Case Studies
Case 4: A 74-year-old man with ataxia and headache
A 74-year-old man presents with a ten day history of ataxia with a dull occipital headache. He has longstanding chronic obstructive airways disease secondary to smoking 20 cigarettes a day which he currently still does). Recently he has had some haemoptysis and weight loss.
On examination he has nystagmus on right and left lateral gaze with a dysarthria, marked ataxia involving gait and limbs.
Your Answer:
Correct answer: Given the bilateral ataxia with nystagmus, dysarthria and gait problems the pathology is likely to lie in the cerebellum.
Your Answer:
Correct answer: An urgent image of the posterior fossa is needed especially as he has a headache and he may be starting to develop hydrocephalus. An urgent CT scan would be the investigation of choice leading on to an MRI.
Your Answer:
Correct answer: The history of subacute onset of a cerebellar syndrome in a smoker with weight loss and haemoptysis suggests that the patient has carcinoma of the lung with secondary metastatic deposits to the cerebellum.
Your Answer:
Correct answer: If he is developing hydrocephalus he may need to be shunted and/or given steroids to reduce the swelling around the metastatic deposits. In terms of the possible carcinoma of the lung this needs investigating with scans, sputum cytology, and bronchoscopy and biopsy.
Axial T2 weighted (a) and axial T1 weighted (b) magnetic resonance images following intravenous gadolinium-DTPA injection. Areas of increased intensity on T2 weighted images indicate oedema (open arrows) and enhancement following contrast medium injection (closed arrows) demonstrates breakdown of the blood-brain barrier with contrast medium leaking into tumour deposits. This appearance is typical of cerebellar metastases.