CLINICAL CASE ANALYSES: CEREBRUM AND HIGHER CORTICAL FUNCTION

Cadua, Shana Ylissa V.

De Los Reyes, Aurielle Nisa K.
Madlangbayan, Missy Mae De Castro
BSPT 2-1 B Group 2

Define CLINICAL QUESTION 1: Cerebrovascular Accident (Stroke) Section 1 and 2; Sections 3 and 4

1)CVA (short definition and discussion only)

- This is an event that occurs as a result of restricted or blocked supply of blood to the brain. The blockage is caused
by a blood clot. Starvation of oxygen and nutrients in the parts of the brain cells start to die which can cause brain
damage or even death.

2) What are the most common clinical signs/symptoms of patients with CVA of the cerebrum? You may base your answers
on your knowledge on cerebrum, or may research on this from your books. Fill the table below with 10 common clinical s/sx
with a corresponding localization of lesion.

Clinical Sign/Symptom Possible Area of Lesion in the Nervous System/Brain

1. Confusion - Parietal Lobe (Inferior Parietal Lobule-

SUPRAMARGINAL)
- Multimodal sensory area (BA 40)

2. Difficulty understanding - Temporal Lobe (Superior temporal)

- Wernicke’s (BA 22)

3. High Blood Pressure - Brain stem

4. Loss of balance - Cerebellum (Flocculonodular Lobe)

5. Numbness - Parietal Lobe ( Post Central)

- Primary somatosensory (BA 3,1,2)

6. Face drooping - Frontal Lobe (Pre-central)

- 1 Motor Area (BA 4)
 7. Trouble in speaking (Aphasia) - Frontal Lobe (Inferior Frontal)
- Broca’s (BA 44,45)

8. Trouble in walking - Superior & Middle Frontal (Premotor &

Supplementary Motor
- BA 6

9. Vision changes - Occipital Lobe (Cuneus and lingual gyrus)

- Primary visual receptor cortex (BA 17)

10. Weakness - Frontal Lobe (Pre-central)

- 1 Motor Area (BA 4)

CLINICAL CASE 1: A man who talks non-sense Sections 1 and 2

You are a physical therapist working in a neurorehabilitation facility. Your first patient today is a new referral from the physiatrist
in charge of your clinic. You met your patient and saw that he is clearly agitated and talks gibberish. You started asking
questions to know his clinical history, but he says very little, but when he does speak, it is non-sensical. He cannot repeat
words nor understand, and obey your instructions, which frustrate you because you cannot complete your PT examination.
Being a good physical therapist that you are, you still tried your best to examine your patient, which revealed the following
findings: he appears to have lost his right visual field in both eyes, his eyes are driven to the left, and cannot look towards the
right. She has a right-sided facial droop, but the tongue, uvula and palate are in midline (normal). Motor examination reveals:
increase in muscle tone of the right upper and lower extremities, increased reflexes on the right side (hyperreflexia, 3+), and
presence of Babinski reflex on the right toe. The patient is unable to move her right upper extremity at all, but the right lower
extremity can move a little, but with apparent severe weakness. Furthermore, the patient is unresponsive to pain and light
touch sensation on the right UE, and has decreased sensation as to pain and light touch on the right LE (described as 50%
deficit as compared to the left side). Because of these findings, coordination is impossible to assess.

Guide Questions

1. What are the neurologic signs and symptoms of your patient #1?

● Cannot repeat words nor understand

● Loss of right visual field in both eyes and his eyes are driven to the left and cannot look at the right
● Has right-sided facial droop but the tongue, uvula and palate in the midline are normal
● Increase in muscle tone of the right upper and lower extremities
● Increased reflexes on the right side of the body
● Presence of Babinski Reflex on the right toe
● Unable to move right upper extremity at all but the right lower extremity can move a little but with apparent severe
weakness
● Unresponsive to pain and light touch sensation on the right upper extremity
● Decreased sensation as to pain and light touch on the right lower extremity (described as 50% deficit compared to
the left side)

2. What is the most likely cerebral hemisphere that is affected? Justify.

 - The most likely cerebral hemisphere that is affected is the left cerebral hemisphere. The reason why is that the
patient presented symptoms that says he is unable to move his right UE and can only move the right LE a little, he
is also unresponsive to pain and light touch sensation on the right UE and decreased sensation to pain and light
touch on the right LE. The patient cannot repeat nor understand words and we all know that the left cerebral
hemisphere controls the language function and when the patient is experiencing difficulty in understanding and
speaking fluently, that means he might be experiencing aphasia.

