Case Studies
Case 10: A young lady with evolving dizziness
A 21-year-old woman presents with a two week history of an evolving neurological problem consisting of dizziness, vomiting, oscillopsia, dysarthria and altered facial sensation. She has never had any previous illnesses and is on no treatment. On examination she has a complex eye movement disorder with nystagmus, ataxia bilaterally, and a scanning dysarthria. She also has some altered sensory feelings to light touch over the whole of her face.
Your Answer:
Correct answer: The most likely site for this lesion is somewhere in the posterior fossa, probably involving the brainstem given the constellation of abnormalities as described. In order to get a complex eye movement disorder the lesion must involve the pons or the mid brain and this could also account for some of the ataxia although there may be spread of the lesion into the cerebellar peduncles. The altered sensation over the face would again point towards a brainstem lesion, this time slightly higher given that the whole face is involved and thus the lesion must reside somewhere in the upper midbrain.
Your Answer:
Correct answer: The most likely pathology of this lesion is an inflammatory demyelinating plaque characteristic of multiple sclerosis given her age, the evolving presentation over two weeks, and the absence of any previous medical history. It is possible that it could be a space occupying lesion or some other infective cause but this seems very unlikely given the nature of the progression and the relatively high prevalence of multiple sclerosis in the population.
Your Answer:
Correct answer: In order to prove this as a diagnosis one would have to arrange for her to have an MRI scan to look at the nature of the abnormality in the brainstem with a view to going on to a lumbar puncture looking specifically for evidence of inflammation typically in the form of oligoclonal bands in the CSF but not the serum. One can also look for disseminated lesions in other sites typically within the visual pathway using visual evoked responses.
Your Answer:
Correct answer: The treatment you would offer to some extent depends on the nature of the disability. However brainstem problems are often very debilitating and whilst one can give symptomatic treatment such as anti-emetics this lady probably merits a course of steroids to try and speed up the natural recovery which is characteristic of lesions of this type.
Your Answer:
Correct answer: The prognosis is that she should make a good recovery from this lesion, but that it is likely that she will go on to have further episodes and progressive disability, which may lead to consideration of disease-modifying therapy targeting specific aspects of the immune system.