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Salient Features: SUBJECTIVE2 y/o maleSudden onset of severe headacheNumbness of the right side of the faceUpward rolling of the eye & rigidity of all extremities associated with loss of
consciousnessTwitching of the right side of the faceDysarthriaDysphagia(-) Fever(-) Trauma(+) Family history of Neurocysticercosis(+) Family history of Stroke, HPN, DM(-) Family history of TBUsually eats raw fish and meat
Salient Features: OBJECTIVE
DysarthicShallow right nasolabial foldTongue deviated to the right
What is the neurologic problem?
• Increased intracranial pressure• Meningeal irritation• Focal neurologic deficits
What is the neurologic problem?• Increased intracranial pressure–A. headache with or without vomiting–B. papilledema–C. lateral rectus palsy–D. deterioration of level of conciousness
What is the neurologic problem?• Increased intracranial pressure– (+) headache with or without vomiting– (-) papilledema– (-) lateral rectus palsy– (-) deterioration of level of conciousness
What is the neurologic problem?• Meningeal irritation–A. headache with or without vomiting–B. nuchal rigidity–C. brudzinski–D. kernig
What is the neurologic problem?• Meningeal irritation– (+) headache with or without vomiting– (-) nuchal rigidity– (-) brudzinski– (-) kernig
What is the neurologic problem?• Focal neurologic deficits
slurring of speech– seizures memory impairment emotional and behavioral changes facial asymmetry
weakness of extremities incoordination reflex asymmetry or pathological reflex sensory impairment
What is the neurologic problem?• Focal neurologic deficits• (+) slurring of speech• (+) seizures• (+) facial asymmetry
(+) shallow right nasolabial fold (+) tongue deviated to the R
(+) sensory impairment (-) memory impairment
(-) emotional and behavioral changes (-) weakness of extremities (-) incoordination (-) reflex asymmetry or pathological reflex
What is the neurologic problem?
FOCAL NEUROLOGIC DEFICITS
Where is the lesion?Levelization, Lateralization, Localization
Levelization
Dysarthic Shallow right nasolabial fold Tongue deviated to the right
upper motor neuron
Levelization
Upper Motor Neuron cerebrum cerebellum brainstem spinal cord
Levelization
autonomic dysfunction sensory level
spinal cord
Levelization
can do APST & FTNT can do heel to shin test (-) Romberg’s test
cerebellum
crossed motor paralysis
Levelization
brainstem
Levelization
right-sided facial numbness and twitching, facial asymmetry and tongue deviation
complex focal seizures
cerebrum
Lateralization numbness of the right side of the face twitching of the right side of the face shallow right nasolabial fold tongue deviated to the right
left
Levelize: cerebrumLateralize: leftLocalization: frontal lobe
Salient Features: OBJECTIVE
MRI findings of a solitary ring enhancing cystic lesion at left posterior frontal cortical and subcortical white matter with surrounding vasogenic edema and focal central calcific focus within the lesion
Differential Diagnoses
RING ENHANCING LESIONS
Differential Diagnoses for Ring-enhancing lesions
• Metastases;• Abscess, (pyogenic abscess and abscess caused by
bacterial fungal and parasitic pathogens;• Glioma and other primary CNS neoplasms;• Infarction;• Contusion;• Demyelination (multiple sclerosis, acute
disseminated encephalomyelitis);• Resolving hematoma/radionecrosis
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ring-enhancing lesions
• Cerebrovascular diseases– acute or sudden
• Demyelinating, inflammatory, or infectious diseases– subacute onset
• Brain tumors– insidious onset and gradual progression of signs
and symptoms
Differential Diagnoses for Ring-enhancing lesions
• Cerebrovascular diseases– acute or sudden
• Demyelinating, inflammatory, or infectious diseases– subacute onset
• Brain tumors– insidious onset and gradual progression of signs
and symptoms
Differential Diagnoses for Ring-enhancing lesions
• Metastases;• Abscess, (pyogenic abscess and abscess caused by
bacterial fungal and parasitic pathogens;• Glioma and other primary CNS neoplasms;• Infarction;• Contusion;• Demyelination (multiple sclerosis, acute
disseminated encephalomyelitis);• Resolving hematoma/radionecrosis
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ring-enhancing lesions
• Largely depend on the immune status of the patient• Immunocompetent host:
– tumors (primary and metastatic)– pyogenic abscesses and abscesses caused by atypical organisms – demyelinating disease
• Immunocompromised host:– toxoplasmosis – primary CNS lymphoma– also at risk for abscesses
• Tuberculous brain abscess should be considered in endemic regions in both immunocompetent and immunocompromised hosts.
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses for Ring-enhancing lesions
• Largely depend on the immune status of the patient• Immunocompetent host:
– tumors (primary and metastatic)– pyogenic abscesses and abscesses caused by atypical organisms – demyelinating disease
• Immunocompromised host:– toxoplasmosis – primary CNS lymphoma– also at risk for abscesses
• Tuberculous brain abscess should be considered in endemic regions in both immunocompetent and immunocompromised hosts.
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Differential Diagnoses
• In the tropics, infectious and post infectious disorders are more common than demyelinating disorders such as Multiple Sclerosis which is more common in the west
Differential diagnosis of white matter diseases in the tropics: An overviewLekha Pandit Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India
Differential Diagnoses for Ring-enhancing lesions
• Metastases;• Abscess, (pyogenic abscess and abscess
caused by bacterial fungal and parasitic pathogens;
• Glioma and other primary CNS neoplasms
Irene Cortese, Clinical Neurophysiology, The Johns Hopkins University, Baltimore, Maryland; 2006.
Impression
• Complex Focal Seizure secondary to an intracranial mass lesion on the left frontal lobe probably secondary to:(1) Metastases(2) Primary brain tumor(3) Infections
What specific kinds of infections can we include in our DDX?
• Differential diagnosis for complete ring enhancing cystic lesions commonly include brain abscess, cysticercosis, tuberculoma and toxoplasmosis in a tropical country set up.
Differential diagnosis of white matter diseases in the tropics: An overviewLekha Pandit Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India
Primary Differentials
• Complex Focal Seizure secondary to an intracranial mass lesion on the left frontal lobe probably secondary to:(1) Metastases(2) Primary brain tumor(3) Abscess(4) Neurocysticercosis(5) Tuberculoma
Salient Features: SUBJECTIVE2 y/o maleSudden onset of severe headacheNumbness of the right side of the faceUpward rolling of the eye & rigidity of all extremities associated with loss of
consciousnessTwitching of the right side of the faceDysarthriaDysphagia(-) Fever(-) Trauma(+) Family history of Neurocysticercosis(+) Family history of Stroke, HPN, DM(-) Family history of TBUsually eats raw fish and meat
Impression
• Complex Focal Seizure secondary to an intracranial mass lesion on the left frontal lobe probably secondary to Neurocysticercosis