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Isolated hand weakness
EJINME-03380; No of Pages 2 European Journal of Internal Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Isolated hand weakness Guan Sen Kew 1, Vijay K. Sharma 1, Jonathan J.Y. Ong ⁎,1 National University Hospital Singapore, Department of Neurology, Singapore
a r t i c l e
i n f o
Article history: Received 11 August 2016 Accepted 2 October 2016 Available online xxxx Keywords: Cerebral infarction Hand weakness Wrist drop
1. Indication A 63-year old man, with a past medical history of hypertension and dyslipidemia, presented with a one-day history of isolated left-hand weakness of sudden onset. Neurological examination revealed a left ‘wrist-drop’ and weak extension of the digits. Sensation was intact. Brain magnetic resonance imaging (MRI) showed a typical ‘omega’ shaped area of restricted diffusion in the ‘motor hand strip’ over the M1 ‘knob area’ (A). There was the presence of a large homogeneous plaque with surface ulceration on cervical duplex sonography of the right internal carotid artery (B) and microembolic signals were observed on transcranial Doppler (C). The patient was commenced on anti-thrombotic medications. The neurological deficits resolved rapidly within a week. What is the diagnosis?
Panel A Axial MRI brain shows a focus of restricted diffusion involving the omega-shaped ‘motor hand area’ of the right precentral gyrus. Panel B Cervical duplex sonography shows a large homogeneous plaque in distal common carotid artery with surface ulceration. Panel C Spontaneous microembolic signal was noted on extended transcranial Doppler monitoring.
⁎ Corresponding author at: Division of Neurology, Department of Medicine, 5 Lower Kent Ridge Road, National University Hospital, Singapore 119074, Singapore. E-mail addresses: [email protected] (G.S. Kew), [email protected] (V.K. Sharma), [email protected] (J.J.Y. Ong). 1 These authors contributed equally to the manuscript.
http://dx.doi.org/10.1016/j.ejim.2016.10.001 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Kew GS, et al, Isolated hand weakness, Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.10.001
e2
G.S. Kew et al. / European Journal of Internal Medicine xxx (2016) xxx–xxx
Cortical wrist-drop from acute stroke secondary to artery-to-artery thromboembolic etiology.
Jonathan J Y Ong — study concept and design, acquisition of data, critical revision of manuscript for intellectual content.
2. Diagnosis Author disclosures This case highlights that a pseudo-peripheral palsy from a cortical etiology needs to be considered when patients present with a wrist-drop of acute onset. This has important clinical relevance as the management strategy for an optimal outcome would greatly differ. Recognition of the ‘omega’ sign on MRI brain, which corresponds to the cortical motor hand area, provides excellent clinical–radiological correlation and allows the diagnosis to be clinched confidently. Cervical duplex sonography and transcranial duplex sonography are useful investigative modalities that can assist in elucidating the stroke etiology in such cases [1].
Guan Sen Kew — reports no disclosures. Vijay K Sharma — reports no disclosures. Jonathan J Y Ong — reports no disclosures.
Conflict of interest statement Dr. Jonathan JY Ong, Dr. Vijay K Sharma and Dr. Guan Sen Kew report no conflict of interest that is relevant to this manuscript.
Author contributions Guan Sen Kew — study concept and design, acquisition of data, critical revision of manuscript for intellectual content. Vijay K Sharma — study concept and design, acquisition of data, critical revision of manuscript for intellectual content.
Reference [1] Peters N, Müller-Schunk S, Freilinger, et al. Ischemic stroke of the cortical “hand knob” area: stroke mechanisms and prognosis. J Neurol Jul 2009;256(7):1146–51.
Please cite this article as: Kew GS, et al, Isolated hand weakness, Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.10.001
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Isolated hand weakness Guan Sen Kew 1, Vijay K. Sharma 1, Jonathan J.Y. Ong ⁎,1 National University Hospital Singapore, Department of Neurology, Singapore
a r t i c l e
i n f o
Article history: Received 11 August 2016 Accepted 2 October 2016 Available online xxxx Keywords: Cerebral infarction Hand weakness Wrist drop
1. Indication A 63-year old man, with a past medical history of hypertension and dyslipidemia, presented with a one-day history of isolated left-hand weakness of sudden onset. Neurological examination revealed a left ‘wrist-drop’ and weak extension of the digits. Sensation was intact. Brain magnetic resonance imaging (MRI) showed a typical ‘omega’ shaped area of restricted diffusion in the ‘motor hand strip’ over the M1 ‘knob area’ (A). There was the presence of a large homogeneous plaque with surface ulceration on cervical duplex sonography of the right internal carotid artery (B) and microembolic signals were observed on transcranial Doppler (C). The patient was commenced on anti-thrombotic medications. The neurological deficits resolved rapidly within a week. What is the diagnosis?
Panel A Axial MRI brain shows a focus of restricted diffusion involving the omega-shaped ‘motor hand area’ of the right precentral gyrus. Panel B Cervical duplex sonography shows a large homogeneous plaque in distal common carotid artery with surface ulceration. Panel C Spontaneous microembolic signal was noted on extended transcranial Doppler monitoring.
⁎ Corresponding author at: Division of Neurology, Department of Medicine, 5 Lower Kent Ridge Road, National University Hospital, Singapore 119074, Singapore. E-mail addresses: [email protected] (G.S. Kew), [email protected] (V.K. Sharma), [email protected] (J.J.Y. Ong). 1 These authors contributed equally to the manuscript.
http://dx.doi.org/10.1016/j.ejim.2016.10.001 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Kew GS, et al, Isolated hand weakness, Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.10.001
e2
G.S. Kew et al. / European Journal of Internal Medicine xxx (2016) xxx–xxx
Cortical wrist-drop from acute stroke secondary to artery-to-artery thromboembolic etiology.
Jonathan J Y Ong — study concept and design, acquisition of data, critical revision of manuscript for intellectual content.
2. Diagnosis Author disclosures This case highlights that a pseudo-peripheral palsy from a cortical etiology needs to be considered when patients present with a wrist-drop of acute onset. This has important clinical relevance as the management strategy for an optimal outcome would greatly differ. Recognition of the ‘omega’ sign on MRI brain, which corresponds to the cortical motor hand area, provides excellent clinical–radiological correlation and allows the diagnosis to be clinched confidently. Cervical duplex sonography and transcranial duplex sonography are useful investigative modalities that can assist in elucidating the stroke etiology in such cases [1].
Guan Sen Kew — reports no disclosures. Vijay K Sharma — reports no disclosures. Jonathan J Y Ong — reports no disclosures.
Conflict of interest statement Dr. Jonathan JY Ong, Dr. Vijay K Sharma and Dr. Guan Sen Kew report no conflict of interest that is relevant to this manuscript.
Author contributions Guan Sen Kew — study concept and design, acquisition of data, critical revision of manuscript for intellectual content. Vijay K Sharma — study concept and design, acquisition of data, critical revision of manuscript for intellectual content.
Reference [1] Peters N, Müller-Schunk S, Freilinger, et al. Ischemic stroke of the cortical “hand knob” area: stroke mechanisms and prognosis. J Neurol Jul 2009;256(7):1146–51.
Please cite this article as: Kew GS, et al, Isolated hand weakness, Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.10.001