A 45-Year-Old Woman Was Brought to the Emergency Room Because of Right Face and Arm Weakness

A 45-year-old woman was brought to the emergency room because of right face and arm weakness and inability to speak. The patient had a past history of alcohol use, cigarette smoking, and uncontrolled hypertension. On the morning of admission, she staggered into her kitchen where her husband was eating breakfast; she was grunting incoherently and grimacing in pain. Her foot caught on the leg of a chair; she tripped and fell to the floor. Her husband called for emergency medical services (ambulance) and she was transported to the emergency department of the closest hospital. Uponexamination, thefollowingwasnoted:

Mental Status:She was alert, but only grunted producing no words. She followed no commands except to close her eyes or and open her mouth, but she could mimic gestures to raise her arms or legs.
Cranial nerves:Her pupils were 3 mm, constricting to 2 mm bilaterally when the pupillary light reflex was tested. She had preserved blink to threat bilaterally, meaning that when startled by rapid, close-range visual approach, she blinked bilaterally in a normal fashion. Her extraocular movements were intact. She did display a decreased, right nasolabial fold at rest (weakness in right lower face), and she showed decreased movements of her right lower face; however, her upper face was spared.
Motor:She showed no spontaneous or voluntary right arm movement, except for flexion-withdrawal from a painful stimulus. She was able to raise her right leg off the bed, but not with normal force against resistance. She did show good, purposeful movements of her left arm and leg against resistance.
Somatic sensory:She grimaced in response to pinch in all extremities, but she showed reduced mechanosensation (light touch and proprioception) over her right face and right arm with sparing of the lower right leg. Similarly, she could not accurately localize the sharp point of contact on her right face and right arm when tested with the point of a pin, but localizations were normal elsewhere.

Over the next few days of in-patient care, the patient’s communication problems evolved into a more focused problem making speech. By 6 days after admission, she was only able to utter a few barely articulate words. She could not repeat words spoken to her, but she could follow many simple commands and answer yes/no questions appropriately.

Case 2

A 71-year-old woman was referred to your clinic because of difficulty walking. In the course of interviewing this woman, you discover a 10-month history of progressive gait difficulty, right leg numbness, and urinary problems. The patient was in good health, walking 3 to 4 miles per day until about 10 months ago, when she first noticed mild gait unsteadiness and bilateral leg stiffness. She felt her feet were not fully under her control. Her left leg gradually became weaker than her right, with occasional left leg buckling when she walked.

Meanwhile, her right leg developed progressive numbness to sharp pricks and tingling sensations, and she had intermittent left-sided thoracic back pain. More recently, she had increasing urinary frequency, with occasional incontinence, and difficulty completing a bowel movement despite laxatives. Uponphysicalexamination, you note thefollowing:

Rectal:normal tone; however, patient could not voluntarily contract anal sphincter.
Cranial nerves:all sensory and motor functions were normal.
Motor:upper extremities—normal bulk and tone, with normal strength throughout; lower extremities—normal bulk, with tone increased in left leg and moderate impairments of strength throughout.
Coordination:normal throughout, except for some ataxia of left lower extremity with heel-to-shin testing (left heel running up and down against right shin).
Gait:stiff-legged and unsteady.
Somatic sensory:pinprick sensation was decreased on the right side below the umbilicus; light touch, vibration and joint position sense were decreased in the left foot and leg.

All sensory and motor functions appear to be intact in the arms and in the face.

Rectal:normal tone; however, patient could not voluntarily contract anal sphincter.
Cranial nerves:all sensory and motor functions were normal.
Motor:upper extremities—normal bulk and tone, with normal strength throughout; lower extremities—normal bulk, with tone increased in left leg and moderate impairments of strength throughout.
Coordination:normal throughout, except for some ataxia of left lower extremity with heel-to-shin testing (left heel running up and down against right shin).
Gait:stiff-legged and unsteady.
Somatic sensory:pinprick sensation was decreased on the right side below the umbilicus; light touch, vibration and joint position sense were decreased in the left foot and leg.

All sensory and motor functions appear to be intact in the arms and in the face.

A 29-year-old man was referred to physical therapy because of a cervical strain injury that happened during a recent motor vehicle accident. The man was attempting to enter traffic from a street-side parking place where he had parallel parked; he admits that he failed to accurately judge the flow of traffic into which he was entering.

In the course of your physical examination of this individual, you decide to perform some simple visual field testing and discover that the man cannot see much of anything to the left of midline with either eye.

How would you BEST describe this patient’svisual field deficit?

Upon further discussion with the patient, you learn that he has a significant medical history. About 5 or 6 years ago, the patient began having complex partial seizures, meaning that he had seizures that began in one location in the brain with an accompanying temporary loss of consciousness. One year ago an MRI revealed a left temporal lobe tumor and he underwent tumor resection. Upon resection, the tumor was found to be a pilocyticastrocytoma, and he was treated with chemotherapy and radiation therapy with an initially good response.

Case6

Despite the presence of abnormal sensorimotor experience in this infant because of its congenital malformation, appropriate physical interventions may promote the acquisition of functional behaviors. At the level of neural circuits and systems, such physical interventions are promoting all of the following activities (we hope!), EXCEPT for which one?

experience-dependent increases in programmed cell death (apoptosis) and excitotoxicity in functional neural circuitsgrowth and development of functional neural circuits due to the structured intervention engendering increased production of neurotrophinmoleculesgrowth and development of functional neural circuits due to the structured intervention engendering the “awakening” of silent synapses in functional neural circuitsgrowth and development of functional neural circuits due to the structured intervention engendering synergy between self-organization and experience-dependent mechanisms of circuit constructiongrowth and development of functional neural circuits due to the structured intervention engendering coordinated patterns of presynaptic and postsynaptic activity

Some months ago, two patients suffered strokes involving small penetrating branches of the arteries that supply the upper medulla. The regions affected by these strokes are indicated in the image below by the regions outlined in red labeled “Case 3” and “Case 4” (note “left” and “right” on the sides of the image indicating the left and right sides of this histological section).