Annals of Medicine: Neglect


Paralysis is a problem. I think I would be pretty alarmed if I woke up and couldn’t move an arm or a leg. And yet the majority of people I see in the ED with this kind of problem come in after a day or so. They usually tell me they thought they would wait and see if it wore off. Some of that delay is denial and some of it is a neurologic phenomenon known as neglect.

Neurologic neglect develops after certain types of strokes damage the brain, usually strokes on the right side of the brain. The right side of the brain primarily controls spatial orientation, while the left side is more often the language center. With neurological neglect, the patient will completely ignore one half their body, typically the left side, and so will not notice the accompanying paralysis from the stroke. They often will ignore objects to their left as well or, even stranger still, will ignore just the left half of all objects regardless of where the object is, to the right or left of the patient. When they dress, they will dress only the right half of their bodies and shave only the right side of their faces.

Neurologic neglect is relatively rare, though, most of the time the delay in seeking care has more to do with wishful thinking, muddled thinking or denial of the seriousness of the problem. Fortunately, with increasing awareness of the signs and symptoms of stroke among the public we are seeing people earlier in the course of their stroke and this improves the prognosis for recovery. If you think you are having a stroke, call 911!

I saw a rather different form of self-neglect recently. It was a Monday afternoon and one of my residents presented a partially paralyzed patient to me. She had woken up the day before unable to move her right wrist or extend her fingers. So of course she waited an entire day and a half to see if it would “wear off” before coming in. The resident wanted to get an emergent head CT and call a stroke alert to activate the emergency neurology team. She had no other deficits. All of the other muscles in her body seemed to work fine; it was just her wrist and hand that were paralyzed. Based on the report of this exam I thought I knew exactly what had happened to her.

“Where did she wake up?” I asked the resident.

“Where?” He looked at me oddly.

“Yes, where did she wake up?”

“In her bed, I guess.”

“Ask her.”

He came back to report that she had actually awakened in her car, in her driveway at noon the previous day.

“And why was she sleeping in her car?”

“I don’t know, but what difference does that make?”

“The difference between having a stroke and not having a stroke.”

I could see my sophistry was beginning to wear on the resident, so I directed him to google Saturday Night Palsy. Yes, this is what medical education has come to.

It turns out that this lady had managed to drive home drunk at midnight and then passed out in her car in her driveway with her arm draped over the steering wheel. Being intoxicated, she did not feel the pain that this would normally elicit, and in her long deep slumber she had compressed her radial nerve between its course along the humerus (upper arm bone) and the steering wheel. The nerve was damaged in a fashion similar to when your arm falls asleep, but longer lasting.

The radial nerve controls wrist extension and finger extension, and so she now had a condition called wrist drop; she could not lift her wrist or fingers against gravity. Treated with a splint and physical therapy, her likelihood of complete recovery was high.

This mechanism of injury of the radial nerve is so characteristically seen after nights of alcohol overindulgence that we have dubbed it Saturday Night Palsy. It can be caused by other awkward sleeping positions like draping your arm over a park bench or a couch and not perceiving the pain that it is causing due to intoxication.

I explained to the patient that she had not had a stroke and did not need a CAT scan or a neurologist. She needed a splint and physical therapy and of course alcohol rehab. She accepted only the splint.


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