Radha comes to your surgery with her husband. She says she woke up and her hand felt funny and she had trouble washing her hair and face as her hand felt clumsy. Her husband advises that the left side of her face does not appear normal as it should.You continue to gather more information to further define the problem. Radha is 35 and was previously well. She awoke with a story of left sided arm and face weakness. There was associated neglect. There was no headache. She now feels well. Radha does not smoke, and is not on the oral contraceptive pill or any other drugs. She is usually well except for migraines which she has had for years. These consist of visual aura and unilateral headaches. Her past history includes two mid trimester abortions (para 2, gravida 4) and a deep vein thrombosis. Her mother suffered a stroke at the age of 48.

Physical Examination

Other than left sided weakness, sensory loss and neglect there were no other positive findings.
Her BP is normal.

Neglect
Some patients with damage to a primary cortical sensory area can have normal or almost normal sensation (visual or somato-sensory) for a particular region but perform poorly when the same stimulus is applied to a comparable region on the other side of the body. Extinction or sensory neglect are commonly used terms for this phenomenon. It is customary to compare opposite sides of the body at the same level e.g. hand-hand, temporal field-temporal field. First ensure sensation is detected in both sides then ask the patient to close their eyes and say which side was touched. Randomly touch one side, then the other or both, similarly asking the patient to identify which temporal field was stimulated by wiggling fingers while stimulating one, then the other or both. Failure to recognise double stimulation and identify it as only on the "normal" side or slow recognition, suggests neglect. Neglect is present only if it is considerably more obvious than what could be expected from the sensory deficit to formal examination. Some people say neglect cannot be diagnosed unless formal sensory testing is normal. Motor neglect is a similar concept. The subject fails to use the hand and this failure is out of proportion to the weakness. This deficit is most obvious in bi-manual tasks (such as using cutlery or knitting) or when use of the left hand is expected but the subject continues to use the right in an awkward manner. Neglect is most obvious with right hemisphere lesions.

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