3. Looking at your patient’s clinical s/sx, what are the possible structures of the brain are affected? You may use a table
for justification.

PATIENT’S CLINICAL SIGNS SYMPTOMS POSSIBLE STRUCTURES OF THE BRAIN AFFECTED

Left Brodmann Area 8

Loss of right visual field in both eyes and his eyes are
driven to the left and cannot look at the right

Facial Nerve (CN VII)

Has right-sided facial droop but the tongue, uvula and
palate in the midline are normal

Hemiparesis Brodmann Area 4

Left Hemisphere
Unable to move right upper extremity at all but the right
lower extremity can move a little but with apparent severe
weakness

Corticospinal Tract
Increased reflexes on the right side of the body

Hyperreflexia

Babinski reflex

Brodmann Area 44, 45

Cannot repeat words nor understand

Upper Motor Neuron

Increase in muscle tone of the right upper and lower
extremities

4. What are the lobes of the brain are affected based from your answers above? What is more affected, the lateral or medial
cerebral hemisphere, or are they equally affected? Justify.

-Based on the answers above, we can say that the lateral and medial cerebral hemisphere are equally affected because the
signs and symptoms are affected in different structures that might have lesions of the brain and are spread out from the lateral
to the medial hemisphere.
CLINICAL CASE 2: Why can’t you remember me?! Sections 1 and 2

Your next patient, patient X, is scheduled for your 10 AM PT session. This patient of yours is diagnosed to have a benign
brain tumor. He greets you good morning, and says “your facial features are moving all around your face and I can’t
remember you but I feel like I know you!” When you greeted him back, he recognized your voice and remembered you
as his Physical Therapist. You decided to reassess this patient to check for any improvements and know what specific
part of the brain is actually affected by the tumor. The patient can walk, there was no noted muscle weakness, no noted
muscle tone and reflex changes. He is able to write normally on a piece of paper her name and address, but when
shown his own writing a few minutes later, he is unable to read it. You tested his short-term memory by asking what he
ate for breakfast and what he did earlier this morning, he also wasn't able to remember anything.

Guide Questions

1. What are the neurologic s/sx of your patient #2?

-Since the patient was not able to recognize the face of the physical therapist or have difficulty in recognizing faces
resulting in Prosopagnosia or Face Blindness. In this case, the patient has damage or lesions to the visual association
area (BA 18, 19). On the other hand, the patient is suffering from a short-term memory resulting in dyslexia or inability
to read. In this case, the patient has damage or lesion to BA 39.

2. Looking at your patient’s clinical s/sx, what are the possible structures of the brain that are affected? You may use a table
for justification.

Patient’s Clinical Signs/Symptoms Possible Structures of the brain affected

Prosopagnosia or Facial Blindness -Cuneus and lingual gyrus

-BA 18, 19

Dyslexia -Inferior parietal lobule (Angular gyrus)

-BA 39

Impairment or damage in the right fusiform gyrus will result in Prosopagnosia. A fold in the brain that appears to coordinate
the neural systems that control facial perception and memory. The temporal lobe is affected since it is responsible for retaining
visual memory and memory retention. In addition, occipital lobe is responsible for visual processing therefore it is affected.

3. Specify the possible location of the brain tumor based on the patient’s clinical manifestations. Justify.

-The first possible location of the brain tumor is in the temporal lobe considering the temporal lobe is the primary auditory
cortex and the one that receives the sensory information. The common symptoms of brain tumor in this area includes forgetting
words and short-term memory loss. The second possible location of the brain tumor is in the occipital lobe considering the
occipital lobe is responsible for visual perception. The common symptoms of brain tumor in this area includes vision issues,
loss of parts in the visual field and inability to read.

