Prof Watsons Epic Neurology Adventures Number 2

CASE 1

Female, 58
Collapsed, immediately afterwards could move right limbs. Week later had
o Unable to open left eye due to ptosis
o Could move the left eyeball laterally, but not upwards or medially
o Left pupil was dilated, and didnt react to light directly or consensually
o Paralysis of the lower right face with sparing of the forehead muscles
o Right upper and lower limbs were paralysed, with increased muscle tone
o The deep tendon reflexes on the right were increased and the right plantar
response was extensor
o Sensory examination was normal
How do you account for restriction of eye movement? Issues with III, LPS for the ptosis,
and loss of the PSNS for the dilation. Every BS reflex has an afferent and efferent, and
these are 2 and 3. So youre having damage of the efferent pathway. She had third
nerve palsy
What can cause ptosis? In this case what is/are the most likely causes? Loss of
innervation to the LPS is the most likely cause in this case. Other causes are Horners
Syndrome, MG (would be worse on exertion, worse at the end of the day, when looking
up for a long time), mitochondrial myopathies (its often with very significant weakness
of the other ocular muscles), trauma, senile ptosis (in older people, can functional
blindness, so they may be operated on), congenital ptosis
Why was the pupil dilated? Loss of the pre-ganglionic PSNS fibers form the EWN
Why was the facial paralysis restricted to the lower part of the face? Its a UMN
involvement of cranial nerve VII. Whats the traditional explanation for this? Youre got
a whole lot of fibers crossing from one side to the other. Or, there are multiple motor
higher centers. Why youd have no weakness in involuntary movements- the smile,
crying
What other motor tracts were damaged? Left CST, above the motor decussation
Can one lesion explain all the other findings? If so, where? Since EWN is damage, could
be the midbrain. Could it be coming form the Cx? Nah, since youve got reflex damage,
and the Cx isnt needed. SO its going to be an issue with midbrain- Occams Razor.
EWN is dorsal, but the motor is anterior/ventral. Could it be midline? Could it be a lesion
of the cerebral peduncles? So how does this help you to explain the 3 rd nerve palsy?
Intra-axial lesion? So were not knocking off the EWN, III, were knocking off the axons.
Therefore the lesion would be in the midbrains ventral midline, as the 3 rd nerve fibers
pass by there. SYNDROME = Webbers Syndrome occlusion of midbrain paramedian
branches of the Basilar artery, sometimes posterior cerebral branches.
EWN fibers run forwards through the red nucleus and between the cerebral peduncles.
At the PMJ. Lateral extent of the lesion determines the extent of body lesions.
Hallmark of a BS lesion. Checkerboard/Harlequin- SS on head one side, below the head
on the other side, it has the be the BS

CASE 2

Female, 53
Insulin dependent diabetic
Sudden onset of left sided weakness and mild numbness
2 days later

Oriented
Speech slightly slurred
Mild weakness of the muscles of the lower left face
Left upper limb was weak, particularly distally, with slow and clumsy fine finger
movements
o Left lower limb was somewhat less weak, with the flexor muscles seemingly more
affected than the extensors
o Coordination was consistent with the degree of weakness
o Impairment of appreciation of light touch, pinprick, joint position and vibration on
the left side of the face and body
o Deep tendon reflexes on the left were brisker than the right, the left plantar
response was up going
Taking the sensory findings alone, what is the level of the nervous system above which
the lesions must lie? Associated sensory loss- lost pretty much everything on one side.
Wont be the transducers, axons, peripheral nerves. Could it be a sudden cord hemi
section? No. Youve got things on the same side of the face and body. It has to be above
the cord. BS and above? It cant be the BS as everything is on the same side. Therefore
its at the thalamus or above. Its the Somatosensory fibers
What does the pattern of facial weakness tell you? This is a UMN lesion of the CN VII,
above the nucleus
In view of the motor findings, between what levels in the nervous system should the
explanatory lesions be found? Not the muscles- one side, all at once. Not the nerves,
not the ventral nerve roots, SC, BS. Could it be widespread motor cortical involvement
on one side? Itd be fairly large, and would affect the sensation as well. Whats the
bridge between the thalamus and the Cx? The Internal Capsule?? It has s somatotopic
lesion. A lesion around the genu would be a good reason for these problems
What are the likely pathological causes of this womans problem? It was sudden; she
has DM, so there could be ischaemic stroke. Would be unusual to have demyelination
over this time frame. Very slowly changing, could be a tumour
A CT scan 4 days after the onset of symptoms was normal, does this change your
answers to 3 and 4? SO it wont be a haemorrhagic stroke, an infarct isnt visible after 4
days, youd see a tumour, so it means- 1. Nothing wrong with the patient. 2. The lesion
is very transient, small, below the limits of detection, or 3. The Sn of the scanning
modality is too low. For CT and stroke, its very low. SO youd need to do an MRI or later
CT, where youd have increased gliotic changes and blackness on the CT
These days, we get 85% ischaemic stroke and the rest are haemorrhagic. Why is this?
Lifestyle changes, better diagnostics and picking up more, weve controlled HTN to
remove most of the risks of haemorrhagic strokes. Ask how much salt they use! Do you
have salt at the table? Soy sauce, oyster and fish sauces. Taking a salt Hx is hard.
CT- left middle cerebral artery. Have loss of the ventricles, string sign (horizontal
portion). Our person had a stroke of one/some of the lenticulostriate arteries form the
MCA. Lacune!
Haemorrhage are more common as you get older, the arteries get stiffer, more cranky,
and form tiny aneurysms
o
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CASE 3

38 woman
Right handed
PHx of rheumatic fever
Had a dental extraction
2 months later

o Run down and unwell

o Lost weight
Week later
o Right sided headache and altered vision
o Major finding was s homonymous left superior quadrantinopia
Where in the CNS could a lesion lie to explain this sign? Its homonymous, so it has to
be behind the chiasm. Superior quadrant means that its the lateral part of the optic
radiation or the optic tract (but the lesion is far too specific for the tract). So it would be
the temporal lobe! It carries fibers from the visual superior world. The Meyers Loop.
Could also be further back in the cerebral Cx
In what arterial distribution is/are these sites? Posterior cerebral artery is V1, the
Meyers loop is the MCA ON THE RIGHT!

She was admitted to hospital but four days later she complained of increased
headache and now had right arm and face weakness and difficulties in
expressing herself
In which location/s is the likely lesion? 1 MCx on the left side is a possibility with the
right arm and face weakness. Broccas area for difficulty expressing herself. Since
theres widespread issues, we could have upper brain stem or IC/thalamus regions
If speech had no been involved would these locations be any different?
o

In spite of treatment she had another event occurred a week later

o Drowsiness and confusion
o Dilated pupils and failure of vertical eye movements
o Resolived, but she had a right homonymous hemianopia
o Profound amnesia
In what parts of the brain and vascular territories would you have a lesion? Behind the
chiasm, posterior or middle cerebral arteries. Can you account for the amnesia? This
would be the hippocampal area, in the PCA. The arteries of memory and vision.
Whats the underlying pathological process? Multiple lesions! The dental extraction
infective endocarditis multiple septic emboli
In this case she might have had only a little bit of memory loss, now she can have more
due to BL loss of her hippocampus