Case Report

Ulnar Nerve Palsy–like Motor and Sensory Loss Caused

by a Small Cortical Infarct

Tatsuya Ueno, MD,*‡ Masahiko Tomiyama, MD,*†‡ Rie Haga, MD,*

Haruo Nishijima, MD,*‡ Tomoya Kon, MD,* Yukihisa Funamizu, MD,*
Yasuo Miki, MD,* Akira Arai, MD,* Chieko Suzuki, MD,* and Masayuki Baba, MD*

A 56-year-old man with a small infarct in the left precentral knob area induced both
motor and sensory impairments that were similar to right ulnar nerve palsy. The
only difference from ulnar nerve palsy was that the patient showed sensory distur-
bance not only on the ulnar side but also on the radial side of the right ring
finger. Key Words: Cortical infarction—precentral knob—ulnar nerve palsy.
Ó 2012 by National Stroke Association

A 56-year-old right-handed man was hospitalized be-
cause of left ataxic hemiparesis caused by branch athero-
matous disease in the right putamen and corona radiata.
He had been hypertensive for a few years without treat-
ment. During hospitalization, he noticed difficulty in fine
movements of the right hand at the time of awakening.
Neurologic examinations revealed no disturbance of con-
sciousness or mental status. Cranial nerves were normal.
A manual muscle test revealed mild weakness of the right
palmar and dorsal interosseous muscles, right abductor
digiti minimi, right flexor digitorum profundus, and right
flexor digiti minimi. Grasping power was 20 kg on the
right and 27 kg on the left side. Muscle strength was nor-
mal in abduction and adduction of the shoulder, flexion
and extension of the elbow, flexor and extension of the
From the *Department of Neurology, †Stroke Unit, Aomori Prefec-
tural Central Hospital, Aomori; and ‡Department of Neurophysiol-
ogy, Hirosaki University Graduate School of Medicine, Hirosaki,
Japan.
Received December 22, 2010; revision received February 9, 2011;
accepted February 14, 2011.
Address correspondence to Tatsuya Ueno, MD, Department of
Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashitsu-
kurimichi, Aomori 030-8553, Japan. E-mail: tatsuya_ueno@med.
pref.aomori.jp.
1052-3057/$ - see front matter
Ó 2012 by National Stroke Association
doi:10.1016/j.jstrokecerebrovasdis.2011.02.008
wrist, and extension of fingers. Weakness was not seen in
lower limbs. In addition, hypesthesia in pinprick and light
touch tests were found in the right ring and little fingers.
However, differences in sense were not observed between
the ulnar and radial side of the right ring finger. The joint
position sense and vibration sense were normal. Tendon
reflexes were preserved and the plantar responses were
flexor. A nerve conduction study revealed no abnormali-
ties in the right median and ulnar nerves. Diffusion-
weighted imaging of a magnetic resonance imaging
(MRI) scan revealed a high-intensity area between the pre-
central knob and subcortical white matter of the left frontal
cortex (Fig 1). No abnormality was seen in magnetic reso-
nance angiography. MRI of the cervical spine was normal.
The results of laboratory examinations were unremark-
able. Electrocardiographic and carotid ultrasound studies
were normal. Transthoracic echocardiography revealed
an expansion of the left atrium and left ventricular hyper-
trophy. The left ventricular wall motion was hypokinetic
in the anteroseptal wall. Transesophageal echocardiogra-
phy revealed plaques on the aortic arch and descending
aorta. However, no certain embolic source was found.
Discussion
A small cortical infarct of the precentral knob causes
weakness similar to ulnar nerve palsy,1,2 often called

Journal of Stroke and Cerebrovascular Diseases, Vol. 21, No. 8 (November), 2012: pp 903.e3-903.e4 903.e3
903.e4
pseudoulnar palsy.3 A posterior wall lesion of the central
sulcus results in sensory impairment on the ulnar side of
the hand.4,5 However, our patient had not only weakness
like right ulnar nerve palsy but also hypesthesia in both
right ring and little fingers. The patient appeared to
have right ulnar nerve palsy. There has been a reported
case presenting with motor and sensory loss like ulnar
nerve palsy3; however, that patient had two distinct small
infarcts in the precentral knob and posterior wall of the
central sulcus.3 Our patient is the first case in which an
isolated cerebral infarct brought about motor and sensory
loss mimicking ulnar nerve palsy. Deep sensation was
preserved in our patient. Primary somatosensory area
3a receives kinesthetic afferents rather than cutaneous
inputs, while areas 3b and 1 receive more superficial
stimuli.6 The infarct of subcortical white matter might
affect projection fibers to areas 3b and 1, not area 3a.
The lesion in the precentral knob (Fig 1) caused weakness
similar to ulnar nerve palsy and the expansion of the in-
farct to the subcortical white matter (Fig 1) might involve
fibers to the posterior wall of the central sulcus and then
T. UENO ET AL.
Figure 1. Upper panel, T1-weighted
magnetic resonance imaging scan.
Lower panel, Diffusion-weighted imag-
ing of the magnetic resonance imaging
scan. Arrowhead indicates the precen-
tral knob. Pictures in the lower panel
reveal a small high-intensity area from
the medial side of the precentral knob
to the subcortical white matter below
the precentral knob.
caused sensory loss in the ring and little fingers. Motor
and sensory loss like ulnar nerve palsy may result from
a small infarct in the precentral knob area.
References
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