Provincial Hub Syndromes, Temporal, Parietal and Acquired Cultural Circuit Syndromes

Abstract

At times, more restricted lesions of the brain areas may lead to involvement of so-called provincial hubs or more localized or confined brain regions. Several typical brain images are presented in Fig. 12.1. The parietal and temporal lobes are often involved with such lesions and both have been reported as relatively “silent” areas of the brain when restricted lesions affect these areas. A case in point is that of image 1 in figure. The middle-aged woman presented as a so-called “stroke alert” to our emergency room with her main presenting symptom a sudden severe headache with otherwise normal neurological examination and normal NIH stroke score of 0. With administration of analgesics, a rapid improvement of her headache ensued and she was cleared for discharge with a presumptive diagnosis of migraine to which she was prone to. Just prior to her discharge, the fasttracked MRI scan became available and revealed a small left parietal hemorrhage. Given the location, she was evaluated for left parietal syndromes including a Gerstmann’s syndrome and angular gyrus syndrome, the former which was her ultimate clinical diagnosis. In emergent as well as most routine stroke presentations, Gerstmann’s syndrome is rarely specifically tested for, and indeed in our case it was the only discernible neurological deficit. This brief case report underscores the value of cognitive and behavioral neurological syndrome evaluation. In emergent cases, neuroimaging is often revealing and can guide the examination. Given a lesion, what specific syndromes may be present?