In message <l03130304b12b9da0e2b5@[129.97.13.62]>, Rhona Thornton
<[log in to unmask]> writes
>I saw a patient today who had a stroke (right hemiplegia) 2 years ago.
>It appears that he did not have lot of muscle weakness at the time
>of the stroke and now his main complaints are poor balance and
>decreased sensation in this lower leg and foot.
>
>From the assessment he seems to have two main problems:
>1) Impaired lower leg sensation especially light touch but also
>proprioception to a lesser extent.
>
>2) Dizziness (ie. the room spins) brought on by:
> -extending his head in sitting or standing
> (unable to do so in standing)
> - turning his head from side to side especially if he moves fast.
>
>He walks independently but is a little unsteady and uses a cane outside.
>His standing balance is poor with a tendancy to lean back and he is
>very dependent on visual feedback.
>
>His muscle strength is almost equal bilaterally but he has slight weakness
>in the right lower limb especially in his dorsiflexors.
>
>Becuase of the dizziness I suspected vestibular problems and crudely
>checked the vestibular occular reflex- when he turns his head from side
>to side he wasn't able to maintain a fixed gaze.
>
>My questions are;
>1) Does this sound like a vestibular problem or have people seen
>similar patterns of dizziness in people with cerebral hemisphere
>stroke?.
>2) If so this would mean he would have had to have a brainstem stroke
>(a CT has not been done) and would this fit with his other symptoms of
>sensory loss and mild weakness (I think that would mean it would have
>had to have affected the ascending and descending fibres and either the
>vestibular nuclei or vestibulo spinal tract).
>
>Sorry this note is so long.
>I'd appreciate any thoughts/ideas on these issues.
>
>Thanks,
>Rhona Thornton
>
>
It does sound like he has a problem somewhere in his balance mechanism
and it could be peripheral or central or a mixture of both!
Peripheral:
Did he fall at all when he had the stroke? Blows to the temporal bone
or occipital area can produce a 'concussion' of the middle ear.
It is posible he had some ischaemia affecting the blood supply to the
labyrinth (I seem to recall that there is a particular branch that is
vulnerable to this over only a short period)
Central:
Central factors are not limited to the nuclei - is there cerebellar
involvement?
Vertebrobasilar insufficiency - is he hypotense?
Multi infarct or small ischeamic patches - repeated episodes of
hypotension or mechanical blocking of already poor blood flow could
affect areas supplied by the vertebral arteries, i.e. brainstem,
cerebellum, labyrinth.
Of course he may have a coincidental peripheral vestibular problem....
Other than excluding treatable medical conditions a differential
diagnosis of causation will help you decide whether to treat actively to
promote any available compensation or stick to compensatory strategies.
Hope this is of some help.
Maggie
--
Maggie Campbell
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+44 (0)114 268 6963
Sheffield UK
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