Case Studies
Case 11: Headache and weakness in a middle-aged patient
A 36-year-old lady presents with a two-week history of increasing headache which is worse at night and in the early morning. Of late she has also become increasingly drowsy with an evolving left-sided hemiparesis. Her headache causes her to vomit and on occasions she has had involuntary movements of the left arm and leg and possibly of the face as well.
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MRI showing a differ space occupying lesion in the hemisphere, characteristic of a glioma.
Your Answer:
Correct answer: The most likely site of this lesion given the left sided hemiparesis is something in the right hemisphere. It is possible it could involve the right brainstem or upper cervical cord but involvement of the face with involuntary movement would exclude the cervical cord and brainstem lesions causing a pure hemiparesis would be unusual. The drowsiness relates to the increased intracranial pressure for which she has the classic story with early morning headache, vomiting and nausea along with the evolving drowsiness.
Your Answer:
Correct answer: The cause of involuntary movements of her left side are almost certainly small epileptic seizures, in other words simple partial seizures of a motor type.
Your Answer:
Correct answer: The investigation that needs to be done urgently is a CT scan as she has symptoms of raised intracranial pressure which could also be confirmed by looking for papilloedema on fundoscopy. This needs to be done urgently given her evolution and the nature of her symptoms.
Your Answer:
Correct answer: In order to prove the diagnosis one would need to do a biopsy, although quite often the imaging abnormalities coupled to the history are suggestive of primary gliomas. Importantly secondary cancer deposits (with a primary tumour located at another site in the body) in the brain are common, and thus searching for a tumour at another site may be needed. However in order to prove beyond doubt that the tumour is what you think it is a biopsy is necessary.