CLINICAL CASE 3: On Denial Sections 3 and 4

Your 3rd patient is already waiting for you, as you approached her, she complained that she tripped while walking on the way
to the clinic. She then says “My husband claims it’s because of my stroke, what is he saying?! I don’t have stroke anymore,
nothing’s wrong with me!”. You calmed her down, as she is very irritable, and asked her to sit for a while checking his vital
signs. Your patient complains of continued numbness and tingling on her left arm and leg. The following findings were revealed
on re-examination: (1) mild weakness of the left leg and left arm, (2) when asked to write or draw a clock, she moved the pen
in the air off to the right of the page (see drawing below) (3) You also showed her this picture (see photo below), and only saw
the curtains and the woman on the right, (4) when asked to hold objects on her hand, she has inability to identify the comb,
key, and pen with closed eyes, but can do so when eyes are opened, and (5) when asked to don and doff her socks and
shoes, she is unable to perform it as of the moment, but claims that she can do it sometimes at home.

Guide Questions

1. What are the neurologic signs and symptoms of your patient #3?

● Anosognosia
● Continued numbness and tingling on her left arm and leg
● Mild weakness of the left leg and arm
● When asked to draw, she moved the pen in the air off to the right of the page
● When shown the picture, she only saw the curtains and the woman
● When asked to hold objects, she has inability to identify objects when eyes are closed but can when eyes are opened
● When asked to don and doff her socks, she is unable to perform it at the moment but claims that she can do it
sometimes at home
● Unable to accept the reality of one’s own condition
● Very irritable

2. What is the most likely cerebral hemisphere that is affected? Justify.

- The most likely cerebral hemisphere that is affected is the right cerebral hemisphere because the right cerebral
hemisphere functions in recognition and the patient showed symptoms that she is having a hard time recognizing
objects when eyes closed and it may be agnosia. It also functions as general behavior and the patient said she can
be irritable. She was also presented with mild weakness of the left leg and arm and that shows that the right cerebral
hemisphere is affected because the right side of the brain controls the left side of the body.

3. Looking at your patient’s clinical s/sx, what are the possible structures of the brain are affected? You may use a table
for justification.

PATIENT’S CLINICAL SIGNS AND SYMPTOMS POSSIBLE STRUCTURES OF THE BRAIN AFFECTED

Hemiparesis (mild weakness of the left leg and arm) -Pre-Central Gyrus → (Primary Motor Area):
Brodmann Area 4

-cuneus and lingual gyrus → (Primary Visual

Right Homonymous Hemianopsia (When asked to draw, area): Brodmann Area 17
she moved the pen in the air off to the right of the page;
Seeing only the right side of the picture)
-Inferior Parietal lobule → (Angular gyrus):
 Hemispatial Neglect Broadmann Area 39
-cuneus and lingual gyrus → ( Visual association
area) : Brodmann Area 18,19

-Superior parietal lobule → (Sensory Association

Astereognosis (inability to identify objects when eyes are area): Brodmann Area 5,7
closed but can when eyes are opened)

-Superior & MiddleFrontal → (Premotor and

Apraxia (When asked to don and doff her socks, she is Supplementary Motor) :Brodmann Area 6
unable to perform it at the moment but claims that she can
do it sometimes at home)

-Inferior parietal lobule-Supramargina →

Anosognosia (unable to accept the reality of one’s condition (Multimodal sensory area): Brodmann Area 40
when accused of having stroke)

4. What are the lobes of the brain are affected based from your answers above?

- Base from the answers above, we can say that the lobes affected are the Frontal Lobe, Parietal Lobe, Temporal
and Occipital Lobe.

5. Why do you think is the PT very cautious in his treatment of this certain patient as compared to the previous ones? What
must be the treatment strategy for this patient? Choose between the two and justify

a. Focus on giving verbal or written instructions

-The Physical Therapist needs to be very cautious in treatment because there are only limited things a patient can do in order
to be treated right and avoid any problems. The treatment strategy for the patient is to focus on giving verbal or written
instructions. Since the patient is experiencing symptoms and signs that are active in the right hemisphere, it is best to give
heavy instructions instead of demonstrating because the right cerebral hemisphere focuses on visual-perceptual functions
which may give the patient a hard time to understand the treatment. It is best to give instructions because the patient’s left
cerebral hemisphere is still functioning well and that side focuses on speech and language so it will be easier for the patient
to understand the treatment.

