Downloaded from http://emj.bmj.com/ on December 20, 2017 - Published by group.bmj.com Original article IMAGE CHALLENGE Don’t neglect the clock drawing test Introduction A 63-year-old, right-handed woman with a history of hypertension presented to the ED with left arm paresis of 2 days duration. Three weeks before admission, she had flu-like symptoms with intermittent left arm weakness that had recovered briefly but recurred 2 days prior to her presentation. On neurological examination, GCS was 15 and cranial nerves’ function was normal. Left upper limb strength was 4/5. There was left arm drift and pronation but the patient denied noticing any difference between the positions of her arms. Hyper-reflexion was presented in the left arm. The rest of her motor, cerebellar, sensation and gait functions were normal. She was asked to draw a clock and set it to 15:30 (figure 1). Question: What is the most probable aetiology? A. Right cerebral bleeding involving the occipital lobe B. Right middle cerebral artery occlusion C. Right parietal lesion, likely neoplasm D. Left cortical stroke 38 Figure 1 Clock drawing test results. For the question see page 45 Fry M, et al. Emerg Med J 2018;35:33–38. doi:10.1136/emermed-2016-206065 Downloaded from http://emj.bmj.com/ on December 20, 2017 - Published by group.bmj.com Original article IMAGE CHALLENGE Don’t neglect the clock drawing test For the question see page 38 Answer: C The clock drawing test examines spatial awareness and revealed left hemineglect in addition to the mild weakness found on examination. CT (figure 2) demonstrated a right parietal lesion, with severe edema and midline shift which was later diagnosed at surgery as a glioblastoma WHO grade 4. Right cerebral hemisphere damage often causes lateralised disruptions of spatial awareness resulting in neglect,1 which is characterised by a general failure to respond to stimuli in the contralesional space. This is different from extinction, which is a selective impairment in responding to a contralesional stimulus when an ipsilesional stimulus is presented simultaneously.2 By revealing that the problem was neglect, the clock drawing test allowed the diagnosis to be made in the ED. The relatively prolonged duration of the symptoms suggests neoplastic aetiology. Right occipital bleeding might cause contralateral hemianopsia, but should not affect the clock drawing test, which examines spatial awareness but not visual fields; right middle cerebral artery occlusion would present a wider neurological deficit including contralateral hemiplegia, hemianaesthesia, homonymous hemianopsia and anosognosia. Left cortical pathology would not present as left neglect.3 Michal Vinker Shuster,1 Maayan Hannah,2 Zalut Todd2 1 Hadassah Ein Kerem Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel 2 Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel Correspondence to Mrs Michal Vinker Shuster, Hebrew University of Jerusalem, Shikun Hariel 3/4, Jerusalem, Israel; ​michal.​vi@​gmail.​com Contributors The case of this image challenge was written by the authors, and the diagnosis was also made by them. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. Deane HC, et al. Emerg Med J 2018;35:39–45. doi:10.1136/emermed-2017-206727 Figure 2 The patient’s CT scan presenting a right parietal lesion, with severe oedema and midline shift. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. To cite Vinker Shuster M, Hannah M, Todd Z. Emerg Med J 2018;35:45. Accepted 25 April 2017 Emerg Med J 2018;35:45. doi:10.1136/emermed-2017-206680 References 1 Kenzie JM, Girgulis KA, Semrau JA, et al. Lesion sites associated with allocentric and egocentric visuospatial neglect in acute stroke. Brain Connect 2015;5:413–22 http:// www.​ncbi.​nlm.​nih.​gov/​pubmed/​25575355 2 Vossel S, Eschenbeck P, Weiss PH, et al. Visual extinction in relation to visuospatial neglect after right-hemispheric stroke: quantitative assessment and statistical lesionsymptom mapping. J Neurol Neurosurg Psychiatry 2011;82:862–8 http://www.​ncbi.​ nlm.​nih.​gov/​pubmed/​21242287 3 Ropper AH, Samuels MA, Klein JP. Adams and Victor’s Principles of Neurology. Tenth edit 2014;477:797. 45 Downloaded from http://emj.bmj.com/ on December 20, 2017 - Published by group.bmj.com Don't neglect the clock drawing test Michal Vinker Shuster, Maayan Hannah and Zalut Todd Emerg Med J 2018 35: 38-39 doi: 10.1136/emermed-2017-206680 Updated information and services can be found at: http://emj.bmj.com/content/35/1/38 These include: References Email alerting service Topic Collections This article cites 3 articles, 1 of which you can access for free at: http://emj.bmj.com/content/35/1/38#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Articles on similar topics can be found in the following collections EMJ Image Challenge (48) Notes To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/