Case Summaries

A sixty-eight year old woman was admitted to the hospital because of the sudden onset of extreme vertigo. She had been well until that morning, except for a long history of hypertension and mild diabetes mellitus. When she awoke, she noted a sensation of the world spinning around. She could not keep her balance well enough to leave her bed, and when her husband brought her breakfast she was unable to swallow her food.

On admission, she was alert, well oriented and had no difficulty in understanding speech or in expressing herself, except that her speech was nasal and therefore indistinct. General physical exam showed a blood pressure of 160/100. The left side of the face was warm, dry and red, and the left side of her body was drier than the right. Funduscopic exam showed mild arteriolar narrowing but no other retinal abnormalities. Pupils reacted well to light and accommodation, but left pupil was 2 mm smaller than the right. Extraocular muscles were all normal except for a droop of the left eye lid and nystagmus in both eyes on looking toward the left. Pain and temperature sensation and the corneal reflex were diminished on the left side of the face. There was slight weakness of all the muscles of facial expression on the left side, including orbicularis oculi and frontalis muscles. Hearing was slightly diminished in the left ear, with bone and air conduction equally affected. The gag reflex was normal on the right but absent on the left. The uvula was tonically pulled to the right. The voice had a soft nasal quality, and attempts at drinking liquids produced coughing and regurgitation through the nose. Sternocleidomastoid and trapezius muscles were normal. The tongue was normal in strength. Pain and temperature sensations were impaired on the right side of the body, but touch, vibration and joint position sensations were normal. There was no weakness anywhere in her body (except for mild left facial weakness), but she could not keep her balance even sitting in a chair. There was incoordination and intention tremor of the left arm and leg, but not the right. Muscle tone was slightly diminished on the left side. Myotatic reflexes were all normal and plantar stimulation produced normal toe flexion on both sides.

Skull films, LP and EEG were normal.

Clinical course was one of very gradual though incomplete improvement in all her symptoms over the next year.

3. Except for the mild left facial weakness and deafness, the findings would be typical of what syndrome? How can we explain the deviations?

5. Why were pain and temperature sensations impaired on the right side of the body but on the left side of the face?

7. How can you account for the unequal pupil size? What other abnormalities can be explained on the same basis?

10. How can you explain the tremor on the left side? What other findings are explained this way?

11. How do you explain the vertigo? What physical finding is explained by the same mechanism?

12. Considering the signs and symptoms, could you delineate the position of the lesion both rostrocaudally and mediolaterally?


	Clinical Neurology Small Group Session 3 Case Summary 9
	A sixty-eight year old woman was admitted to the hospital because of the sudden onset of extreme vertigo. She had been well until that morning, except for a long history of hypertension and mild diabetes mellitus. When she awoke, she noted a sensation of the world spinning around. She could not keep her balance well enough to leave her bed, and when her husband brought her breakfast she was unable to swallow her food. On admission, she was alert, well oriented and had no difficulty in understanding speech or in expressing herself, except that her speech was nasal and therefore indistinct. General physical exam showed a blood pressure of 160/100. The left side of the face was warm, dry and red, and the left side of her body was drier than the right. Funduscopic exam showed mild arteriolar narrowing but no other retinal abnormalities. Pupils reacted well to light and accommodation, but left pupil was 2 mm smaller than the right. Extraocular muscles were all normal except for a droop of the left eye lid and nystagmus in both eyes on looking toward the left. Pain and temperature sensation and the corneal reflex were diminished on the left side of the face. There was slight weakness of all the muscles of facial expression on the left side, including orbicularis oculi and frontalis muscles. Hearing was slightly diminished in the left ear, with bone and air conduction equally affected. The gag reflex was normal on the right but absent on the left. The uvula was tonically pulled to the right. The voice had a soft nasal quality, and attempts at drinking liquids produced coughing and regurgitation through the nose. Sternocleidomastoid and trapezius muscles were normal. The tongue was normal in strength. Pain and temperature sensations were impaired on the right side of the body, but touch, vibration and joint position sensations were normal. There was no weakness anywhere in her body (except for mild left facial weakness), but she could not keep her balance even sitting in a chair. There was incoordination and intention tremor of the left arm and leg, but not the right. Muscle tone was slightly diminished on the left side. Myotatic reflexes were all normal and plantar stimulation produced normal toe flexion on both sides. Skull films, LP and EEG were normal. Clinical course was one of very gradual though incomplete improvement in all her symptoms over the next year. QUESTIONS: CASE SUMMARY 9 1. What type of pathological process is this? 2. In what part of the brain is the lesion? 3. Except for the mild left facial weakness and deafness, the findings would be typical of what syndrome? How can we explain the deviations? 4. How do you explain the fact that there is no muscle weakness below the face? 5. Why were pain and temperature sensations impaired on the right side of the body but on the left side of the face? 6. Why were touch, vibration and joint position sensations not impaired? 7. How can you account for the unequal pupil size? What other abnormalities can be explained on the same basis? 8. What is the anatomical significance of the absent gag reflex on the left? 9. Why was the tongue normal in strength? 10. How can you explain the tremor on the left side? What other findings are explained this way? 11. How do you explain the vertigo? What physical finding is explained by the same mechanism? 12. Considering the signs and symptoms, could you delineate the position of the lesion both rostrocaudally and mediolaterally?
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	Last updated: 10/05/2002	© 2000 John Rose, MD