CLINICAL CASE 4: Split Sections 3 and 4

Another new patient today came in, your 4th patient, came with difficulty walking as manifested by her preference being brought
to the clinic using her wheelchair. You looked at her medical chart and saw that the diagnosis is “CVA due to atrial fibrillation”.
This patient complains of paralysis on both the right UE and LE, there is noticeable right facial droop. Motor examination
reveals: increase in muscle tone of the right upper and lower extremities, increased reflexes on the right side (hyperreflexia,
3+), and presence of Babinski reflex on the right toe. During the rest of your neurologic examination, your patient can recall
almost all information, can speak without difficulty, and has no noted sensory or visual deficit except for one: When you placed
a pen on both the left then the right hand after, there was inability, with closed eyes, to identify verbally an object held in the
left hand. However, the patient was able to identify the pen verbally when placed on the right.

Guide Questions

1. What are the neurologic signs and symptoms of your patient?

The neurologic signs and symptoms of the patient were:

● Difficulty in walking
● Paralysis on both the right UE and LE
● Right facial droop
● Increase in muscle tone of the right UE and LE
● Increased reflexes on the right side (Hyperreflexia, 3+)
● Presence of Babinski on the right toe
● Astereognosis (inability to recognize object by touch when eyes are closed but can when eyes are opened)

2. Looking at your patient’s clinical s/sx, what are the possible specific structures of the brain that are affected? You may
use a table for justification.

PATIENT’S CLINICAL SIGNS AND SYMPTOMS POSSIBLE STRUCTURES OF THE BRAIN AFFECTED

Difficulty in walking -Pre-central → (Primary Motor Area) : Brodmann

Area 4
-Superior Frontal → (Premotor and Secondary
Motor Cortex) :Brodmann Area 6

Hemiparesis-Paralysis on both right UE and LE -Pre-central → (Primary Motor Area) :Brodmann

Area 4

Bell’s Palsy-Right facial droop -Cranial Nerve VII

Increase in muscle tone of the right UE and LE -Upper motor neuron, Basal ganglia, Frontal lobe
(Hypertonia) -BA 6

Increased reflexes on the right side of the body -Corticospinal tract

(Hyperreflexia,3+)

Presence of Babinski reflex on toe -Corticospinal tract

Astereognosis (inability to recognize object by touch in left -Superior parietal lobule → (Sensory
hand when eyes are closed but can when eyes are Association area) : Brodmann Area 5,7
opened)

3. Which is affected: lateral cerebral hemisphere, medial cerebral hemisphere, or none?

-Both the motor and sensory homunculus are affected. Paralysis or unilateral weakness of right UE and LE will affect both
lateral and medial cerebral hemisphere.
4. Based from your answers above, and from your own clinical analysis of your patient’s s/sx, which is most likely affected?
Justify.

Based on the answers above, we can say that the most likely affected are the Frontal Lobe and Parietal Lobe of the Cerebral
Cortex.

a. Cerebral cortex

- The Cerebral cortex is the most affected from our own clinical analysis of the patients clinical signs and symptoms, the most
likely affected is the cerebral cortex. The patient is experiencing difficulty in walking which is possibly caused by a lesion to
the frontal lobe of the precentral gyrus which is responsible for motor activity. A lesion to the corticospinal tract causes the
increased reflexes of the right side of her body (hyperreflexia). The increase in muscle tone of the right UE and LE is caused
by a lesion in the Superior frontal lobe (BA 6), Basal Ganglia and the upper motor neuron. The parietal lobe of the precentral
gyrus (BA 3,1,2) which presented a Babinski reflex on the toe. Astereognosis can be possibly caused from the cerebral cortex
specifically, the superior parietal lobule in the Sensation association area of Brodmann area 5,7

b. Subcortical white matter

c. Basal ganglia

References

Increased Tone. (2006, July 17). Case Western Reserve University School of Medicine. Retrieved from
http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Increased%20Tone.htm#:%7E:text=When%20muscle%2
0tone%20is%20increased,with%20upper%20motor%20neuron%20disorders.

Lohia, A. (2020, July 31). Neuroanatomy, Pyramidal Tract Lesions - StatPearls - NCBI Bookshelf. NCBI. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK540976/#:%7E:text=Damage%20to%20the%20corticospinal%20tract,cranial%20ne

rves%20VII%20or%20X.

Mandal, A. (n.d.). What is Cerebrovascular Disease? Retrieved from News Medical Life Science: https://www.news-
medical.net/health/Cerebrovascular-Disease.aspx

Guyton and Hall textbook of medical physiology / John E. Hall.—Thirteenth edition.