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Case 6: Unbuttoned

When seen in clinic, the patient had no apparent motor deficit: there was no weakness and no gait abnormality.  Although movements of the arms and hands were fluid and skillful, he had to labor for several minutes to button a single shirt button because he seemed not to understand how a button relates to a buttonhole. His repeated efforts to put on a pair of work gloves were equally unsuccessful, and he ended up with the left glove on his right hand and 3 fingers where his thumb should go. Throughout all these efforts his face remained blank, with no indication of either concern or frustration. He spoke in a monotone. Pinprick, temperature and touch sensation were normal over both sides of the face, arm and leg when they were tested separately. However, when tactile stimuli were presented simultaneously on the left and right, only the right-sided stimuli were recognized. He could not see objects on his left with either eye (visual field testing showed an incomplete left homonymous hemianopsia). 

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Diagrams

DX

Occlusion of inferior branches in non-dominant hemisphere

Note

Expert Note Case 6.

Unbuttoned

This patient demonstrates several aspects of left-sided neglect. In addition, he seems to have lost an understanding of 3-D spatial concepts in general, as exemplified by his inability to button his shirt or put on gloves correctly (dressing apraxia).  The precise localization of his problem is not known, but often the posterior parts of the parietal and temporal lobes are involved. His face and speech indicate little emotion, but it is difficult to know whether he is unconcerned by his deficit, or is unable to express emotion through facial expressions or intonation as a result of the stroke. The incomplete homonymous hemianopsia is produced by damage to some of the fibers in the visual radiations that run through this region. The primary motor and somatosensory cortex, which tends to lie in the territory of superior MCA branches, was ultimately spared in this patient. However in the acute phase of his stroke he showed some facial weakness because of brain swelling that affected the functioning of the motor cortex.