- 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
- Meds: Synthroid
- 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
Figure 2: T1-post contrast
1. The ER physician asks how you would like to proceed. Based on the clinical presentation and imaging, which of the following would you most likely do at your hospital?
2. What is the best next step to identify the likely cause for progressive weakness in this patient?
3. Of the following, which is most likely to present with a paraneoplastic syndrome?
4. Which of the following describes you?
5. I practice in one of the following locations.
6. Please add any suggestions or comments regarding this case:
- CXR and USG OF ABDOMEN AE USEFUL FOR FURTHER NARROW DOWN OF DIAGNOSIS.
- Guillian Barre syndrome
- this meningeoma is red hearing. I think she might have GBS or pareneoplastic syndrome. I will admitted her under my care and involved neurology to help diagnose the true cause of the ascending bilateral weakness.
- Pt.has to be prepared for surgery as soon as possible to have the biopsy after excision of mass. Further adjuvant therapy depends upon biopsy report
- Something about réflex?
- This seems to be an obvious case of a progressively symptomatic parietal parasagittal meningioma, but even with this size should not cause quickly progressive bilateral weakness. Dyspnea could be related to her COPD. I would certainly admit her for further evaluation, initially on a general floor. Surgery would, depending on further results, be needed in that same course of admission.
- the diagnostic is falx meningioma
- Why is there no option for Caribbean neurosurgeons. I apologies I know it's a little off topic.
- I would do a spinal MRI if there is bilateral weakness, although the intracranial lesion could cause such a picture. Then excision biopsy of the lesion.
- Good and thought challenging test.
- I will go for direct excision of this mass.
- At the risk of sounding pedantic, I believe the first step would be to do a thorough exam. We need information about her sensory exam, her motor tone, the distribution of weakness in her arms and legs (proximal vs. distal), her gait characteristics, and her cerebellar exam. This is because paraneoplastic syndromes come in several varieties, including motor neuropathy (demyelinating), sensory neuropathy, myopathy, myelopathy, and cerebellar dysfunction. Finally, a common unrelated disorder such as cervical spondylotic myelopathy should never be discounted in a patient with unexplained quadriparesis, the hypoactive reflexes notwithstanding. Therefore, my very first test would be a cervical MRI. I suspect the pathology is lymphoma and the patient has paraneoplastic acute demyelinating polyneuropathy. Peyman Pakzaban, MD, FAANS
- Concerning thé approch, which one would you recommend?
- nice case. neurosurgeons must be able to recognize AIDP, Myasthenia, paraneoplastic syndromes, etc.
- Good and thought chalanging test.
- Good and thought challenging test
- This is a caractheristic image of a meningioma that it would be operate at once.
- I would get a neurology opinion immediately
- It looks a very simple diagnosis of an intracranial meningioma, but her clinical status is not related to the intracranial mass, it seems to be coincidental.
- Remove the mass and advis the family that prolonged rehab is in order with possible seizures in the future.
- I practice in Puerto Rico, US territory, not included in your distribution. We are a small group (14-18) of neurosurgeons- most of us, fellows of the AANS servicing a population of 3.5M. Following the standards of the AANS makes this classification more difficult. I chose Tx because that's where I completed my fellowship.