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A 72 year old man with acute onset weakness of the right upper and lower…
A 72 year old man with acute onset weakness of the right upper and lower limbs and right facial droop
Neuromuscular (objective muscle weakness: loss of strength that’s noted during a physical exam + tone flaccid on right side)
Possible lesions in nervous system. Hemiparesis results from upper motor neuron (UMN) lesions above the midcervical spinal cord. Facial droop is ipsilateral to the side of weakness => no crossed hemiparesis so does not localize to the brainstem. Lesion is superior to the brainstem.
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Check for other signs
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Cortical lesion: consider other cortical signs. Rare to cause only pure motor hemiparesis if cortical lesion
Inferior portion of the precentral gyrus of the left posterior frontal lobe and left parietal lobe (most often in the angular gyrus)
Other cortical sensory defects, e.g. right-left confusion, agraphia (inability to write, independent of motor weakness), acalculia (inability to calculate) and finger agnosia (inability to designate the fingers)
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Aphasia: an inability to comprehend and formulate language because of damage to specific brain regions)
Usually corresponds to a left hemispheric stroke since the left hemisphere is dominant in the majority of individuals
Apraxia: motor disorder caused by damage to the brain (specifically posterior parietal cortex) and difficulties with motor planning to perform tasks or movements
Confirming an UMN lesion
UMN facial weakness spares the forehead because there is bilateral innervation within the central nervous system from the precentral gyrus until their synapse at the facial nerve nucleus.
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Differential diagnoses
Multiple Sclerosis (less likely than stroke, most commonly affects people between the age of 15 and 50 but can occur at any age, and women twice as likely as men to develop MS)
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Stroke: use diffusion weighted MRI (DW-MRI) to detect type, detects acute brain ischemia in about 90% of patients with ischemic stroke
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