was associated with spasticity (increased tone), hyperreflexia (increased deep tendon reflexes) at the knee and ankle, which also demonstrated clonus. On the right side there was loss of two-point touch, vibratory sense and proprioception at levels below the hip. The left side showed a loss of pain and temperature sensation below dermatome T-7.

lateral corticospinal tract Conclusion of the diagnosis that the patient was determined to have an extramedullary tumor expanding from the dorsal roots at spinal cord levels T-5,6. Pure hemisection of the cord rarely occurs but it is among the best cases for illustrating the features of spinal cord injury. spastic paralysis lateral corticospinal tract loss of position sense, discriminative touch and vibratory sense on the side of the lesion – -involvement of the and the posterior white column on the side of the lesion. On the side opposite the lesion there is a loss of pain and temperature due to involvement of the lateral spinothalamic tract. At times, it is possible to also demonstrate a bilateral sensory deficit and flaccid paralysis at the level of the lesion.

Case 2 A 55 year old man noticed a weakness of his left hand and loss of pain in his both arms which was progressing and causing him mental apathy and he felt he should visit neurologist . On examination he demonstrated bilateral weakness, atrophy, and fasciculations of the intrinsic muscles of his hands and shoulders. Upper motor neuron syndrome signs, i.e., weakness, hypertonia, hyperreflexia, positive Babinski, were evident in both lower extremities. Dermatomes C-2 through T-6 demonstrated bilateral loss of pain and temperature sensation. There was bilateral impairment of position and vibratory sense below the hips.

Case 2 cont… MRI investigation showed a central cavitation at C-2 through T-7 which expanded symmetrically in all directions. It involved the anterior white commissures (spinothalamic fibers) and included portions of the posterior white columns, lateral white funiculus, and anterior gray horns.

Syringomyelia

Case 3 A 52 year old Mc David gym a trainer collapses in the gym. A medical student on a nearby cycling machine sees this happen and summons an attendant to call 911. Several weeks later his friend who is a doctor visits Mc David in the hospital. His friend noticed that. He speaks poorly but he notes that he seems to understand him well. He also sees on his chart that a Neurologist has noted the following symptoms:

Weakness and hyperreflexia in the right arm and shoulder. Mild weakness and a slight hyperreflexia in the lower parts of the face on the right side. Reduction in fine touch and vibration sensations from the right arm. Reduction in pain and temperature sensations from the right arm. Non-fluent speech with preserved comprehension.

Case .4 A patient with a bullet wound to the head is referred to you for neurological examination. Upon entering the hospital room you find the patient on a respiratory and cardiac monitor. You have difficulty arousing the patient and once awake you note the following: Right pupil is constricted; there is medial strabismus of the right eye and upon attempted right lateral gaze the left eye fails to adduct; loss of pain and temperature sensitivity on the right side of the face and left side of the body; deafness of the right ear; a pronounced intention tremor in the right arm and leg. The deep tendon reflexes on the right side are not as brisk as those on the left and there appears to be a complete facial paralysis on the right side.

Case .4 cont…. The right caudal pons The Left caudal pons The left side of the midbrain at the level of the superior colliculus The right side of the medulla at the level of the dorsal column nuclei The left side of the medulla at the level of the dorsal column nuclei

Case. 5 60 year old woman suddenly remarked that she was seeing double and felt a weakness in her left arm and leg. Her husband noticed that her right eyelid was drooping. At the hospital, she was awake, oriented, and articulate. Her visual fields were normal but here right eye deviated to the right. On attempted lateral gaze to the left only the left eye responded; only the left eye constructed in response to light. Upon smiling, there was a minor weakness on the left. The gag, corneal, and jaw jerk reflexes were normal as were the sensory examinations of the face and body. Motor strength was normal in the extremities on the right but reduced on the left especially in the arm where there was a heightened biceps reflex and resistance to passive stretch.  

Case. 5 cont… Where is the site of lesion? Cerebellum Substantia nigra Mid brain None of above.  

Case. 5 cont… By looking at the patient's condition and physical findings. What is your diagnosis? Superior alternating hemplegia inferior alternating hemplegia lateral pontine syndrome None of above.