It has actually been several months due to the fact that we introduced the last Neurology Today-NeuroBowl Case Challenge, and along with this issue we grab spine to the firm of solving a case. To recap the last case presented (http://bit.ly/NT-casechallenge), we checked out a 53-year-old man along with a long term history of smoking, hypertension, and kind 1 diabetes mellitus that called for insulin. He presented along with generalized weakness for 24 hrs and was unable to stand. He likewise had nausea and vomiting. Over the path of the next day, the weakness failed to resolve and he had shortness of breath and swallowing difficulties.
Figure. PHOTO A: DWI…
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His computed tomography head scan and labs were unremarkable, as was his lumbar puncture. He reported that he been bitten by a tick recently, yet the serology was unremarkable. He denied any type of recent respiratory or gastrointestinal infections.
On bodily exam, his speech was hypophonic devoid of aphasia, and cranial nerves were unremarkable. His strength was 1/5 throughout all of extremieties, reflexes were brisk throughout, and his toes were upgoing bilaterally. His sensation to light touch and pinprick were lessened here the jaw line, yet his ache and temperature were intact.
Based on the presentation, we asked: Where would certainly you localize the lesion? Just what would certainly you do beside make and confirm the diagnosis?
The patient had swiftly progressive paralysis of the limbs — not in an ascending fashion, merely sudden weakness in the limbs. However, along with hyper-reflexive and upgoing toes, an top motor neuron pathology was much more most likely compared to a lesser motor neuron pathology. Guillain-Barré syndrome (GBS) was much less most likely as his reflexes were preserved, and cerebrospinal fluid findings were not consistent along with it either. Also, sensory findings — lessened light touch and pinpick, preserved ache and temperature — along along with nausea/vomiting and swallowing/speech/breathing difficulties were suggestive of a lesser brainstem lesion quite compared to an top cervical spinal column lesion.
Some of our readers responded that the case indicated an top cervical spinal column lesion — suggesting an infarction, myelitis, syringomyelia, or a mass — which would certainly have actually been excellent localization, yet symptoms of hypophonia, nausea/vomiting, respiratory difficulties, and preserved ache and temperature would certainly suggest a lesion localized to the lesser medial medulla. Offered the patient’s risk factors and the negative workup in the case, the patient was much more most likely to have actually a vascular lesion.
The patient did indicate that he had had a tick bite, so we did think of tick-related paralysis, yet the serology was negative for that. We likewise considered that he may have actually been exposed to a toxin, yet it wouldn’t spare ache and temperature sensory modalities and top cranial nerves. GBS was likewise considered, yet the patient had preserved reflexes so a substitute diagnosis was much more likely.
To solve the case, we did magnetic resonance imaging (MRI) of the brain, which indicated the following: The DWI sequence (photo A) showed a hyperintense heart-shaped lesion here the medial medulla in the distribution of the paramedian branches of the vertebral and anterior spinal arteries. And ADC sequences (photo B) showed a hypointense lesion corresponding to a DWI lesion, confirming our suspicion of diffusion restriction.
The patient’s diagnosis was bilateral medial medullary syndrome. Just what caused this? The MR images showed just a hypoplasitic left vertebral, and there was no evidence of any type of thrombosis —the circulation through basilar was intact — to suggest it as a trigger of infarct. The a lot of most likely etiology is atherosclerotic disease, Offered his risk factors of hypertension, smoking history, and diabetes.
Dr. Patel is a neurology resident at the Medical College of Georgia.
