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 Table of Contents  
TEACHING IMAGES
Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 111-112

Pseudoperipheral palsy: A rare stroke "chameleon" due to cortical "hand knob" infarction


1 Department of Medicine, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India

Date of Web Publication4-Jun-2014

Correspondence Address:
Bhaskara P. Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.133851

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How to cite this article:
Rappai SC, Harishchandra P, Shelley BP. Pseudoperipheral palsy: A rare stroke "chameleon" due to cortical "hand knob" infarction. Arch Med Health Sci 2014;2:111-2

How to cite this URL:
Rappai SC, Harishchandra P, Shelley BP. Pseudoperipheral palsy: A rare stroke "chameleon" due to cortical "hand knob" infarction. Arch Med Health Sci [serial online] 2014 [cited 2019 Dec 14];2:111-2. Available from: http://www.amhsjournal.org/text.asp?2014/2/1/111/133851


  Case Report Top


A 60-year-old lady with hypertension and dyslipidemia developed acute onset of isolated pure motor flaccid fractional weakness of the left distal hand while waking up in the morning after an uneventful night's sleep. For the last 2 months, she developed a new onset right-side locked vascular headache accompanied by intermittent visual obscuation in her right eye, right-sided scalp allodynia, and scored four on the Wong-Baker faces rating scale and 8 out of 10 in the numerical pain rating scale. Neurologic abnormalities revealed partial differential median nerve greater than radial nerve involvement [Figure 1]. The right superifical temporal artery was tender with decreased pulsations. Her nerve conduction study was normal, erythrocyte sedimentation rate (ESR) was 40 mm/1 st hour, elevated C-reactive protein with a thrombocytosis of 8 lakh cells/mm 3 . Temporal artery biopsy revealed histopathological evidence of treated temporal arteritis. Neuroimaging showed acute infarct in right precentral gyrus with selective involvement of the hand motor cortex. [1] She was started on 1 mg/kg/day of prednisolone and triple therapy. During follow-ups, she had made almost complete recovery of her pseudoperipheral weakness. [2]
Figure 1: (a, b) Patient image demonstrating high-grade flaccid isolated fractional median more than the radial pseudoperipheral nerve palsy of the left hand and wrist, demonstrating pathological "circle sign" due to inability to oppose the tips of digits I and II due to weakness of flexor pollicis longus muscle and the flexor digitorum profundus muscle of the index finger; and (b) demonstrating wrist drop and partial finger drop, (c) FLAIR magnetic resonance imaging (MRI) showing acute infarction of the right precentral "hand knob" area with the "omega sign"

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Even though the diagnosis of stroke is often straightforward, this case does pose the initial question "Is this a CNS event?" To separate the "pearl from the oyster," this case demonstrates clinical "pattern recognition" skills to differentiate stroke "mimics" from stroke "chameleons." This report illustrates the association of giant cell arteritis as the etiology of pseudoperipheral weakness, and reiterates the urgent need for early diagnosis of stroke especially so when selective hand motor cortex infacrtion is documented to be 1% of all ischemic strokes.


  Acknowledgment Top


Informed patient consent was obtained for publication of the case details and [Figure 1].

 
  References Top

1.Celebisoy M, Ozdemirkiran T, Tokucoglu F, Kaplangi DN, Arici S. Isolated hand palsy due to cortical infarction: Localization of the motor hand area. Neurologist 2007; 13:376-9.  Back to cited text no. 1
    
2.Pikula A, Stefanidou M, Romero JR, Kase CS. Pure motor upper limb weakness and infarction in the precentral gyrus: Mechanisms of stroke. J Vasc Interv Neurol 2011; 4:10-3.  Back to cited text no. 2
    


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