A case report of isolated distal upper extremity weakness due to cerebral metastasis involving the hand knob area

Abstract

Background: Unilateral weakness of an upper extremity is most frequently caused by traumatic nerve injury or compression neuropathy. In rare cases, lesion of the central nervous system may result in syndromes suggesting peripheral nerve damage by the initial examination. Pseudoperipheral hand palsy is the best known of these, most frequently caused by a small lesion in the contralateral motor cortex of the brain. The 'hand knob' area refers to a circumscribed region in the precentral gyrus of the posterior frontal lobe, the lesion of which leads to isolated weakness of the upper extremity mimicking peripheral nerve damage. The etiology of this rare syndrome is almost exclusively related to an embolic infarction.

Case presentation: We present the case of a 70-year-old male patient with isolated left sided upper extremity weakness and clumsiness without sensory disturbance suggesting a lesion of the radial nerve. Nerve conduction studies had normal results excluding peripheral nerve damage. Neuroimaging (cranial CT and MRI) detected 3 space occupying lesions, one of them in the right precentral gyrus. An irregularly shaped tumor was found by CT in the left lung with multiple associated lymph node conglomerates. The metastasis from this mucinous tubular adenocarcinoma with solid anaplastic parts to the 'hand knob' area was responsible for the first clinical sign related to the pulmonary malignancy.

Conclusions: Pseudoperipheral palsy of the upper extremity is not necessarily the consequence of an embolic stroke. If nerve conduction studies have normal results, neuroimaging - preferably MRI - should be performed, as lesion in the hand-knob area of the precentral gyrus can also be caused by a malignancy.

Keywords: Brain metastasis; Hand knob; Isolated distal upper extremity weakness.

Fig. 1

Isolated central weakness of the left upper extremity. Wrist drop (a) and decreased handgrip strength (b)

Fig. 2

Contrast-enhanced axial CT (a), T2W axial MR (b), contrast-enhanced T1W axial (c) and coronal (d) MR. Intensive contrast enhancement (11 mm) in the right precentral gyrus, corresponding to the ‘hand knob’s area, with large perifocal edema. The left ‘hand knob’ is normal (arrow). Four other smaller enhancing metastases in the brain (not shown)

Fig. 3

Pulmonary malignancy (mucinous tubular adenocarcinoma with anaplastic solid parts), 400× magnification, Hematoxylin & Eosin + alcian blue (a). Cerebral metastasis (mucinous tubular adenocarcinoma with anaplastic solid parts), 200×, magnification, Hematoxylin & Eosin + alcian blue (b)