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This 79 year old right-handed White Male presented to University Hospital
with a chief complaint of inability to use his computer.
The patient had been working at his computer all night; he took a break
approximately 8 AM. At 9:30 AM he tried to resume, but he found that he did
not know how to use his computer. He also was unable to play his guitar. When
his symptoms failed to improve as the day wore on, he decided to come to
the ER for evaluation.
On examination, he had several subtle problems with language. His ability
to name both high and low frequency objects was impaired. His speech had an
expressive aprosody; there was little variation in speech with emotion. He
had echolalia. He could remember 3/3 objects immediately, but none (0/3) in
5 minutes. He could spell the word "WORLD" forwards, but not backwards. He
was unable to identify his fingers correctly. He reported that an apple,
peach, and pear were "fruits"; but that a table, chair, and bed were "just
three objects". He was unable to adequately demonstrate how to use a
toothbrush without using his finger as a prop.
There was a mild right lateral rectus paresis and a right homonymous
hemianopsia. He ignored those that spoke to him from the right. There
was only a mild right pronator drift and mild weakness of his right
upper extremity. He had a Babinski sign on the right and decreased
appreciation of light touch and pin-prick in his right hand.
A CT Scan showed a 3 cm X 4 cm hemorrhage in the left posterior
parietal lobe with surrounding edema and minimal mass effect.
Questions:
- How does this lesion explain Mr. W's deficits? Answer this for:
a) his language problem
b) his apraxia
c) his neglect
d) his hemianopsia
e) his motor and sensory signs
f) his lateral rectus paresis.
- Define Gerstmann's Syndrome.
- What is the differential diagnosis of a hemorrhage such as this one?
- What work-up would you obtain for this patient?
- What are the major long-term complications of an intracerebral hemorrhage?
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