Presentation

• 72 yo male, lives at home with wife.Four children, retired engineer

• PC: Progressive right-sided weakness• HPC: • Tripped and fell playing tennis 2/52 ago.– No LOC. – No injuries.– Progressive difficulty using L upper extremity– Progressive weakness in L leg– Headaches of progressive frequency and intensity

History

• PMHx: BPH, melanoma• PSHx: melanoma removed 5 yrs ago• Allergies: penicillin• Social: Married with four adult children. Lives

at home with his wife. Retired engineer• Cigarettes: None.• Alcohol: glass of wine nightly

Exam

• O/E Afebrile; BP 136/85; HR 92; RR 16• Alert and oriented to person, place & time; CNs intact• Healing ecchymosis on the right forearm and thigh.• Increased tone in the left upper extremity. No

associated muscle fasciculation or muscle wasting• Pronator drift is noted on the left side.• Weakness (4/5) is noted in all motor groups of the left

upper extremity.• Reflexes are brisk and symmetric throughout the

upper and lower extremities. Extensor plantar response on the left.

Pronator drift

There are only three causes for drift of the arms:1. Upper motor neurone (pyramidal) weakness.

The drift of the affected limb(s) here is due to muscle weakness and tends to be in a downward direction. The drifting typically starts distally with the fingers and spreads proximally. There may be slow pronation of the wrist and flexion of the fingers and elbow.

2. Cerebellar disease.The drift here is usually upwards. It also includes slow pronation of the wrist and elbow.

3. Loss of proprioception.The drift here (pseudoathetosis) is really a searching movement and usually affects only the fingers. It is due to loss of joint position sense and can be in any direction.

Is this an upper or lower MN lesion?

• Signs of upper motor neurone (pyramidal) lesions1. Weakness2. Very little muscle wasting.3. Increased tone is present (may be clasp-knife, may have clonus).4. The reflexes are increased (except absent superficial reflexes).5. Extensor (Babinski) plantar response (upgoing toe).

• Signs of lower motor neurone lesions1. Weakness2. Wasting is a prominent feature.3. Tone is reduced.4. Reflexes are reduced5. Plantar response is normal or absent.6. Fasciculation may be present.

DDx

• Progressive hemiparesis + progressively worse headaches + fall 2/52 + elderly

• How is hemiparesis different to hemiplegia?• What is missing for a diagnosis of acute

subdural hematoma?• Has had a melanoma.

Differential diagnosis

• Hemiparesis – UMN weakness affecting both limbs on one side

• Subacute hemiparesis DDx(Harrison’s 17e Chapter 23)– Subdural hematoma (PDx from age and history)– Cerebral abscess, meningitis, parasitic infection– Neoplasm– AIDS (toxoplasmosis, CNS lymphoma)– Others (rare, headache doesn’t fit):• Sarcoidosis, Multiple Sclerosis, Cerebral Lupus

Investigations

• Brain CT or MRI– Consider Spinal MRI if no pathology found

• Complete blood count• Coagulation profile• Electrolytes• Type and screen/cross(Medscape, Harrison’s chapter 23)

CT

• What would we expect to see with an epidural hematoma?

Subdural hematoma

• Aetiology – Head trauma – shearing forces – rupture of

bridging veins (arterial rupture 20-30%), more likely in the elderly

• Where do they typically occur?

Subdural hematoma – Clinical presentation

• How large is the hematoma?• Acute

– symptomatic mins/hrs after injury, 1/3 lucid, other 2/3 confusion after injury

– Unilateral headache, slightly enlarged pupil on same side, vomiting etc..• Subacute

– Symptomatic days/weeks after injury– Drowsiness, headache, confusion, mild hemiparesis (contralateral or

ipsilateral?)• Chronic

– 20-30% recall no traumatic event– Headaches, slowed thinking, change in personality, seizure, mild

hemiparesis weeks/mths afterwards

Subdural hematoma – management and prognosis

• Overall mortality if requiring surgery - 40-60%.• If coma prior to surgery – 57-68%.• Prognostic indicators

– GCS – Age– CT findings – thickness, volume etc..

• Reverse any anticoagulation (weight up benefit if no surgery…)• To operate or not to operate….

– Consider: GCS, stability, comorbidities, CT findings, acuity, neuro exam findings

– Sooner is better than later

Subdural hematoma – management and prognosis

• Acute– Nonoperative if: clinically stable or improving, so

signs of herniation, clots thickness < 10 mm, midline shift < 5mm

– Otherwise operate if there is potential for recovery.

• Chronic– Similar to the above.– Moderate to severe cognitive impairment.

Which tumours most commonly metastasise to the brain?

• Carcinomas – lung, breast, skin, kidney, GIT• Choriocarcinoma has a very likelihood of

metastasising to the brain.• Which are most likely to haemorrhage?• Of those that metastasise to the brain: thyroid

papillary carcinoma, hepatocellular carcinoma• Of primary brain tumors: Glioblastoma,

pilocytic astrocytomas (?)