Welcome to CNS Case of the Month Section. The purpose of this Web area is to provide a forum for discussion and debate regarding the management of both ordinary and extraordinary cases. There are no right or wrong answers, but rather, there are various opinions on what should be the "standard of care." The answers given will be collected anonymously, and be presented in a graphical format at the end of each month. We will then see the spectrum of thought regarding the management of these patients.
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Brian L. Hoh, MD University of Florida
Ashok R. Asthagiri, MD Associate Professor Department of Neurological Surgery University of Virginia
Maryam Rahman, MD MS Assistant Professor
Department of Neurosurgery
University of Florida
Alexander A. Khalessi MD, MS University of California San Diego
Wilson Z. Ray, MD Assistant Professor in Neurosurgery Department of Neurological Surgery Washington University School of Medicine
Edward R. Smith, MD Director, Pediatric Cerebrovascular Surgery Department of Neurosurgery Children's Hospital Boston / Harvard Medical School
Sameer Sheth, MD, PhD Assistant Professor of Neurosurgery Columbia University Medical Center New York Presbyterian Hospital
March 2014: Intracranial Lesion and Progressive Weakness
A 64-year-old female presents to the ER with progressive ascending bilateral weakness that has been evolving over the course of the past week.
She initially had minor difficulty with balance, but is now having difficulty standing and holding objects with both hands. She reports increased dyspnea.
She has headaches, but these are no worse than usual headaches she’s had for years. Denies recent travel history or sick contacts.
Past medical history: Hypothyroidism, COPD
Past surgical history: none
Pupils are equal, round and reactive
Fundoscopy: no pappilledema
Motor exam reveals 4-/5 weakness in lower extremities and 4/5 weakness in upper extremities
Deep tendon reflexes are absent
Figure 1: T2-weighted MRI [Click to view larger image]
Figure 2: T1-post contrast [Click to view larger image]
a. Manage further evaluation and management as an outpatient
b. Admit to a general floor room
c. Admit to a monitored bed with telemetry and pulse oximetry
d. Direct admission to an intensive care unit
e. Defer to the general medical team &/or neurology service
2. What is the best next step to identify the likely cause for progressive weakness in this patient?
a. Sural nerve biopsy
b. Physostigmine challenge
d. Lumbar puncture
e. Biopsy +/- resection of mass
3. Of the following, which is most likely to present with a paraneoplastic syndrome?
b. Renal cell cancer
c. Pleomorphic xanthoastrocytoma
d. Small cell lung cancer
e. Atypical meningioma
f. Prostate cancer
4. Which of the following describes you?
b. Private practice
5. I practice in one of the following locations.
a. I practice in one of the following states: WA, OR, CA, AK, HI
b. I practice in one of the following states: AZ, ID, NV, MT, WY, CO, NM, UT
c. I practice in one of the following states: ND, SD, NE, KS, OK, MN, IA, MO, WI, IL MI, IN, OH
d. I practice in one of the following states: TX, AR, AL, LA, KY, TN, MS, WV, NC, SC, GA, FL
e. I practice in one of the following states: ME, VT, NH, MA, RI, CT, NJ, NY, PA, DE, MD, DC, VA
f. I practice in Mexico or Canada
g. I practice in South America
h. I practice in Europe
i. I practice in Asia
j. I practice in Australia/Pacific Rim
k. I practice in Africa
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