Transcript
An Interesting Case
One hand better than both
Dr.ARUL SELVAN .V.L
Presenter: Dr.M.Ramesh Babu
Brief History
• Mr .X 62 yrs old gentleman , from Andhra ,
retired bank employee, right handed individual
, HTN , Alcoholic Cirrhosis of liver
• Presented with chief complaints of weakness
in left upper and lower limb - 15 days duration.
• Fever with chills & rigours - 5 days
HOPI
• H/O weakness left sided upper and lower limb -
sudden in onset, gradually progressive , initially he
felt weakness of left upper limb in the form of
raising above the shoulder, difficulty in buttoning
the shirt, holding the objects with left hand
• weakness of left lower limb in the form of difficulty
while walking , used drag the left foot, difficulty in
wearing and gripping the sandals.
• H/o feeling that he is not feeling his left upper and lower limb
in between ( used to check)
• No H/o deviation angle of mouth , slurring of speech
• No H/o headache, LOC, seizures
• No H/o diplopia, dysphasia
• No h/o neck pain , restriction of movements
• No h/o trauma/ fall
• No h/o sensory symptoms
• No H/o bowel / bladder symptoms
• No h/o loss of appetite, weight loss
• No h/o similar complaints in the past
• No h/o tuberculosis or contact with TB persons
• past h/o : K/C/O cirrhosis of liver undergone
esophageal variceal banding - 3 times
• personal h/o : Alcoholic - used to drink daily -
stopped 2 yrs back.
• Family History- nil significant
Summary
• Mr.X 62 yrs old gentleman, right-handed person,
k/c/o alcoholic cirrhosis of liver presented with fever
with chills & rigors-5 days, sudden onset gradually
progressive weakness of left upper and lower limb of
15 days duration, without cranial nerve symptoms,
with symptom of phantom limb, without sensory ,
bowel / bladder symptoms, neck pain, other
constitutional symptoms.
• Probabilities:
• Fast growing tumour
• Tuberculoma
• Subdural hematoma
• AV malformations
• Ruptured Tumor/ Abscess
On Examination
• GPE: Well built & obese BMI - 38kg/m2
• NO P I C C L E , Varicose veins in both LL+
• No Neuro-cutaneous markers
• Vitals: PR-98/min, BP-130/80 mmhg, T- 101F
• CNS Examination:
• HMF
• Attention & orientation -Conscious , alert, well oriented to
time place & person
• Memory - Immediate, recent, past - intact
• MMSE- 30/30
• Speech - Fluency, comprehension, repetition , reading
,writing -N
• Lobar functions:
• Frontal lobe : No apathy, disinhibition, gaze preference,
normal primitive reflexes, no motor aphasia
• Parietal lobe: hemi-spatial neglect left sided, Asterognosis, &
agraphaesthestia + Lt. , no ideomotor & ideational apraxia,
calculation - n, no finger agnosia, left - right confusion+,
• Motor , visual , auditory extinction + on left side
• Other lobes - normal
Video
• Cranial Nerve examination :
• CN I - N
• CN - II pupils - b/l 3mm symmetrical ,reactive , Fundus- N
• CN III, IV, VI - EOM full, no gaze preference
• CN V - N
• CN - VII - No facial lag
• CN - VIII - hearing -N
• CN - IX& X - Palate movements -n
• CN- XI - N
• CN XII - N
• Motor System : bulk - normal, no muscle wasting or
twitching
• Tone- normal
• power - 5/5 4/5
• 5/5 4/5
• On closing the eyes & asking him to lift both hands- not
able to lift on left side ( Motor Extinsion)
• DTR’S - 1+
• plantar - flexor Rt. , extensor Lt.
• Sensory Sytem Examination:
• Touch, Pain , Temperature, Vibration and Position sense -
Normal
• Superficial reflexes - corneal, conjunctival, palatal,
abdominal - N
• Cortical senses : Stereognosis, Graphaesthestia, 2 point
Discrimination, Sensory Extinction - impaired on left side.
• No Cerebellar/ Meningeal signs
• Cranium & Spine - N
• Other systemic examination - Normal
Summary
• Mr.X 62 yrs old gentleman, right-handed person, k/c/o
alcoholic cirrhosis of liver presented with fever with
chills & rigors-5 days, sudden onset gradually
progressive weakness of left upper and lower limb of
15 days duration, without cranial nerve symptoms,
with symptom of phantom limb, without sensory , bowel
/ bladder symptoms, neck pain, other constitutional
symptoms, With signs of left hemispacial neglect,
motor, sensory, visual and auditory extinction.
• Probable Diagnosis
• Structures involved : Right parietal lobe ( non dominant )
• Probable Diagnosis: SOL
• Tuberculoma
• Abscess
• Fast growing tumour
CT Brain
Imaging
Clues from imaging
• Many features of the lesion as well as clinical presentation and patient demographics need to be
taken together to help narrow the differential. Helpful rules of thumb include:
• enhancing wall characteristics
● thick and nodular favoursneoplasm● thin and regular favoursabscess● incomplete ring often opened toward the cortex favours demyelination● intermediate to low T2 signal capsule favours abscess● restricted diffusion of enhancing wall favours GBM or demyelination
● surrounding oedema● extensive oedema relative to lesion size favours abscess
● increased perfusion favours neoplasm (metastases or primary cerebral malignancy)● central fluid / content● restricted diffusion favoursabscess
● number of lesions● similar sized rounded lesions at grey white matter junction favours metastases
or abscesses
● irregular mass with adjacent secondary lesions embedded in the same region of 'oedema' favours GBM
● small (<1-2cm) lesions with thin walls especially if other calcific foci are present suggestneurocysticercosis
What is Extintion?
• Extinction is a simultaneous sensory / motor
stimulation (ESS) - is a phenomenon in which a
patient perceives a U/L sensory stimulus
presented in isolation but fails to perceive the
same stimulus when presented simultaneously
with a second stimulus.
• ESS is most commonly seen after Rt.
hemisphere strokes and may adversely affect
prognosis.
• The proposed mechanisms of ESS -
• The delayed information processing model proposes
that delays in the transfer of sensory information in
the damaged hemisphere increase the susceptibility
to interference from the intact hemisphere.
• The sensory hypothesis proposes the elevations in
afferent sensory threshold increase the susceptibility
to obscuration by the intact hemisphere.
• The reciprocal inhibition model states that ESS
results from imbalance of interhemispheric inhibition.
Types of Extinsion
• Sensory extinction
• Motor extinction
• Visual extinction
• Auditory extinction
Thank you
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