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Stereoanesthesia or astereognosia?

Article  in  Neurological Sciences · August 2009

DOI: 10.1007/s10072-009-0117-8 · Source: PubMed

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Neurol Sci (2009) 30:409–411
DOI 10.1007/s10072-009-0117-8
CASE REPORT
Stereoanesthesia or astereognosia?
E. Kararizou Æ D. Lykomanos Æ A. Kosma Æ
P. Kokotis Æ K. Giatas Æ I. Markou Æ D. Vassilopoulos
Received: 12 October 2008 / Accepted: 2 June 2009 / Published online: 8 July 2009
Ó Springer-Verlag 2009
Abstract This case attempts to explicit the importance of
clinical examination in the differential diagnosis of two
similar clinical entities namely astereognosia and stereo-
anesthesia. The patient presented below involves a multiple
sclerosis patient whose symptoms were considered at first
to be a case of astereognosia since she mainly complained
of an inability to recognize and name the form and nature
of objects by touch. However, a thorough clinical exami-
nation and the results of neurophysiological and neuroim-
aging testing demonstrated that it involved a case of
stereoanesthesia due to a demyelinating lesion at the cer-
vical region of the spinal cord.
Keywords Stereoanesthesia
Astereognosia

Tactile agnosia
MRI
SEP
Introduction
Astereognosia represents a disordered tactile recognition
with no gross alterations in the threshold for pain and touch
and is frequently a manifestation of cortical disease,
involving the sensory cortex [1–6].
However, the same clinical pattern, namely lack of
recognition of the shape and size of objects, may occur if
tracts that transmit proprioceptive and tactile sensation are
interrupted by lesions in the spinal cord, brainstem and
peripheral nerves. The latter type of sensory defect is called
E. Kararizou (&)
D. Lykomanos
A. Kosma
P. Kokotis

K. Giatas
I. Markou
D. Vassilopoulos
Department of Neurology, Athens National University,
Eginition Hospital, 72–74 Vas. Sofias Av.,
11528 Athens, Greece
e-mail: ekarariz@med.uoa.gr
stereoanesthesia and needs to be distinguished from aste-
reognosia [7–9]. The aim of the present study is to describe
a patient who initially presented as astereognosia, but the
clinical evaluation and the analytical neurologic and lab-
oratory examinations established the diagnosis of
stereoanesthesia.
Case report
Medical history
A 28-year-old right-handed woman had a first episode of
numbness of her left arm that lasted for 2 weeks. Five
months later, she complained for numbness of both arms
distally and a feeling resembling an electric shock running
down the spine, provoked by forceful flexion of the neck
(Lhermitte’s sign). Since 2 weeks before admission, the
patient was experiencing paraesthesiae and ‘‘stiffness’’ and
clumsiness of her left arm. She was not able to recognize
any object placed in her hand and sometimes did not even
know that there was something placed there. In addition,
the patient had absolutely no knowledge of position of her
hands and fingers.
Physical examination
Vibration sense was tested with the use of a tuning fork and
the answers were compared with those of the examiners
and was found diminished in the upper extremities and
normal in the lower extremities. A proprioceptive deficit
was also prominent since the patient was unaware of the
position and movement of her hands and fingers while the
examination and accompanied by pseudoathetotic move-
ments. Sense of light touch tested with a wisp of cotton,
123
410
sense of pain tested with a pinprick, and thermal sense
tested with test objects and figure writing (graphesthesia)
were diminished in both arms distally, up to the level of
wrists.
Finally, the examination of sensation revealed an addi-
tional inability of the patient to appreciate the nature and
size of objects that were placed in her hands.
She thought a glass was first a ticket and then felt glass
as something soft.
Deep tendon reflexes were increased in both arms and
legs with mild left predominance and plantar reflex was
normal.
Muscle strength evaluation displayed a mild weakness
in adduction–abduction-flexion and extension of fingers in
left arm (MRC:4/5).
Ancillary diagnostic tests
Cervical T2-weighted MRI demonstrated an extended
C-shaped lesion of high signal intensity on T2-weighted
images, with contrast enhancement consistent with MS at
the C4 level. The peculiar shape of the lesion seemed that
involved the posterior columns and in particular the
fasciculus cuneatus bilaterally.
Brain MRI revealed a demyelinating lesion with no
contrast enhancement, located next to the frontal horn of
the right lateral ventricle.
SEP recordings of both tibial nerves showed normal
latencies and amplitudes of cortical potentials. Each tibial
nerve was stimulated at tarsus. The cortical potentials of
left median nerve, stimulated at wrist, were of very low
amplitude and slightly prolonged latency. No clear spinal
potentials were received from the same nerve. As for right
median nerve, cortical and spinal potentials were normal,
except for C2 level where the recording was no clear
enough. These findings are compatible with the lesion
demonstrated in the Cervical MRI.
Discussion
Discriminative sensation is a well-developed function in
humans that allows us to feel with our hands fine textures
and determine what an unknown object is without looking
at it (stereognosis).
From the other hand, medical terms that describe dis-
turbances of stereognosis, are called astereognosia in the
older English literature and Tastblindheit (touch-blindness)
and tactile agnosia in the older German literature [1, 2, 7, 8].
However, this term should be used with caution since it
predisposes that the primary sensory input is intact [8, 9].
For the rest of the cases, meaning the loss of the ability to
understand the form and nature of objects due to impaired
123
Neurol Sci (2009) 30:409–411
position and vibration sense and tactile sensation, Boshes
and Padberg [10] first proposed the more correct term of
stereoanesthesia. Stereoanesthesia also implies a different
lesion location, including the brainstem, spinal cord or
even in peripheral nerves.
In this case, the diagnosis of stereoanesthesia was based
on:
Clinical features The patient could not be able to
recognize the shape and size of objects, had no idea of
the position of her upper limbs, no sense of vibration in
her hands and also tactile sensation was impaired. In
addition, the symptoms affected both the hands, and this
is quite uncommon in the presence of a cortical lesion,
although there have been sporadic reports of patients
who had bilateral astereognosia due to a unilateral
cerebral lesion [8].
Neuroimaging findings Brain MRI excluded the pres-
ence of a cortical lesion whereas MRI of cervical spine
demonstrated a lesion with abnormal signal at the C4 level.
Evoked potentials SEP recording demonstrated an
impedance to the conduction of sensory stimuli at the
cervical level, especially on the left side.
Anatomical considerations The posterior column-medial
lemniscus pathway is the sensory pathway responsible for
transmitting fine touch, vibration, and conscious proprio-
ceptive information from the body to the cerebral cortex.
We should remember, however, that there is a somatotopic
representation of the body in the dorsal columns (fasciculus
gracilis and cuneatus). Sacral and lumbar body parts are
represented medially, while the upper thoracic and cervical
segments are represented laterally. Nucleus gracilis
receives its input from about T7 and downward, while
nucleus cuneatus receives its input from spinal levels above
that.
The inability to recognize the shape and nature of
objects is commonly considered and named astereognosia
in clinical practice and it is attributed predominantly to
lesions in the postcentral gyrus. However, the term should
be encountered only after excluding that superficial and
vibratory hand sensation is intact. A thorough clinical
examination is considered of prime importance both for
correct diagnosis, patient manipulation as well as for esti-
mating drug treatment outcomes and prognosis.
References
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