A case of Extinsion

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