Expanding on Case-Based Question

[Masato Kobayashi]

Hoping to expand on the answers to the question below:

49. A 62-year-old male presents to an outpatient physical therapy clinic via direct access for a stroke incurred 20 years ago. The patient is accompanied by his wife who provides much of his history, including details about positive results from previous episodes of physical therapy. The patient responds to questions appropriately, although his speech appears effortful and is marked by short sentences lacking details. The patient is concerned about deteriorating gait and increasingly frequent falls due to tripping on his weaker right leg. The patient has more profound upper extremity involvement with chronic shoulder subluxation and absent hand function. He denies any spasticity or spasms.

Complete manual muscle testing in the lower extremities is as follows:
– Hip flexion: 4/5 RLE, 5/5 LLE
– Hip extension: 4/5 RLE, 5/5 LLE
– Knee flexion: 3/5 RLE, 5/5 LLE
– Knee extension: 4/5 RLE, 5/5 LLE
– Ankle dorsiflexion: 2/5 RLE, 5/5 LLE
– Ankle plantarflexion: 4/5 RLE, 5/5 LLE
– Ankle inversion: 2/5 RLE, 5/5 LLE
– Ankle eversion: 2/5 RLE, 5/5 LLE

No spasticity noted in the right upper or lower extremity. Mild hypotonia noted in the right shoulder.

Range of motion is grossly within functional limits with no contractures noted.

Sensation is grossly intact to light touch and proprioception in bilateral upper and lower extremities.

The patient has no previous notes in the electronic medical record. Based on the information obtained during examination, which area of his brain do you suspect was affected in his stroke?
a. Left frontal lobe
b. Left parietal lobe
c. Left temporal lobe
d. Left internal capsule

Left parietal lobe would be correct if patient presents with Wernicke’s aphasia and/or right hemibody sensory deficits?
Left temporal lobe would be correct if patient presents potentially with right homonymous hemianopia?
Left internal capsule would be correct if patient presented primarily with motor and/or sensory deficits and no “cortical” deficits such as speech dysfunction?

Is my thinking on the right track with lesion localization?

[Chrissy Durrough Lugge]

Hi Masato!

Wernicke’s area is located in the temporal lobe. The parietal lobe plays some role in auditory processing and comprehension, so some degree of aphasia may be present with a left parietal lobe stroke – though this is less clean than a frontal or temporal lobe infarct.

Homonymous hemianopsia could occur with damage to the occipital lobe, inferior temporal lobe, or deep structures like the thalamus and internal capsule.

An internal capsule stroke would be most likely to present with pure motor and sensory deficits. The patient could have dysarthria affecting speech but aphasia would not be present.

Hope this helps!

Chrissy

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